Pregnancy, Childbirth & Puerperium

Postpartum hemorrhage: causes and CCS-style management

Clinical Overview and When to Suspect Postpartum Hemorrhage

— Prior threshold of >500 mL for vaginal delivery is still used as a trigger for heightened surveillance and the "stage 1" hemorrhage bundle.

— Primary (early) PPH: within 24 h — almost always atony, trauma, retained tissue, or coagulopathy.

— Secondary (late) PPH: 24 h to 12 weeks — typically retained products, subinvolution of placental site, endometritis, or inherited bleeding disorder unmasking.

— Tone (uterine atony, ~70–80%)

— Trauma (lacerations, hematoma, uterine rupture/inversion, ~20%)

— Tissue (retained placenta, accreta spectrum, ~10%)

— Thrombin (coagulopathy — DIC, HELLP, AFE, dilutional, ~1%)

— Any postpartum patient with HR >110, SBP <90, shock index (HR/SBP) ≥1.0, oliguria, or ongoing visible bleeding

— Boggy fundus above the umbilicus after delivery

— Continued bright red bleeding despite a contracted uterus → think trauma or coagulopathy

— Delayed presentation (days 7–14) with heavy bleeding ± fever → retained products vs endometritis

CCS pearl: On the CCS interface, the moment you see "estimated blood loss 1000 mL" or "heavy vaginal bleeding postpartum," your first three orders should be IV access ×2 large-bore, type and crossmatch, and CBC/coags/fibrinogen — before you finish your bimanual exam. Activating the massive transfusion protocol early is rewarded; waiting for a second set of vitals is punished.

Definition (ACOG reVITALize, 2017): Cumulative blood loss ≥1000 mL OR blood loss accompanied by signs/symptoms of hypovolemia within 24 hours of birth (regardless of route).

Epidemiology: Leading cause of maternal mortality worldwide; in the US, accounts for ~11% of pregnancy-related deaths and is the single most preventable cause.

Temporal classification:

The 4 T's mnemonic (memorize cold):

When to suspect on the CCS screen:

Presentation Patterns and Key History

Key risk factors to mine from the history:

— Prior PPH (recurrence ~15%), multiple gestation, polyhydramnios, grand multiparity

— Prolonged or precipitous labor, chorioamnionitis, prolonged oxytocin

— Prior uterine surgery (CS, myomectomy), placenta previa, accreta spectrum

— Preeclampsia/HELLP, abruption, IUFD, sepsis, AFE

— Inherited bleeding disorders (von Willebrand most common), anticoagulant use

Board pearl: A firm uterus with ongoing bleeding redirects you away from atony and toward trauma or coagulopathy — this single distinction is high-yield on exam day. Conversely, a boggy uterus = atony until proven otherwise, and bimanual massage is your first physical intervention.

Classic atony stem: Multiparous woman, prolonged labor with oxytocin augmentation, macrosomic infant or twins, delivers vaginally, then has a steady gush of dark red blood with a soft, boggy fundus palpable above the umbilicus.

Trauma stem: Precipitous delivery, operative vaginal (forceps/vacuum), or large infant; firm, well-contracted uterus but persistent bright red bleeding — think cervical/vaginal laceration or vulvovaginal hematoma (severe rectal/perineal pain disproportionate to exam).

Retained tissue stem: Placenta delivered but appears incomplete, or succenturiate lobe noted; bleeding persists despite uterotonics. Late PPH (days 7–14) with bleeding + cramping → retained products.

Coagulopathy stem: Abruption, intrauterine fetal demise, amniotic fluid embolism, severe preeclampsia/HELLP, sepsis, or massive transfusion → oozing from IV sites, gums, episiotomy; clot doesn't form in collection basin.

Uterine inversion stem: Excessive cord traction or fundal pressure on a non-contracted uterus → sudden hemorrhage + vasovagal shock out of proportion to blood loss + fundus not palpable abdominally, mass at introitus.

Placenta accreta spectrum stem: Prior cesarean(s) + placenta previa on this pregnancy; placenta fails to separate after delivery → torrential bleeding when forced separation attempted.

Physical Exam Findings and Hemodynamic Assessment

— Normal pregnancy SI 0.7–0.9

— SI ≥1.0 → activate massive transfusion protocol consideration

— SI ≥1.7 → predicts need for intensive resuscitation, transfer to higher-level care

— Fundus: Boggy and above umbilicus → atony. Firm and bleeding → trauma/tissue/coagulopathy.

— Lower genital tract inspection: Speculum exam under good lighting — look for cervical, vaginal, periurethral, and perineal lacerations; sulcus tears are easily missed.

— Hematoma check: Vulvar/vaginal/retroperitoneal — severe pain, bulging mass, falling Hct without external bleeding; broad-ligament hematoma can be occult and life-threatening.

— Placenta inspection: Cotyledons complete? Membranes intact? Vessels coursing to the edge (suggests succenturiate lobe).

— Bimanual exam: Assesses tone and detects clot or retained tissue; concurrent uterine massage is therapeutic.

