Review refractory postpartum hemorrhage severity and therapeutic approaches

Abstract

Refractory postpartum hemorrhage (PPH) occurs in 10–20% of individuals who inadequately respond to first-line interventions. These patients necessitate second-line interventions, comprising three or more uterotonics, supplementary drugs, transfusions, non-surgical treatments, and/or surgical procedures. Numerous studies indicate that patients with resistant PPH exhibit distinct clinical characteristics and etiologies of PPH in contrast to those who respond to first-line treatments. This review emphasizes contemporary perspectives on therapeutic strategies for managing refractory PPH. The first therapy of refractory postpartum hemorrhage necessitates hypovolemic resuscitation and hemostatic control, prioritizing prompt blood product replacement and adherence to large transfusion procedures. Point-of-care assays, such as thromboelastography, can facilitate the swift and precise identification of transfusion requirements. Medical interventions for refractory postpartum hemorrhage (PPH) encompass the management of uterine atony and the associated coagulopathy, including tranexamic acid and supplementary therapy such factor replacement. The concepts governing the management of refractory postpartum hemorrhage (PPH) involve the restoration of normal uterine and pelvic anatomy through the assessment and treatment of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices represent innovative approaches for managing refractory postpartum bleeding due to uterine atony, among other uterine-sparing surgical techniques now under examination. Resuscitative endovascular balloon occlusion of the aorta may be utilized in instances of critical refractory postpartum hemorrhage to mitigate or reduce persistent blood loss during definitive surgical procedures.