Postpartum Hemorrhage

What is the quantitative definition of Postpartum Hemorrhage (PPH) for vaginal and cesarean deliveries?

Blood loss > 500 cc for a vaginal delivery, and > 1,000 cc for a cesarean delivery (or any loss causing hemodynamic instability).

What is the timeline distinction between Primary and Secondary Postpartum Hemorrhage?

Primary PPH: Occurs within 24 hours of delivery.Secondary PPH: Occurs after 24 hours of delivery.

What are the "4 Ts" that represent the main pathophysiological causes of Postpartum Hemorrhage?

Tone (Uterine Atony)Trauma (Lacerations, Inversion)Tissue (Retained products of conception)Thrombin (Coagulopathy/DIC).

What is the single most common cause of Postpartum Hemorrhage?

Uterine Atony (Tone).

Why are both prolonged labor AND rapid (precipitous) labor considered major risk factors for uterine atony?

Prolonged labor: Exhausts the uterine muscle (especially with oxytocin use), leading to a lax uterus.Rapid labor: Involves extremely strong contractions that subsequently fail to relax properly.

If a patient presents with heavy postpartum bleeding but physical examination reveals a firmly contracted uterus, what is the most likely cause?

Trauma (genital tract lacerations, cervical tears, or vaginal hematomas).

What physical examination findings strongly suggest "Tissue" (retained products of conception) as the cause of PPH?

A contracted uterus accompanied by a placenta with missing cotyledons (indicating a piece of the placenta or an accessory lobe remains inside).

What is the immediate, first-line mechanical management for PPH caused by uterine atony?

Bimanual uterine massage.

Which uterotonic medication used for PPH is strictly contraindicated in patients with Hypertension or Preeclampsia?

Methergine (Methylergometrine), because it causes severe vasoconstriction and can trigger acute hypertensive crises or stroke.

Which uterotonic medication used for PPH is strictly contraindicated in patients with Asthma?

Hemabate (Carboprost / Prostaglandin F2-alpha), because it can trigger severe bronchospasm.

What are the surgical or mechanical step-up options for managing severe uterine atony that fails to respond to medical therapy?

1. Bakri balloon tamponade2. B-Lynch compression sutures3. Arterial embolization4. Ligation of the uterine or internal iliac arteries5. Hysterectomy (as a life-saving last resort).

A patient develops PPH with generalized oozing from IV sites and petechiae following a severe placental abruption. What is the "T" category, and how is it managed?

Thrombin (Obstetric DIC). Management involves removing products of conception, ICU care, and rapid transfusion of blood products (FFP, cryoprecipitate, platelets).

What common intrapartum complication caused by premature rupture of membranes (PROM) is a major risk factor for uterine atony?

Chorioamnionitis (intra-amniotic infection impairs the myometrium's ability to contract effectively).