— Uterine inversion: Smooth, beefy red mass at introitus or in vagina; fundus not palpable abdominally.

Step 3 management: Order a calibrated under-buttocks drape and graduated collection containers at delivery in any patient with PPH risk factors. The first management point you score is converting from "EBL" to QBL — early, accurate quantification triggers earlier intervention and improves outcomes.

Vital signs caveat: Healthy pregnant patients can lose up to 1500 mL (Class II shock) before classic hypotension appears due to expanded plasma volume — do not be reassured by a "normal" BP. Tachycardia, narrowed pulse pressure, and anxiety/air hunger come first.

Shock Index (SI) = HR ÷ SBP:

Systematic postpartum bleeding exam (do in this order):

Quantitative blood loss (QBL): Replaces visual estimation, which underestimates by 30–50%. Weigh blood-soaked materials (1 g = 1 mL).

Diagnostic Workup — Initial Labs and Bedside Studies

— CBC with platelets (baseline Hgb/Hct will lag actual loss by hours)

— PT/INR, aPTT

— Fibrinogen — the single most sensitive lab for obstetric coagulopathy

— Type and crossmatch ≥2 units PRBCs (cross 4 units if active hemorrhage, 6+ if MTP activated)

— Comprehensive metabolic panel, lactate, ionized calcium

— Arterial or venous blood gas for pH/base deficit if hemodynamically unstable

— Normal in third trimester: 350–650 mg/dL (elevated baseline)

— Fibrinogen <200 mg/dL has a positive predictive value ~100% for severe PPH

— <150 mg/dL → give cryoprecipitate or fibrinogen concentrate immediately

— Bedside clot test: Draw 5 mL into a red-top tube; failure to form a firm clot in 8–10 minutes suggests fibrinogen <150 — useful when lab turnaround is slow.

— Thromboelastography (TEG)/ROTEM: Where available, FIBTEM A5 <12 mm = functional hypofibrinogenemia; guides goal-directed transfusion and reduces total product use.

— Retained products: echogenic intrauterine material, increased endometrial thickness (>10 mm suggestive but nonspecific)

— Free fluid in Morison's pouch → suspect uterine rupture or broad ligament hematoma extension

— Bladder distention can mask atony — confirm catheter patency

Board pearl: A falling fibrinogen with rising D-dimer in a postpartum patient with oozing from IV sites = DIC, often from abruption, AFE, or sepsis — not primary atony. Treatment pivots from uterotonics to aggressive product replacement (cryo, FFP, platelets) and treating the trigger.

Send immediately with the first IV (CCS order set):

Fibrinogen — the killer number:

Point-of-care tests:

Bedside ultrasound:

EKG and continuous monitoring: Tachycardia, ischemic changes from demand in anemia; baseline before transfusion.

Diagnostic Workup — Advanced or Confirmatory Studies

— CBC, fibrinogen, PT/INR, aPTT, ionized Ca²⁺, K⁺, lactate, pH

— Goals: Hgb >7–8, platelets >50K (>75K if ongoing bleed), fibrinogen >200 mg/dL, INR <1.5, ionized Ca²⁺ >1.1 mmol/L

— Best initial imaging for suspected retained products of conception (RPOC) in late PPH

— Color Doppler increases sensitivity — hypervascular focus suggests RPOC vs avascular clot

— Endometrial thickness >10 mm + symptoms → consider D&C

— Reserved for stable patients with suspected occult bleed (broad ligament, retroperitoneal hematoma) or pre-embolization planning

— Active contrast extravasation localizes target vessel for interventional radiology

— Indicated when bleeding source is unclear despite bedside evaluation, or pain precludes adequate exam

— Allows thorough inspection of cervix (often misses sulcus tears), repair of deep lacerations, manual exploration of uterine cavity, and dilation/curettage

Key distinction: Primary PPH evaluation is clinical and bedside — speculum, bimanual, US if needed. Secondary PPH (24 h to 12 weeks) almost always needs pelvic ultrasound + β-hCG (rule out gestational trophoblastic disease) and a CBC + coag panel — and frequently uncovers an inherited bleeding disorder, especially von Willebrand disease, which should be screened in any woman with recurrent PPH or heavy menses prepregnancy.

Repeat labs every 30–60 minutes during active hemorrhage:

Formal pelvic/transabdominal ultrasound:

CT angiography of abdomen/pelvis:

MRI: Not acute — useful postpartum for suspected placenta accreta planning in a subsequent pregnancy or for evaluating arteriovenous malformations as a cause of secondary PPH.

Examination under anesthesia (EUA):

Hysteroscopy: Selected late PPH cases for targeted removal of RPOC with less endometrial trauma than blind curettage.

