Postpartum Hemorrhage
A Step 2 CK–focused lesson on postpartum hemorrhage built around the 4 T's, emphasizing bedside uterine assessment, uterotonic contraindications, and next-best-step management from massage through hysterectomy.
Overview: the 4 T's framework
Postpartum hemorrhage (PPH) is a leading cause of maternal death worldwide. ACOG (Practice Bulletin 183 / reVITALize) defines PPH as cumulative blood loss ≥1000 mL, OR blood loss with signs/symptoms of hypovolemia, within 24 hours of birth — regardless of delivery route (older thresholds: ≥500 mL vaginal, ≥1000 mL cesarean; ≥500 mL after vaginal birth still warrants evaluation). Primary (early) PPH occurs within 24 hours; secondary (late) PPH from 24 hours to 12 weeks postpartum.
On the boards, every PPH vignette is a hunt for the cause among the 4 T's: Tone (uterine atony), Trauma (lacerations, hematoma, rupture, inversion), Tissue (retained placenta/products, accreta), and Thrombin (coagulopathy). Atony is by far the most common (~70–80%). The two tested skills: (1) read the uterus — a soft, boggy fundus = atony, whereas a firm, well-contracted uterus with ongoing bleeding = trauma or retained tissue; and (2) pick the correct next uterotonic when the first-line agent is contraindicated.
- Definition (ACOG): cumulative blood loss ≥1000 mL, or blood loss + signs of hypovolemia, within 24 h of delivery
- Most common cause: uterine atony (Tone) — a soft, boggy, enlarged uterus
- Atony risk factors: uterine overdistension (twins, polyhydramnios, macrosomia), prolonged/augmented labor, high parity, chorioamnionitis, magnesium sulfate, retained placenta
- Trauma clue: bleeding despite a firm, well-contracted uterus → inspect cervix/vagina for lacerations
- Tissue clue: placenta undelivered >30 min, or missing cotyledons → retained products
- Thrombin clue: oozing from IV/venipuncture sites, abnormal coags → DIC (abruption, amniotic fluid embolism, sepsis, severe preeclampsia/HELLP); consider von Willebrand disease in a lifelong bleeder
- Secondary PPH (24 h–12 wk): think retained products or endometritis (also subinvolution of the placental site)
- Universal first moves: 2 large-bore IVs, crystalloid, CBC, type & cross, fibrinogen/coags, and call for help
The 4 T's — the differential for every postpartum bleed, in rough order of frequency:
- Tone — uterine atony (~70–80%; most common)
- Trauma — lacerations, hematoma, uterine rupture, uterine inversion
- Tissue — retained placenta/products, placenta accreta
- Thrombin — coagulopathy (DIC, von Willebrand disease, dilutional)
Work through them in order: massage the uterus and give a uterotonic (Tone), inspect the birth canal (Trauma), explore for retained products (Tissue), and check/replace clotting factors (Thrombin).
Uterotonics — the contraindication is the tested point
| Drug | Class / MOA | Key contraindication |
|---|---|---|
| Oxytocin | Nonapeptide; first-line, also given prophylactically | (no classic absolute CI); rapid IV bolus → hypotension; water intoxication/hyponatremia at high dose |
| Methylergonovine | Ergot alkaloid | Hypertension / preeclampsia |
| Carboprost (15-methyl PGF2α) | Prostaglandin F2α | Asthma (bronchospasm) |
| Misoprostol | Prostaglandin E1 | (well tolerated; causes fever/shivering) |
| Tranexamic acid | Antifibrinolytic; give early, within 3 h | adjunct — not a uterotonic |
Vignette 1: After a prolonged, oxytocin-augmented vaginal delivery of a 4.2-kg infant, a G4P4 woman has brisk vaginal bleeding. The uterus is soft and boggy, palpable above the umbilicus. → Dx: uterine atony. Next step: uterine (fundal) massage / bimanual uterine compression while ensuring IV oxytocin is running; if bleeding persists, add a second uterotonic.
Vignette 2: Bleeding continues despite massage and oxytocin; BP 155/98. → Avoid methylergonovine (hypertension). Give carboprost — unless she is asthmatic.
Vignette 3: The uterus is firm and well-contracted, yet bright-red bleeding continues. → Not atony. Next step: inspect the cervix and vagina for lacerations (Trauma).
Vignette 4: Refractory atonic hemorrhage unresponsive to all uterotonics. → Escalate: intrauterine balloon tamponade (Bakri) → uterine artery embolization (if stable) or surgery (B-Lynch suture, uterine/O'Leary or internal iliac artery ligation) → hysterectomy (definitive last resort).
Uterine inversion: After delivery a smooth mass appears at the introitus/vagina, the fundus is not palpable abdominally, and there is hypotension out of proportion to blood loss (vagal/neurogenic). Often follows excessive cord traction/fundal pressure. → Next step: immediate manual replacement (Johnson maneuver); STOP uterotonics and give a uterine relaxant (terbutaline, nitroglycerin, magnesium, or halothane) if the ring is clamped down — then resume uterotonics once replaced to prevent re-inversion.
Retained placenta: placenta undelivered >30 min despite active management, or bleeding with a boggy uterus. → Next step: manual removal; ultrasound for retained products. Suspect placenta accreta if it will not separate (esp. prior cesarean + placenta previa) → often requires hysterectomy.
Secondary PPH (24 h–12 wk): subacute bleeding days to weeks later. → Most common causes: retained products of conception and endometritis; evaluate with ultrasound; treat with uterotonics/curettage and antibiotics as indicated.
- 1. Resuscitate + call for help: 2 large-bore IVs, crystalloid, CBC, type & cross, coags/fibrinogen; monitor vitals
- 2. Uterine (fundal) massage + bimanual uterine compression — the first mechanical maneuver
- 3. Uterotonics (choice bends around contraindications): oxytocin first-line → add methylergonovine (not if HTN) → carboprost (not if asthma) → misoprostol; give tranexamic acid early (within 3 h)
- 4. Tamponade: intrauterine balloon (Bakri) or uterine packing
- 5. Interventional/surgical: uterine artery embolization (if hemodynamically stable) → B-Lynch compression suture, uterine artery (O'Leary) or internal iliac (hypogastric) artery ligation
- 6. Definitive: hysterectomy (last resort for life-threatening/refractory bleeding)
Transfuse to keep pace with loss; activate the massive transfusion protocol (~1:1:1 RBC:FFP:platelets) for ongoing hemorrhage.
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