← Diagnosis and Management Guides
Postpartum Hemorrhage
Key considerations: Uterine atony (most common cause — 80%), Retained placenta/products, Uterine rupture
Cannot miss
- Uterine atony (most common cause — 80%)
- Retained placenta/products
- Uterine rupture
- Cervical/vaginal laceration
- Coagulopathy/DIC
- Uterine inversion
Likely diagnoses
- Uterine atony
- Genital tract laceration
- Retained placental fragments
- Coagulopathy
Red flags
- EBL >1000mL or hemodynamic instability
- Tachycardia, hypotension
- Active hemorrhage not responding to uterotonics
- Signs of DIC (oozing from IV sites, petechiae)
Workup
- history: Mode of delivery; Risk factors: prolonged labor, macrosomia, polyhydramnios, multiple gestation, prior PPH, chorioamnionitis; Time since delivery; Anticoagulant use; exam: Quantitative blood loss measurement; Uterine tone (boggy = atony); Cervical/vaginal inspection for lacerations; Manual exploration for retained products; Bimanual uterine massage; labs: CBC, type and crossmatch (order 2-4 units pRBC); Coagulation studies (PT, PTT, fibrinogen); Fibrinogen <200 mg/dL predicts need for massive transfusion; imaging: Bedside US to assess for retained products or uterine inversion; bedside: Quantitative blood loss measurement; Uterine massage assessment
Management
- immediate: Bimanual uterine massage; Uterotonics stepwise: oxytocin 10-40 units in 1L LR → methylergonovine 0.2mg IM → carboprost 250mcg IM q15min → misoprostol 800-1000mcg PR; Large-bore IV access x2; Type and crossmatch, activate massive transfusion protocol if needed; general: 4 Ts mnemonic: Tone (atony), Trauma (laceration), Tissue (retained), Thrombin (coagulopathy); TXA 1g IV if hemorrhage not controlled within 30 min (WOMAN trial); Transfuse 1:1:1 ratio (pRBC:FFP:platelets) in massive hemorrhage; Keep fibrinogen >200; specific: diagnosis: Uterine Atony; steps: Bimanual massage; Uterotonics (stepwise above); Bakri balloon tamponade if refractory; B-Lynch suture or uterine artery ligation if surgical; Hysterectomy as last resort; diagnosis: Retained Products; steps: Manual exploration and removal; Curettage under US guidance; Antibiotics if infected; diagnosis: Genital Tract Laceration; steps: Thorough inspection and repair; Consider OR for high/complex lacerations
Disposition
- admit: All PPH patients; ICU if massive transfusion, DIC, or hemodynamic instability; discharge: After hemodynamic stability, stable Hb, and adequate uterine tone maintained; consults: OB if EM is primary team; Blood bank for massive transfusion; Interventional radiology for uterine artery embolization if available
Clinical pearls
- 4 Ts: Tone (atony 80%), Trauma (laceration 15%), Tissue (retained placenta 5%), Thrombin (coagulopathy 1%)
- TXA should be given within 3 hours of delivery for maximum benefit (WOMAN trial)
- Fibrinogen <200 mg/dL is the best early lab predictor of severe PPH
- Bakri balloon can be placed by any provider — tamponades the uterine cavity with 300-500mL saline
Source and review
- ACOG Practice Bulletin No. 183, 2017; WOMAN Trial, Lancet 2017. Last reviewed: 2024-11-01