Risk Stratification and First-Line Management Logic

— Low risk: No prior CS, singleton, <4 prior vaginal births, no bleeding disorder, no PPH history → type and screen

— Medium risk: Prior CS or uterine surgery, multiple gestation, >4 prior vaginal births, chorioamnionitis, large fibroids → type and screen, 2 units available

— High risk: Placenta previa/accreta, active bleeding, known coagulopathy, Hct <30 + other factors, prior PPH → type and crossmatch 2 units, deliver in facility with blood bank + OR + IR

— Stage 0 (every birth): Active management of third stage — oxytocin 10 U IM or 10–40 U in 500–1000 mL crystalloid IV after delivery of anterior shoulder, controlled cord traction, fundal massage

— Stage 1 (EBL >500 mL vaginal / >1000 mL CS or abnormal vitals): Two large-bore IVs, increase oxytocin, methylergonovine or carboprost, bimanual massage, identify cause via 4 T's, T&C 2 units

— Stage 2 (continued bleed, EBL 1000–1500 mL): Mobilize team (OB attending, anesthesia, nursing lead, blood bank), all uterotonics, TXA 1 g IV, transfuse 2 units PRBCs, consider tamponade

— Stage 3 (EBL >1500 mL or >2 units transfused or vitals unstable): Massive transfusion protocol (1:1:1), OR for surgical intervention or IR for embolization

CCS pearl: The CCS grader looks for parallel orders, not sequential heroics. In Stage 2, on a single screen, order: IV access #2, oxytocin titration, methylergonovine 0.2 mg IM, carboprost 250 mcg IM, TXA 1 g IV over 10 min, CBC/fibrinogen/coags repeat, T&C 4 units, call OB and anesthesia, place Foley, warm IV fluids. Move clock 30 minutes only after orders are in.

Antepartum risk stratification (California Maternal Quality Care Collaborative tool):

Stage-based response (CMQCC obstetric hemorrhage bundle):

Pharmacotherapy — Uterotonics and Adjuncts

— 10 U IM or 10–40 U in 500–1000 mL NS/LR IV at 200–500 mL/h

— Never give undiluted IV push (hypotension)

— Side effects: hypotension, hyponatremia with prolonged high-dose infusion

— Use in every delivery as prophylaxis

— 0.2 mg IM, may repeat q2–4 h (max 5 doses)

— Contraindicated in hypertension, preeclampsia, coronary disease, Raynaud's — causes vasoconstriction

— Onset 2–5 min

— 250 mcg IM or intramyometrial, may repeat q15–90 min (max 8 doses = 2 mg)

— Contraindicated in asthma (bronchospasm); use cautiously in hepatic/renal/cardiac disease

— Side effects: diarrhea (premedicate with antiemetic/antidiarrheal), fever, flushing

— 800–1000 mcg rectal or 600 mcg sublingual for PPH

— Useful when other agents contraindicated (asthma + HTN) or unavailable

— Side effects: shivering, fever (often confused for endometritis)

— 1 g IV over 10 minutes within 3 hours of bleed onset; may repeat 1 g if bleeding continues after 30 min

— WOMAN trial: reduces death from bleeding by ~30% when given <3 h

— Safe across PPH causes; minimal thrombotic risk at this dose

— Ionized Ca²⁺ <1.1 → 1 g IV calcium gluconate; citrate in transfused blood chelates calcium and worsens coagulopathy and atony

— Cryoprecipitate 10 units or fibrinogen concentrate 2–4 g if fibrinogen <200 mg/dL

Board pearl: Remember contraindications by drug: Methylergonovine = HTN, Carboprost = Asthma, Misoprostol = always usable. A preeclamptic asthmatic with PPH → oxytocin + misoprostol + TXA, not methergine or hemabate.

Oxytocin (Pitocin) — first-line:

Methylergonovine (Methergine) — second-line:

Carboprost (Hemabate, 15-methyl PGF2α) — third-line:

Misoprostol (Cytotec, PGE1):

Tranexamic acid (TXA):

Calcium:

Fibrinogen replacement:

Procedures and Invasive Management

— Indication: atony refractory to medical therapy, lower uterine segment bleeding, or placenta previa bleeding after CS

— Fill 250–500 mL warm saline; leave 12–24 h with antibiotic coverage and Foley

— Tamponade test: if bleeding stops with balloon = high success rate avoiding surgery

— Best for stable patient with persistent bleeding, suspected genital tract hematoma, or as fertility-sparing alternative

— Not for hemodynamically unstable patient who needs OR

— Uterine compression sutures (B-Lynch, Hayman, Cho): For atony at the time of laparotomy; preserves fertility

— Uterine artery ligation (O'Leary stitch) → utero-ovarian ligation → internal iliac (hypogastric) ligation — stepwise devascularization

— Hysterectomy: Definitive — supracervical faster, but total hysterectomy preferred for placenta previa/accreta with lower-segment bleeding. Decision should not be delayed in unstable patients or accreta spectrum.

— Uterine inversion: Stop uterotonics, Johnson maneuver (manual replacement through cervical ring) under uterine relaxation with nitroglycerin 50–100 mcg IV or terbutaline; once replaced, restart uterotonics

— Retained placenta: Manual extraction under anesthesia; if accreta — leave in place and proceed to hysterectomy or methotrexate management

— Placenta accreta spectrum: Planned cesarean hysterectomy at 34–36 weeks at a level III/IV center with massive transfusion capability and IR

CCS pearl: When uterotonics + TXA + balloon fail, the next CCS order is "transfer to operating room" — not another round of carboprost. The grader rewards decisive escalation; indecision behind multiple doses of the same medication is penalized.

