← Diagnosis and Management Guides
Postpartum Hemorrhage
Key considerations: Uterine rupture, DIC, Retained placenta
Cannot miss
- Uterine rupture
- DIC
- Retained placenta
- Genital tract laceration
Likely diagnoses
- Uterine atony (70-80%)
- Genital tract laceration
- Retained products
- Coagulopathy
Red flags
- EBL >1000mL
- Hemodynamic instability
- Altered mental status
- Boggy uterus
Workup
- history: Mode of delivery, prolonged labor, overdistention, prior PPH; exam: Uterine tone (boggy = atony), vaginal/cervical inspection for lacerations, manual exploration for retained products; labs: CBC, coags (PT/PTT/fibrinogen), type and crossmatch, TEG/ROTEM if available; imaging: Ultrasound for retained products; bedside: Quantitative blood loss measurement, visual estimation underestimates
Management
- immediate: Bimanual uterine massage; Oxytocin 40 units in 1L NS rapid infusion; Second-line uterotonics: methylergonovine 0.2mg IM, carboprost 250mcg IM, misoprostol 800-1000mcg rectal; general: Massive transfusion protocol if needed (1:1:1 pRBC:FFP:platelets); Tranexamic acid 1g IV within 3 hours; Bakri balloon tamponade; B-Lynch suture if surgical intervention needed; Hysterectomy as last resort
Disposition
- admit: All PPH patients for close monitoring; discharge: After hemodynamic stability and adequate hemoglobin; consults: OB/GYN, anesthesia, blood bank for MTP
Clinical pearls
- The 4 T's of PPH: Tone (atony), Tissue (retained), Trauma (laceration), Thrombin (coagulopathy)
- TXA reduces PPH mortality when given within 3 hours — WOMAN trial
- Fibrinogen <200 mg/dL is a strong predictor of severe PPH requiring intervention
Source and review
- ACOG PPH PB 2017, WHO PPH Guidelines 2023. Last reviewed: 2024-11-01