eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pregnancy, Postpartum Hemorrhage: Differential Diagnoses & Workup

Author: Maame Yaa A B Yiadom, MPH, MD, Staff Physician, Department of Emergency Medicine, Brigham and Women's Hospital and Massachusetts General Hospital
Coauthor(s): Daniela Carusi, MSc, MD, Instructor, Obstetrics and Gynecology and Reproductive Biology, Harvard Medical School; Consulting Physician, Department of Obstetrics and Gynecology, Medical Director, Department of General Ambulatory Gynecology, Brigham and Women's Hospital
Contributor Information and Disclosures

Updated: Oct 21, 2009

Differential Diagnoses

Endometritis

Other Problems to Be Considered

Endometritis: Consider uterine infection, or endometritis, particularly with late postpartum hemorrhage. Signs and symptoms that should peak the clinical suspicion for this diagnosis include fever, chills, foul discharge, tender abdomen/uterus, and elevated WBC count with a differential favoring bacterial infection (neutrophilia with or without bands). Start early broad-spectrum antibiotic coverage and consider sepsis.

Wound breakdown: Internal wound breakdown from repaired genital tract lacerations or previously closed cesarean delivery incisions should be considered as a potential cause of vaginal bleeding, internal bleeding, or hematoma.

Genital tract manipulation: Genital tract lacerations may be induced by intercourse, finger penetration, or foreign object insertion (including tampons) into the genital tract.

Nongenital sources of bleeding: Birth trauma may lead to retroperitoneal hematomas, which may be initially difficulty to identify. Women who have undergone cesarean delivery may have an abdominal wall or subfacial hematoma. Rarely, HELLP syndrome can produce life-threatening bleeding into and rupture of the liver capsule, and this should be suspected in the setting of severe epigastric or right upper quadrant pain. Ruptured splenic artery aneurysms have been reported in pregnancy as well. 

Workup

Laboratory Studies

  • Complete blood count (CBC)
    • The hemoglobin and hematocrit are helpful in estimating blood losses. However, in a patient with acute hemorrhage, several hours may pass before these levels change to reflect the blood loss and platelet count.
    • If the white blood cell count is elevated, suspect endometritis or toxic shock syndrome.
    • Look for thrombocytopenia.
  • Coagulation laboratory studies: Elevations of the prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) can indicate a present or developing coagulopathy.
  • Electrolytes: Check for complicating electrolyte derangements such as a hypocalcemia, hypokalemia, and hypomagnesemia. Use this first set as a baseline for comparison during and after fluid and/or blood resuscitation.
  • BUN/creatinine: These measurements can be helpful in identifying renal failure as a complication of shock. If the BUN level rises during or after resuscitation with blood products, consider red blood cell hemolysis as a complication.
  • Type and crossmatch: Begin the process of finding appropriately matched blood for resuscitation in the event that it is needed.
  • Fibrinogen level: Levels are normally elevated to 300-600 mg/dL in pregnancy. Normal or low values raise concerns for a consumptive coagulopathy.
  • Liver function tests (LFTs), amylase, lipase: These studies can be helpful in considering other abdominal pathology, such as HELLP syndrome, if there is abdominal pain in addition to, or instead of, uterine tenderness.
  • Lactate: Consider ordering this if the initial electrolyte study shows an anion gap or septic or hypovolemic shock is suspected as a concomitant diagnosis.

Imaging Studies

Studies to be considered with vaginal bleeding and decreasing red blood cell counts in the postpartum patient include ultrasonography (U/S), computed tomography (CT), or magnetic resonance imaging (MRI).

Ultrasonography is a fast and helpful modality for imaging pelvic structures and should be the first-line study for pelvic pathology.

Ultrasonography

In a hemodynamically unstable patient, a bedside ultrasonography can be performed by an experienced emergency medicine provider as an extension of the physical examination. In general, a dedicated pelvic ultrasonography (transabdominal and/or transvaginal) is helpful in identifying large retained placental fragments, hematomas, or other intrauterine abnormalities. Retained placenta and hematoma can look ultrasonographically identical. Using a Doppler ultrasound to look for vascularity can help to differential between the two, with clots being avascular and retained placenta often receiving persistent blood flow from the uterus.