Bimanual uterine massage: First non-pharmacologic step — one hand in vagina compressing anterior wall against external hand on fundus. Continue while uterotonics infuse.

Intrauterine balloon tamponade (Bakri, ebb, or condom catheter):

Uterine artery embolization (UAE) by IR:

Surgical interventions (in escalating order):

Specific scenario procedures:

Special Populations — Elderly, Renal, and Hepatic Considerations

— Increased PPH risk due to higher rates of fibroids, prior uterine surgery, placenta previa/accreta, hypertensive disorders, and operative delivery

— Lower cardiovascular reserve — earlier hemodynamic decompensation; consider arterial line and CVP/POCUS-guided resuscitation at lower thresholds

— Higher baseline thrombotic risk — TXA still indicated (benefit > risk in active hemorrhage), but post-event VTE prophylaxis is essential once bleeding controlled

— Hypovolemia and hypotension predispose to acute tubular necrosis and cortical necrosis (especially with abruption, DIC, AFE)

— Avoid nephrotoxic agents (NSAIDs, contrast if possible) during active resuscitation

— Adjust LMWH dose for VTE prophylaxis once stable if CrCl <30

— Methylergonovine and carboprost — no major renal dose adjustment but use cautiously

— TXA — reduce dose in CrCl <50 (though acute single-dose protocol typically unchanged in life-threatening bleed)

— Baseline coagulopathy + thrombocytopenia compounds PPH risk

— Fibrinogen production impaired — replace early and aggressively; target >200 mg/dL

— Methylergonovine and carboprost have hepatic metabolism — use with caution but not absolutely contraindicated in emergency

— HELLP syndrome: platelet transfusion threshold ~50K for vaginal, ~70K for cesarean; consider DDAVP if von Willebrand–type dysfunction

— Document specific blood product preferences antepartum (some accept albumin, fractionated factors, cell salvage)

— Optimize iron stores (IV iron) in pregnancy, plan cell salvage at delivery, use TXA aggressively, lower threshold for surgical control

Step 3 management: In any AMA patient with prior cesarean and current previa, schedule delivery at 34 0/7–35 6/7 weeks at a level III/IV center with MFM, anesthesia, IR, and blood bank — antepartum referral is the highest-yield management point.

"Elderly" in obstetrics = advanced maternal age (AMA, ≥35) and very AMA (≥40):

Chronic kidney disease and AKI in PPH:

Hepatic disease (HELLP, acute fatty liver, viral hepatitis, cirrhosis):

Jehovah's Witness patients:

Special Populations — Adolescents, Inherited Bleeding Disorders, and the Critically Ill

— Higher rates of preeclampsia, preterm delivery, and operative delivery → elevated PPH risk

— Lower baseline iron stores — antepartum anemia common; treat aggressively with oral or IV iron

— Confidentiality and consent: in most US states, pregnancy emancipates a minor for pregnancy-related decisions including transfusion — verify state law

— Von Willebrand disease — most common (1% of population). Factor VIII and vWF rise in pregnancy and fall rapidly postpartum → delayed PPH at 1–2 weeks is classic

— Management: DDAVP 0.3 mcg/kg IV (type 1 vWD), vWF/Factor VIII concentrate (Humate-P) for types 2/3, TXA for all types, avoid NSAIDs

— Hemophilia carriers: factor VIII or IX levels <50% require factor replacement before delivery and for 3–5 days postpartum

— Platelet disorders (ITP, Glanzmann's, Bernard-Soulier): platelet transfusion, IVIG, steroids as appropriate

— Therapeutic LMWH/UFH must be held ≥24 h before planned delivery; if unplanned bleed, reverse with protamine (UFH) or andexanet/PCC (DOACs — rarely used in pregnancy)

— Warfarin in postpartum period (breastfeeding-compatible) — reverse with 4-factor PCC + vitamin K for acute hemorrhage

— Chorioamnionitis or postpartum endometritis can precipitate DIC — fibrinogen <200 + oozing + falling platelets

— Treat infection (broad-spectrum: ampicillin + gentamicin + clindamycin or pip-tazo) and support coagulation simultaneously

— AFE: sudden cardiovascular collapse + DIC + hypoxia during/just after delivery — supportive ICU care, massive transfusion, often ECMO

Board pearl: Delayed PPH at 7–14 days postpartum in a patient with a history of heavy menses, easy bruising, or family bleeding history → screen for von Willebrand disease with vWF antigen, ristocetin cofactor activity, and factor VIII levels at least 6–8 weeks postpartum (pregnancy elevates levels and masks diagnosis).

