Postpartum Hemorrhage Diagnosis

Clinical Presentation and Diagnosis

• In a patient with postpartum bleeding and a firm uterus after vaginal delivery, genital tract laceration is the most common cause, as uterine atony is effectively ruled out by the presence of a firm, well-contracted uterus 1
• Uterine atony is indeed the most common cause of postpartum hemorrhage overall, accounting for 70.6% of all PPH cases and up to 80% in some series, but it presents with a soft, boggy uterus that fails to contract properly 1
• When postpartum hemorrhage occurs with a firm, well-contracted uterus, genital tract trauma becomes the leading cause, according to the American College of Radiology 2, 3
• The American College of Radiology Appropriateness Criteria specifically identifies vaginal lacerations as causes of bleeding that can be elucidated by history and physical examination 2, 3

Clinical Approach and Management

• The American College of Radiology recommends assessing uterine tone first when evaluating postpartum hemorrhage, and if the uterus is firm, thoroughly inspecting the genital tract for lacerations 1, 2
• The clinical approach algorithm for postpartum hemorrhage with 1000 cc blood loss involves assessing uterine tone, inspecting the genital tract, verifying complete placental delivery, and assessing for coagulopathy if bleeding persists 1, 2

Postpartum Hemorrhage Causes and Evaluation

Evidence-Based Hierarchy of PPH Causes

• Uterine atony accounts for 70-80% of all postpartum hemorrhage cases and is the leading cause of early PPH (within first 24 hours after delivery) according to the American College of Radiology 4, 5
• Trauma-related hemorrhage from lacerations, uterine rupture, or incision extensions is the second leading cause of postpartum hemorrhage, as stated by the American College of Radiology 4, 5
• Retained Products of Conception (RPOC) complicates approximately 1% of third-trimester deliveries and is the second most common etiology for PPH after uterine atony overall, as reported by the American College of Radiology 4, 5
• Coagulopathy, whether inherited or acute, is less common but potentially life-threatening, according to the American College of Radiology 4, 5

Clinical Approach Algorithm

• When evaluating postpartum hemorrhage after SVD, verifying complete placental delivery is crucial, as stated by the American College of Radiology 4

Postpartum Hemorrhage Causes and Risk Factors

Primary Causes

• Retained placenta is defined by WHO as spontaneous placental delivery occurring more than 30 minutes after fetal expulsion, according to the American College of Obstetricians and Gynecologists guidelines 6

Iatrogenic/Medication-Related Causes

• Women receiving therapeutic-dose LMWH have increased PPH risk: 29.6% experienced PPH after vaginal delivery compared to 17.6% of controls (OR 1.9, 95% CI 1.1-3.5), as recommended by the American Society of Hematology 7
• Spontaneous labor in anticoagulated women carries 1.9-fold higher risk of PPH compared to planned induction, according to the American College of Obstetricians and Gynecologists guidelines 7
• The timing of last LMWH dose (<24 hours vs >24 hours before delivery) did not significantly affect PPH risk after vaginal delivery, as stated by the American Society of Hematology 7
• Major hemorrhage within 24 hours of delivery occurred in 1.2% of women receiving therapeutic anticoagulation, as reported by the American Society of Hematology 8
• Do not assume anticoagulation timing matters for vaginal delivery: Evidence shows no difference in PPH risk whether LMWH was given <24 hours or >24 hours before delivery, according to the American Society of Hematology 7

Postpartum Hemorrhage Evaluation and Management

Clinical Presentation and Risk Factors

• The patient received vigorous uterine massage and uterotonic medications with documented firm fundus, making atony an unlikely diagnosis, according to the American College of Radiology 9
• A history of prior cesarean section may alter tissue integrity of the lower genital tract, increasing the risk of genital tract lacerations, as noted by the American College of Radiology 10
• No prenatal care may contribute to an increased risk of complications, including genital tract lacerations, as suggested by the American College of Radiology 11

Diagnostic Approach

• The American College of Radiology recommends a systematic visual inspection under adequate lighting of the cervix, vaginal walls, perineum, and periurethral area to identify lacerations 10
• Examination under anesthesia should be considered if the patient cannot tolerate adequate inspection, as recommended by the American College of Radiology 10

Management

• Immediate surgical repair with absorbable suture under adequate anesthesia and lighting is recommended for identified lacerations, according to the American College of Radiology 10
• Ensure hemostasis with figure-of-eight sutures for arterial bleeders, as suggested by the American College of Radiology 10
• Consider packing if diffuse oozing from multiple small lacerations, as recommended by the American College of Radiology 10
• If no laceration is found, reconsider retained placental tissue with transvaginal ultrasound with Doppler, and assess for coagulopathy with PT/PTT, fibrinogen, platelet count, as recommended by the American College of Radiology 9

Postpartum Hemorrhage Management

Uterine Atony Prevention and Treatment

• Vigorous bimanual uterine massage should be performed to stimulate contraction when a soft fundus is encountered, as recommended by the American College of Radiology 12

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