Harvey's Garden

Postpartum hemorrhage

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tags—
aliasesPuerperal hemorrhage, Retained placenta

2 min read

Mnemonic

4Ts of Postpartum Hemorrhage: Tone, Trauma, Tissue, Thrombin.

Tone

Uterine atony

  • Epidemiology: Most common cause of primary postpartum hemorrhage (PPH) (>80%).
  • Risk Factors:
    • Uterine overdistension (twins, polyhydramnios, fetal macrosomia).
    • Uterine fatigue (prolonged labor, oxytocin overuse, MgSO4).
    • Intra-amniotic infection (chorioamnionitis), high parity.
  • Clinical Features: Continuous profuse bleeding + soft, boggy, enlarged uterus (palpated above umbilicus).
  • Diagnosis: Clinical via bimanual exam. Bedside US to rule out retained products of conception (RPOC) or uterine inversion.
  • Differential:
    • Genital tract laceration: Firm, well-contracted uterus.
    • RPOC: Echogenic mass on US, missing placental cotyledon.
    • Uterine inversion: Absent uterine fundus on abdominal exam, vaginal mass.
  • Management Algorithm:
    • Step 1 (Initial): Bimanual uterine massage + IV Oxytocin + IV Tranexamic acid (TXA) + IVF/pRBCs. c
    • Step 2 (2nd-Line Uterotonics):
      • Methylergonovine (IM) – Contraindicated in HTN / Preeclampsia.
      • Carboprost (IM) – Contraindicated in Asthma.
      • Misoprostol (Sublingual/Rectal) – Used if methylergonovine/carboprost contraindicated.
    • Step 3 (Refractory Procedural): Intrauterine balloon tamponade (Bakri balloon).
    • Step 4 (Refractory Surgical):
      • Uterine artery embolization (UAE) if stable.
      • Surgical ligation (uterine/internal iliac artery) or B-Lynch sutures.
      • Emergent Hysterectomy: Definitive/last resort.
  • Key Complications: Sheehan syndrome (anterior pituitary necrosis → agalactorrhea, amenorrhea, hypotension), DIC, hypovolemic shock.

Abnormal placental separation (Tissue)

Retained placenta

  • Definition
    • Retention of the placental tissue inside the uterine cavity following the first 30 min postpartum.
  • Risk factors
    • Prior history of retained placenta (most common)
    • Placenta previa
    • Placenta accreta spectrum
  • Clinical features
    • Main feature: severe bleeding before placental delivery
    • Physical examination
      • Inability to completely separate the placenta during the third stage of labor
      • Speculum inspection: visualization of placental fragments or fetal membranes within the uterus

Abnormal placentation

Treatment

Prevention

  • Active management of the third stage of labor: delivery of the placenta which involves the following components
    • Uterotonic agents (IV/IM oxytocin)
    • Controlled umbilical cord traction (Brandt-Andrews maneuver)
    • External compression of the uterus and bimanual uterine massage

Graph View

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