Adolescents:

Inherited bleeding disorders (often unmasked by PPH):

Patients on anticoagulation:

Critically ill / septic patients:

Complications and Adverse Outcomes

— Hemorrhagic shock with multi-organ hypoperfusion

— Disseminated intravascular coagulation (DIC) — consumptive coagulopathy, often from underlying trigger (abruption, AFE, sepsis, retained dead fetus)

— Acute kidney injury — prerenal initially, then ATN; rarely renal cortical necrosis with permanent dialysis dependence

— Acute respiratory distress syndrome (ARDS) — from massive transfusion, TRALI, AFE, sepsis

— Transfusion-related complications: TRALI (most common cause of transfusion-related death), TACO, hemolytic reactions, citrate toxicity (hypocalcemia), hyperkalemia, hypothermia, dilutional coagulopathy

— Air embolism with rapid infusion under pressure

— Sheehan syndrome (postpartum pituitary necrosis): Inability to lactate is often the first sign; later → amenorrhea, hypothyroidism, adrenal insufficiency. Always suspect in any woman with significant PPH who fails to lactate — check prolactin, TSH/free T4, cortisol/ACTH, FSH/LH

— Asherman syndrome: Intrauterine adhesions from aggressive curettage of postpartum uterus — secondary amenorrhea and infertility

— Postpartum venous thromboembolism: Hemorrhage + immobilization + intrinsic hypercoagulability — restart mechanical and pharmacologic prophylaxis as soon as bleeding controlled

— Postpartum depression and PTSD: Significantly elevated after severe PPH and ICU admission — screen at 2- and 6-week visits with EPDS

— Iron deficiency anemia — replenish with PO or IV iron for 3–6 months

— Reduced fertility (after hysterectomy or Asherman's)

— Recurrence risk in next pregnancy: ~15% overall, higher if accreta or atony

Key distinction: DIC = global consumption (low fibrinogen, low platelets, prolonged PT/PTT, high D-dimer). Dilutional coagulopathy = massive crystalloid/PRBC resuscitation without FFP/platelets/cryo — preventable with 1:1:1 ratio transfusion from the start of MTP.

Acute (hours to days):

Subacute (days to weeks):

Long-term:

When to Escalate — ICU, Consults, and Inpatient Triage

— EBL >1500 mL with ongoing bleeding

— Transfused ≥4 units PRBCs in 1 hour or projected need

— Shock index ≥1.4 or persistent hemodynamic instability

— Fibrinogen <150 mg/dL with active bleeding

— MTP delivers PRBC:FFP:platelets in 1:1:1 ratio (e.g., 6 PRBC : 6 FFP : 1 apheresis platelet unit per round)

— OB/GYN attending — if not already at bedside

— Anesthesiology — airway, central access, pressors, OR readiness

— Blood bank — confirm MTP activation, ongoing product release

— Interventional radiology — for embolization in stable patients with ongoing bleeding

— Critical care/MICU — post-resuscitation management

— Hematology — refractory coagulopathy, suspected inherited disorder

— Maternal-fetal medicine — for accreta spectrum and complex cases

— Ongoing vasopressor requirement

— Mechanical ventilation

— >6 units PRBC transfused

— DIC with end-organ dysfunction

— Post-hysterectomy with hemodynamic instability

— AFE or septic shock

— Anticipated placenta accreta spectrum

— Bleeding disorder requiring specialty factor replacement

— Continued bleeding despite all local resources

CCS pearl: On the CCS, simultaneous orders of "consult OB/GYN," "consult anesthesia," "consult IR," "activate massive transfusion protocol," and "transfer to ICU" within the same screen are rewarded over the same orders staggered across three time advances. The grader detects timely team mobilization as a discrete scoring node — be aggressive and parallel.

Activate massive transfusion protocol (MTP) when:

Consults to mobilize in parallel (CCS-style):

ICU admission criteria:

Transfer to higher level of care (level III or IV maternity facility):

Key Differentials — Same-Category Causes (the 4 T's expanded)

— Overdistension: macrosomia, multifetal gestation, polyhydramnios

— Exhaustion: prolonged or precipitous labor, high parity

— Pharmacologic: prolonged oxytocin, magnesium sulfate, halogenated anesthetics, nifedipine

— Infection: chorioamnionitis

— Anatomic: fibroids, uterine anomalies

— Tx: uterotonics → tamponade → compression sutures → devascularization → hysterectomy

— Lacerations: cervical (especially with operative vaginal delivery), vaginal sulcus tears, perineal extensions, periurethral

— Hematomas: vulvar, vaginal, retroperitoneal, broad ligament — present with pain disproportionate to visible bleeding and falling Hct

— Uterine rupture: prior CS scar, induction with oxytocin or misoprostol post-CS, obstructed labor — fetal bradycardia, loss of station, hemoperitoneum

— Uterine inversion: excessive cord traction, fundal pressure — vasovagal shock + mass at introitus

— Tx: Repair under adequate exposure and anesthesia; embolization for hematomas; laparotomy for rupture

— Retained placenta (>30 min third stage), succenturiate or accessory lobe, placenta accreta spectrum (accreta–increta–percreta)

— Retained products of conception — common cause of secondary PPH

— Tx: Manual extraction, controlled curettage (suction preferred over sharp), hysteroscopic removal; hysterectomy for accreta

— Inherited: vWD, hemophilia carriers, platelet function disorders

— Acquired: DIC (abruption, AFE, sepsis, IUFD, HELLP), dilutional, anticoagulant-related, ITP

— Tx: Replace specific deficit; treat underlying trigger

Board pearl: A firm, well-contracted uterus + persistent bright red bleeding points to trauma. Firm uterus + oozing from multiple sites + abnormal labs points to thrombin. Boggy uterus points to tone. Placental fragments visible or boggy uterus refractory to all uterotonics points to tissue. This four-way mental triage drives every PPH stem.

