Haemorrhage Prophylaxis

Preventing excessive bleeding during and after medical procedures or childbirth can save lives and reduce serious complications. Understanding when and how to prevent hemorrhage helps healthcare teams protect patients from life-threatening blood loss.

Table of contents

• What is Haemorrhage Prophylaxis?
• Prevention of Postpartum Hemorrhage
• Active Management of the Third Stage of Labor
• Medications Used for Prevention
• Risk Factors and Preparation
• Tranexamic Acid for Hemorrhage Prevention
• Prophylaxis in Bleeding Disorders

What is Haemorrhage Prophylaxis?

Haemorrhage prophylaxis means taking steps to prevent severe bleeding before it happens. A hemorrhage is excessive blood loss from damaged blood vessels that can be life-threatening if not controlled quickly. Prophylaxis involves using medications, specific medical procedures, or careful planning to reduce the risk of dangerous bleeding during surgery, childbirth, trauma care, or in people with bleeding disorders.

Prevention is especially important because hemorrhage can cause serious complications including shock, organ damage, and death. In many medical situations, preventing bleeding is safer and more effective than treating it after it occurs.

Prevention of Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is severe bleeding that occurs after giving birth. It affects approximately 3% to 5% of all deliveries and is one of the leading causes of maternal death worldwide^[1]. In the United States, PPH causes about 12% of maternal deaths^[1]. Despite being common, most cases of PPH can be prevented with proper prophylaxis.

PPH is defined as blood loss of at least 1,000 mL or any blood loss with signs of low blood volume within 24 hours after delivery^[1]. Primary PPH occurs within the first 24 hours after birth, while secondary PPH can happen from 24 hours up to 12 weeks after delivery^[3].

What makes postpartum hemorrhage particularly dangerous is that it can happen to anyone. About 20% of cases occur in women who have no known risk factors^[1]. This means healthcare providers must be prepared to prevent and manage hemorrhage at every delivery.

Active Management of the Third Stage of Labor

The best way to prevent postpartum hemorrhage is through active management of the third stage of labor. The third stage of labor is the time from when the baby is born until the placenta is delivered. Active management is a set of specific steps taken by healthcare providers during this time to reduce bleeding.

Active management decreases the risk of postpartum hemorrhage by 68% compared to expectant management, where the placenta is allowed to come out on its own^[5]. With active management, for every 12 deliveries, one case of postpartum hemorrhage is prevented^[5].

Active management includes giving medication (usually oxytocin) with or soon after delivery of the baby’s anterior shoulder, controlled cord traction to help deliver the placenta, and early cord clamping and cutting^[5]. This approach shortens the third stage of labor and significantly reduces blood loss without increasing the risk of a retained placenta^[5].

Medications Used for Prevention

Several medications can be used to prevent postpartum hemorrhage, with oxytocin being the most important and effective choice.

Oxytocin is the first-choice medication for preventing PPH. It is given after delivery of the baby’s anterior shoulder, which is the most important and effective part of hemorrhage prevention during childbirth^[1]. Oxytocin works by making the uterus contract strongly, which compresses blood vessels and stops bleeding. It is more effective than other options and has fewer side effects^[1][5].

Misoprostol is another medication that can prevent PPH, especially when oxytocin is not available. For every 18 deliveries where misoprostol is used, one case of postpartum hemorrhage is prevented^[5]. However, misoprostol causes more side effects than oxytocin^[5].

Other medications include ergot alkaloids and prostaglandins, which can also help the uterus contract. The choice of medication depends on availability, the patient’s medical condition, and what works best in each situation^[5].

Risk Factors and Preparation

Understanding who is at higher risk for hemorrhage helps healthcare teams prepare better preventive measures. Risk factors for postpartum hemorrhage include prolonged labor, having more than one baby, maternal obesity, maternal anemia before delivery, previous postpartum hemorrhage, preeclampsia, and procedures that speed up labor^[1][5].

Strategies for minimizing the effects of postpartum hemorrhage include identifying and treating anemia before delivery, understanding the mother’s beliefs about blood transfusions, and avoiding routine episiotomy^[5]. An episiotomy is a surgical cut made during delivery, and avoiding it unless absolutely necessary decreases blood loss and reduces the risk of severe tears^[1].

For women at high risk of hemorrhage, delivering at facilities with immediately available surgical services, intensive care, and blood bank services is an important preventive strategy^[1]. Having a hemorrhage cart with medications, supplies, checklists, and clear instructions readily available helps ensure rapid response when bleeding occurs^[1].

Tranexamic Acid for Hemorrhage Prevention

Tranexamic acid (TXA) is a medication that prevents the breakdown of blood clots, helping to stop bleeding. It has been used since 1966 and is considered essential for preventing and treating bleeding in many medical situations^[4].

Tranexamic acid works by blocking fibrinolysis, which is the body’s natural process of dissolving blood clots. In some cases, this process becomes overactive (called hyperfibrinolysis), leading to uncontrolled bleeding. TXA helps prevent this from happening^[4].

For postpartum hemorrhage, giving tranexamic acid within the first three hours after birth reduces deaths caused by bleeding^[1]. The medication is particularly important for patients undergoing major surgery or those at high risk for excessive bleeding during procedures involving organs rich in clotting activators, such as the liver, kidney, pancreas, uterus, and prostate^[4].

TXA has proven effective in reducing bleeding during various types of surgery including cardiac surgery, orthopedic surgery, cesarean section, and other gynecologic procedures^[11]. It reduces the need for blood transfusions and decreases overall blood loss during and after these procedures^[4].

Prophylaxis in Bleeding Disorders

Bleeding disorders are conditions where the blood does not clot properly, leading to excessive or prolonged bleeding. People with these disorders need special prophylaxis to prevent bleeding episodes.

Prophylaxis in bleeding disorders typically involves regular replacement of the missing clotting factor or using medications that help control bleeding. The goal is to prevent bleeding before it starts, rather than treating it after it occurs^[10].

For rare bleeding disorders, prophylaxis strategies are tailored to the specific disorder and the patient’s individual needs. These may include scheduled infusions of clotting factor concentrates or the use of medications like tranexamic acid to support normal clotting^[10].

Proper prophylaxis for bleeding disorders requires careful planning with healthcare providers who specialize in blood disorders. The treatment plan considers the type and severity of the disorder, the patient’s lifestyle and activities, and the risk of bleeding in different situations.