Diagnostic Considerations
Other conditions to consider
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.
Important considerations
Note the following important considerations:
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Active management of the third stage of labor is key to reducing the incidence and severity of postpartum hemorrhage (PPH). Be sure to perform early uterine massage and administer oxytocic agents.
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Contact an OB/GYN consultant before or upon initiating the evaluation of the patient.
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Some typical vaginal deliveries are associated with blood loss of more than 500 mL. However, emergency department personnel should assume that any patient with blood loss greater than 500 mL and ongoing bleeding has postpartum hemorrhage. Resuscitation should be started while evaluating the patient for the cause of postpartum hemorrhage.
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Always suspect occult hemorrhage (eg, hematoma, intra-abdominal) in postpartum patients who have unstable vital signs with little or no external bleeding. Consider atypical signs of hemorrhage, such as restlessness, dyspnea, and back and abdominal pain, which may be the first signs of hemorrhage in a hemodynamically stable patient.
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Early recognition of a coagulopathy and prompt administration of coagulation factors may be life saving. This may entail immediate transfusion based on clinical suspicion, rather than waiting for laboratory results to return.
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When a patient is delivered to a facility without obstetrical services, adequate resuscitation should be achieved before the patient is transferred. An en route resuscitation plan should be communicated to the transporting EMS team, and the patient's condition upon departure should be reported to the receiving providers. All institutional, state, and national regulations for patient transfer should be followed.
Special concerns
With early postpartum hemorrhage occurring right after delivery, remember that 2 patients—the mother and the newborn—require evaluation and intervention.
Because of the hemodynamic changes in pregnancy (increased blood volume and physiologic anemia), the signs and symptoms of hypovolemia may not be apparent until the hemorrhage is severe.
Differential Diagnoses