Tone (atony) — 70–80%:

Trauma — 20%:

Tissue — 10%:

Thrombin (coagulopathy) — 1%:

Key Differentials — Other-Category Mimics and Distractors

— Fever >38°C, uterine tenderness, foul-smelling lochia, leukocytosis — typically days 2–7 postpartum

— Can coexist with or trigger DIC and secondary PPH from subinvolution

— Tx: IV antibiotics (clindamycin + gentamicin ± ampicillin or piperacillin-tazobactam); continue until afebrile 24–48 h

— Triad: sudden hypoxia, hemodynamic collapse, DIC during labor or within 30 min of delivery

— Often mistaken for PE, anaphylaxis, eclampsia, or anesthetic complication

— Tx: Supportive — intubation, vasopressors, MTP, ECMO; mortality 20–40%

— Postpartum is highest VTE-risk period; presents with dyspnea, tachycardia, pleuritic chest pain — not with vaginal bleeding, but can mimic shock state

— CTPA is study of choice; anticoagulation must be balanced against bleeding risk

— Cause of secondary PPH at 1–2 weeks — abnormally large, soft uterus with brisk bleeding; ultrasound may be unremarkable

— Tx: uterotonics, sometimes D&C

— Persistent or rising β-hCG postpartum, irregular bleeding weeks to months later

— Always send β-hCG in secondary PPH

— Rare; presents with intermittent heavy bleeding refractory to standard therapy

— Color Doppler ultrasound shows tangle of vessels; treat with embolization

Key distinction: Secondary PPH (24 h–12 weeks) demands a broader differential than primary PPH — always send β-hCG, CBC, coags, fibrinogen, pelvic ultrasound, and consider endometritis, RPOC, subinvolution, GTD, AVM, and inherited bleeding disorders.

Postpartum sepsis / endometritis:

Amniotic fluid embolism (AFE):

Pulmonary embolism:

Subinvolution of placental site:

Gestational trophoblastic disease (postmolar bleeding or choriocarcinoma):

Uterine arteriovenous malformation:

Cervical or vaginal cancer: Bleeding that doesn't match obstetric trajectory — biopsy any suspicious lesion noted on speculum exam.

Secondary Prevention, Discharge Medications, and Long-Term Plan

— Iron repletion: Oral ferrous sulfate 325 mg daily or every other day (better absorption); IV iron sucrose or ferric carboxymaltose if Hgb <7 or intolerant to PO

— Transfusion threshold: Hgb <7 in stable patient, <8 if symptomatic or cardiac comorbidity. Avoid over-transfusion — many patients tolerate Hgb 7–8 with oral/IV iron and recover well

— VTE prophylaxis: Restart mechanical (SCDs) immediately, pharmacologic (LMWH 40 mg daily) within 12–24 h of bleeding control — postpartum patients with PPH are at especially high VTE risk

— Continue uterotonic infusion 12–24 h after stabilization in atony cases

— Oral iron × 3–6 months with Hgb recheck

— Stool softener (iron-induced constipation)

— Acetaminophen-based analgesia; avoid NSAIDs in patients with vWD or significant renal injury, otherwise NSAIDs are acceptable and useful

— Prophylactic antibiotics if balloon tamponade was used or operative intervention (cefazolin or doxycycline regimens)

— Contraception counseling (see chunk 16)

— Document the PPH event clearly in the chart for future pregnancies — recurrence risk 15%+

— Refer to hematology for any unexplained or recurrent PPH for inherited bleeding disorder workup at 6–8 weeks postpartum (when factor levels normalize)

— Sheehan syndrome screening: Check prolactin, TSH/free T4, AM cortisol, FSH/LH at 6-week visit in patients with severe PPH or failure to lactate

— Mental health: Screen for postpartum depression and PTSD at 2 and 6 weeks, with referral for any positive screen

Step 3 management: Every patient discharged after PPH gets (1) oral or IV iron, (2) VTE prophylaxis plan, (3) clearly documented PPH history, (4) a follow-up appointment within 1–2 weeks, and (5) postpartum depression screening — these are five distinct discrete scoring opportunities.

