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Bleeding postpartum

Specialties > Obstetrics

Differential Diagnosis Schema 🧠

Tone

  • Uterine atony: The most common cause of postpartum haemorrhage (PPH); uterus is soft and boggy on examination.
  • Uterine inversion: May occur following excessive traction on the umbilical cord; often presents with shock out of proportion to blood loss.

Tissue

  • Retained placenta: Presence of retained placental tissue can prevent the uterus from contracting properly.
  • Placenta accreta: Abnormal attachment of the placenta to the uterine wall, making separation difficult.

Trauma

  • Genital tract lacerations: Includes vaginal, cervical, or perineal tears; often associated with instrumental delivery or macrosomia.
  • Uterine rupture: A rare but life-threatening condition, usually in women with a previous uterine scar (e.g., from caesarean section).

Thrombin

  • Coagulopathies: Includes conditions such as disseminated intravascular coagulation (DIC), which may occur in severe preeclampsia, sepsis, or amniotic fluid embolism.
  • HELLP syndrome: A variant of preeclampsia with haemolysis, elevated liver enzymes, and low platelets.

Key Points in History 🥼

Onset of Bleeding

  • Immediate postpartum: Suggests uterine atony, genital tract trauma.
  • Delayed postpartum (after 24 hours): May indicate retained products of conception or infection.

Quantity and Nature of Blood Loss

  • Heavy, bright red bleeding: Typically suggests atony or trauma.
  • Persistent, light bleeding: May suggest coagulopathy or retained tissue.

Associated Symptoms

  • Pain: Severe pain may indicate uterine rupture or inversion.
  • Fever: Suggests infection such as endometritis.
  • Dizziness, weakness: May indicate significant blood loss and hypovolemia.

Background

  • Past obstetric history: Previous postpartum haemorrhage or caesarean section may increase risk.
  • Drug history: Use of anticoagulants or tocolytics may predispose to bleeding.
  • Family history: Conditions such as hereditary bleeding disorders.
  • Social history: Risk factors such as smoking or substance abuse.

Possible Investigations 🌡️

Laboratory Tests

  • Full blood count (FBC): To assess haemoglobin levels and platelet count.
  • Coagulation profile: Includes PT, APTT, and fibrinogen levels to identify coagulopathies.
  • Crossmatch: For blood transfusion if necessary.

Imaging

  • Ultrasound: To check for retained products of conception or uterine abnormalities.
  • CT/MRI: May be required in cases of suspected uterine rupture or deep pelvic hematomas.

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Obstetrics