The abdominal views of the focused assessment with sonography in trauma (FAST) examination are helpful in identifying fluid within the peritoneum that may be the result of hemorrhage. This study is designed to identify intra-abdominal and pericardial fluid that requires early operative intervention in trauma patients. However, the abdominal views are useful in any patient with suspected intra-abdominal free fluid. These include views of the right upper quadrant (RUQ)/Morison's pouch area (the most dependent area of a supine patient's peritoneal cavity), the left upper quadrant (LUQ) spleno-renal recess, and views of the pelvis (sagittal and coronal views of the uterus and pouch of Douglas). This study can detect 250-500 mL of fluid in the peritoneum, but it is a poor study for identifying retroperitoneal or paravaginal hemorrhage (extra-peritoneal bleeding).

Ultrasonography cannot reliably differentiate between blood, urine, or ascites; however, in the setting of suspected hemorrhage, any fluid in the abdomen should prompt further investigation.

More stable patients can have their abdominal and/or pelvic ultrasonography confirmed with an official study performed by a radiologist.

Computed tomography
In the event that ultrasonography is not diagnostic, CT is a helpful follow-up study. This may also be the first-line study when a pelvic hematoma or abscess is suspected, which may be missed with a sonogram. The traditional teaching is that pelvic CT is a less than ideal study for pelvic structures, due to artifact from the surrounding pelvic bones that reduces the image quality. However, this is generally not the case with modern multidetector CT studies. When enhanced with intravenous (I+) and intra-intestinal (O/R+...either oral or rectal contrast), CT can detail pelvic hematomas, cesarean delivery wound dehiscence, and retained placental tissue.

Magnetic resonance imaging
MRI is a time consuming study that is rarely performed from the ED in these patients. It can be helpful in delineating tissue planes to determine if a fluid collection (hematoma or abscess) is intrauterine or extrauterine when this is not clear from ultrasonography or CT. It can also help to distinguish a placenta accreta from simple retained products of conception.

Limited literature is available on abdominopelvic imaging in postpartum hemorrhage since the presentation of significant bleeding prompts rapid resuscitation and immediate intervention based on the clinical picture rather than documented imaging. Nonetheless, all 3 imaging modalities can assist in the evaluation of a bleeding source, but ultrasonography is usually sufficient for emergent situations.

More on Pregnancy, Postpartum Hemorrhage

Overview: Pregnancy, Postpartum Hemorrhage
Differential Diagnoses & Workup: Pregnancy, Postpartum Hemorrhage
Treatment & Medication: Pregnancy, Postpartum Hemorrhage
Follow-up: Pregnancy, Postpartum Hemorrhage
References
Further Reading
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References

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Further Reading

Postpartum Hemorrhage (PPH). Shahid M. Ahmad, Atif Farid, Demitra del Silva, Harish Kodi.

New Technologies to Save Mothers Lives from PPH. PATH/USAID.

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Keywords

postpartum hemorrhage, postpartum bleeding, PPH, bleeding after delivery, vaginal delivery, cesarean delivery, birth, giving birth, blood loss after birth, blood loss after delivery, maternal death, 4 T's, 4 Ts, tone, tissue, thrombosis, uterine atony, uterine prolapse, oxytocin, hemorrhage, coagulopathy, living ligatures, physiologic sutures, DIC, uterine inversion, maternal mortality, uterotonic, oxytocin, Pitocin, misoprostol, Cytotec, ergotamine, methylergotamine, carboprost, Hemabate, recombinant factor VIIa, retained products of conception, retained placenta, obstetrics, pelvic ultrasound, bedside ultrasound, third stage of labor, 3rd stage of labor

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Contributor Information and Disclosures

Author

Maame Yaa A B Yiadom, MPH, MD, Staff Physician, Department of Emergency Medicine, Brigham and Women's Hospital and Massachusetts General Hospital
Maame Yaa A B Yiadom, MPH, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Daniela Carusi, MSc, MD, Instructor, Obstetrics and Gynecology and Reproductive Biology, Harvard Medical School; Consulting Physician, Department of Obstetrics and Gynecology, Medical Director, Department of General Ambulatory Gynecology, Brigham and Women's Hospital
Daniela Carusi, MSc, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Reproductive Health Professionals, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Assaad J Sayah, MD, Chief, Department of Emergency Medicine, Cambridge Health Alliance
Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Medicines Company Consulting fee Consulting; Pfizer Salary Employment

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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