In-hospital recovery (post-stabilization):

Discharge medications:

Long-term:

Follow-Up, Monitoring, and Counseling

— Initial contact within 3 weeks of birth (phone, telehealth, or in-person) — accelerated to 3–7 days for women with PPH, hypertensive disorders, diabetes, or significant comorbidity

— Comprehensive postpartum visit by 12 weeks — physical, mental health, contraception, chronic disease optimization

— CBC at 1–2 weeks and 6 weeks to track Hgb recovery and adjust iron therapy

— Reticulocyte count if response inadequate

— Ferritin to confirm iron repletion before stopping therapy (target >50 ng/mL)

— Pelvic exam to confirm uterine involution; ultrasound only if persistent bleeding

— Discuss interpregnancy interval — ≥18 months recommended; <6 months associated with recurrence and adverse outcomes

— LARC (IUD, implant) ideal — can be placed immediately postpartum or at 6-week visit

— Combined estrogen-containing contraceptives: avoid until ≥21 days postpartum (VTE risk); 42 days if other VTE risk factors; breastfeeding women — progestin-only preferred until milk supply established (~6 weeks)

— Document and inform patient of PPH cause and recurrence risk

— Refer to MFM preconceptionally if accreta spectrum, recurrent PPH, or inherited bleeding disorder

— Plan delivery at appropriate level facility

— Pelvic floor PT for severe perineal trauma or operative deliveries

— Gradual return to activity; avoid heavy lifting × 6 weeks

— Lactation support — Sheehan syndrome must be on the differential if breastfeeding fails after severe PPH

Board pearl: A patient who had massive PPH and cannot initiate lactation at the 1-week visit needs immediate endocrine workup for Sheehan syndrome — don't attribute it to stress or fatigue. Untreated panhypopituitarism causes adrenal crisis with the next stressor.

Postpartum visit schedule (per ACOG 2018 redesign):

Specific monitoring after PPH:

Contraception counseling after PPH:

Counseling for future pregnancies:

Rehab and recovery:

Ethical, Legal, and Patient Safety Considerations

— Antepartum: discuss PPH risk, transfusion, hysterectomy, and IR options with all high-risk patients (placenta previa/accreta, prior PPH, bleeding disorders) — document specifically

— Intrapartum emergencies: if patient lacks capacity due to hemodynamic instability, two-physician emergency consent is acceptable for life-saving intervention; document the medical necessity carefully

— Hysterectomy consent: explicitly discuss loss of fertility — required when feasible, but life over fertility is the ethical standard in true emergencies

— Document specific products accepted/refused antepartum with patient signature; many accept albumin, cell salvage, recombinant factors, fractionated derivatives

— Court orders generally not granted for competent adults refusing blood, even when life-threatening

— Plan: optimize antepartum iron stores, cell salvage at delivery, aggressive TXA, early surgical control, fibrinogen concentrate (recombinant, not pooled)

— Maternal "near-miss" (severe maternal morbidity per CDC criteria — any transfusion ≥4 units, ICU admission, hysterectomy) should be reported to hospital quality and state maternal mortality review committee

— Document quantitative blood loss (QBL), timing of all interventions, team members present, and patient response — these are key in any subsequent legal review

— Highest-risk handoff is from L&D to postpartum unit or ICU — explicit verbal handoff of QBL, products given, ongoing infusions, and pending labs reduces missed deterioration

— Discharge summary must include PPH cause, products transfused, iron plan, VTE prophylaxis, and follow-up appointment — incomplete handoff to outpatient provider is a common malpractice trigger

— Black women have 3–4× higher maternal mortality in the US, with PPH a major contributor — implicit bias and delayed recognition are documented contributors. Use objective, protocol-driven triggers (QBL, shock index) rather than clinician gestalt to reduce disparity.

Step 3 management: Implementing a standardized PPH bundle and structured handoff is the single highest-yield system-level intervention to reduce both mortality and disparities.

Informed consent in the bleeding patient:

Jehovah's Witness and other refusal of blood products:

Mandatory reporting and documentation:

Transition-of-care risks (Step 3 favorite):

Health disparities:

High-Yield Associations and Rapid-Fire Facts

— Methylergonovine: HTN, preeclampsia, CAD, Raynaud's

— Carboprost: asthma

— Misoprostol: essentially none in PPH (safe in HTN and asthma)

Board pearl: If the stem mentions "placenta delivered intact, firm uterus, but ongoing bright red bleeding" — the answer is inspect the cervix and vagina for lacerations, not another dose of oxytocin.

Most common cause of PPH overall: uterine atony

Most common cause of secondary (late) PPH: retained products of conception

Most common inherited bleeding disorder unmasked by PPH: von Willebrand disease

Single most useful lab for predicting severe PPH: fibrinogen (<200 mg/dL = bad)

Single drug shown to reduce PPH mortality if given within 3 hours: tranexamic acid (WOMAN trial)

Drug contraindications to memorize:

Sheehan syndrome: first sign = failure to lactate; full panhypopituitarism — replace cortisol before levothyroxine to avoid adrenal crisis

Uterine inversion treatment: stop uterotonics, give uterine relaxant (NTG, terbutaline, halothane), manually replace, then resume uterotonics

Placenta accreta spectrum risk: previa + each prior CS multiplies risk (3% with 1 prior, ~40% with 3 prior + previa)

Active management of third stage (oxytocin + controlled cord traction + fundal massage) reduces PPH by ~50%

Shock index ≥1.0 in postpartum patient = call for help and activate stage 2 response

Massive transfusion ratio: PRBC:FFP:platelets = 1:1:1

Calcium chelation: Every 4 units of PRBC → check ionized Ca²⁺

Recurrence risk of PPH in next pregnancy: ~15%

Most common cause of maternal mortality worldwide: hemorrhage

Most common cause of maternal mortality in the US: cardiovascular conditions overall, but hemorrhage is the most preventable

TRALI: most common cause of transfusion-related death

Postpartum VTE prophylaxis: restart within 12–24 h after hemorrhage controlled

Combined OCPs postpartum: wait ≥21 days (≥42 if other VTE risk factors)

Quantitative blood loss (QBL) is now the standard — visual estimation underestimates by 30–50%

Tamponade test: balloon stops bleeding → high likelihood of avoiding surgery

Board Question Stem Patterns

"G4P4 delivers a 4.2 kg infant after 18 hours of oxytocin-augmented labor. 20 minutes after delivery, she has continued vaginal bleeding with EBL 1200 mL. Uterus is soft and palpable above the umbilicus."

→ Best next step: Bimanual uterine massage + increase oxytocin infusion. Not methergine first if patient has HTN; not carboprost first if asthmatic.

"Forceps-assisted delivery; 30 min postpartum, EBL 1500 mL, uterus firm, ongoing bright red bleeding."

→ Answer: Inspect cervix and vagina under adequate light/anesthesia for lacerations.

"Patient with severe preeclampsia delivers vaginally. Postpartum she has oozing from IV sites and episiotomy, fibrinogen 110, platelets 60, INR 1.8."

→ Answer: Activate massive transfusion (1:1:1) with priority on cryoprecipitate/fibrinogen concentrate; treat HELLP.

"During controlled cord traction, the patient develops sudden hypotension and bradycardia with massive bleeding; fundus is not palpable abdominally, mass at introitus."

→ Answer: Stop uterotonics, give nitroglycerin or terbutaline, manually replace uterus, then restart uterotonics.

"10 days postpartum, heavy vaginal bleeding, mild cramping, afebrile."

→ Answer: Pelvic ultrasound for retained products; consider misoprostol or D&C; check CBC, coags, β-hCG.

"6 weeks after severe PPH requiring 8 units PRBC, patient reports inability to breastfeed, fatigue, cold intolerance."

→ Answer: Check prolactin, TSH/free T4, AM cortisol, FSH/LH; start hydrocortisone before levothyroxine.

"Second PPH with this delivery; she reports lifelong heavy menses and easy bruising."

→ Answer: vWD workup (vWF antigen, ristocetin cofactor, factor VIII) at 6–8 weeks postpartum.

"G3P2 with 2 prior CS, current pregnancy complicated by complete previa."

→ Answer: Schedule cesarean hysterectomy at 34–35 weeks at level III/IV center with MFM, IR, anesthesia, blood bank.

CCS pearl: On the CCS, the first-screen orders that virtually always score are: IV ×2 large-bore, NS bolus, CBC, type and crossmatch, coags, fibrinogen, oxytocin infusion, bimanual massage, Foley catheter, and consult OB. Add TXA when EBL >1000 mL.

Stem 1 — Classic atony:

Stem 2 — Trauma masquerading as atony:

Stem 3 — Coagulopathy:

Stem 4 — Uterine inversion:

Stem 5 — Delayed PPH:

Stem 6 — Sheehan syndrome:

Stem 7 — Recurrent PPH with menorrhagia history:

Stem 8 — Placenta accreta:

One-Line Recap

Postpartum hemorrhage is a time-critical diagnosis driven by the 4 T's (Tone, Trauma, Tissue, Thrombin) where parallel resuscitation, protocol-driven stage-based escalation, early TXA within 3 hours, and decisive surgical or interventional control save lives.

Board pearl: When in doubt on exam day — massage, oxytocin, TXA, type and cross, call for help — five answers that are almost never wrong as a first move in a PPH stem.

The clinical pivot: Boggy uterus = atony (massage + oxytocin → methergine → carboprost → misoprostol); firm uterus + bleeding = trauma (inspect, repair) or thrombin (replace products, treat trigger); refractory bleed = balloon → compression sutures → embolization → hysterectomy.

The lab pivot: Fibrinogen <200 mg/dL is the single most predictive marker of severe PPH; replace with cryoprecipitate or fibrinogen concentrate; check ionized calcium every 4 units PRBC; transfuse in 1:1:1 ratio during massive transfusion.

The drug pivot: Oxytocin always first; methergine avoided in HTN/preeclampsia; carboprost avoided in asthma; misoprostol always usable; TXA 1 g IV within 3 hours reduces mortality (WOMAN trial); calcium gluconate for citrate-induced hypocalcemia.

The longitudinal pivot: After stabilization — iron repletion, VTE prophylaxis, postpartum depression screening, contraception counseling with attention to VTE timing, MFM referral for next pregnancy, Sheehan syndrome workup if lactation fails, vWD workup if recurrent or unexplained, structured handoff to outpatient care within 1–2 weeks, and documentation of QBL and intervention timing for quality review.