Postpartum Hemorrhage

Postpartum Hemorrhage
Anne Kennedy, MD
DIFFERENTIAL DIAGNOSIS
Common
  • Uterine Atony
  • Intrauterine Blood Clot
  • Retained Products of Conception
Less Common
  • Placenta Accreta Spectrum
  • Uterine Dehiscence/Rupture
  • Endometritis
Rare but Important
  • Gestational Trophoblastic Disease
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
  • Primary postpartum hemorrhage (PPH) is defined as loss of > 500 mL of blood within 24 hours of delivery
    • Vulval/vaginal lacerations are managed clinically & do not require imaging
    • Retained placenta diagnosed by inspection of delivered placenta
      • Managed with manual evacuation or immediate curettage; imaging does not play a major role in diagnosis
  • Secondary PPH is defined as abnormal bleeding from the genital tract, from 24 hours after delivery until 6 weeks postpartum
  • Risk factors
    • Antepartum hemorrhage in current pregnancy
    • Placenta previa (15x risk)
    • Multiple pregnancy (5x risk)
    • Pre-eclampsia
    • Cesarean section (9x risk for emergency, 3x risk for elective)
  • Important to differentiate conditions requiring surgical intervention from others
    • Most cases of retained products of conception (RPOC) are managed with dilation & curettage (D&C)
    • Intrauterine clot, without RPOC, managed conservatively
    • Endometritis may require hospitalization & intravenous antibiotics
    • Gestational trophoblastic disease (GTD) requires D&C ± chemotherapy, radiation therapy
  • Remember that it is normal to have some blood & air within the uterus in the puerperium
    • In one study, 21% of healthy women had gas visible up to 3 wks after uncomplicated spontaneous vaginal delivery
    • In another study, 64% of healthy women requesting sterilization had intrauterine blood on CT at 24 hours postpartum
    • Uterine involution takes 6-8 weeks for uterus to return to normal size
Helpful Clues for Common Diagnoses
  • Uterine Atony
    • Uterus does not contract after delivery of placenta
    • Immediate postpartum event treated with massage, Pitocin, other uterotonic medications
    • May necessitate emergency hysterectomy for control of bleeding
    • Imaging generally not performed
    • Increased risk with multiparity, excessive uterine distension (multiple gestation, polyhydramnios)
  • Intrauterine Blood Clot
    • Hypoechoic material in endometrial cavity
    • No perfusion to endometrial contents
  • Retained Products of Conception
    • Mass in endometrial cavity
      • Echogenic material much more suspicious for RPOC than hypoechoic
    • Use color Doppler to look for perfusing vessels from myometrium
      • Echogenic material with feeding vessels highly suggestive of RPOC, but lack of flow does not exclude the diagnosis
Helpful Clues for Less Common Diagnoses
  • Placenta Accreta Spectrum
    • Abnormal penetration of placental tissue beyond endometrial lining of uterus
    • Placenta fails to separate after delivery with potentially catastrophic bleeding
      • If diagnosis made prior to onset of labor, delivery is planned in tertiary center with neonatal intensive care, appropriate subspecialty surgeons alerted, blood banked
    • Strong association with placenta previa & prior C-section
    • For preemptive diagnosis, maintain high level of suspicion and look for
      • Loss of normal subplacental hypoechoic zone
      • Abnormal placental lacunae: “Swiss cheese” placenta or “tornado” vessels
      • Interruption in bright reflector of bladder mucosa
      • Large vessels or nodularity in bladder wall
  • Uterine Dehiscence/Rupture
    • Dehiscence or rupture most common at site of cesarean hysterotomy
    • Most commonly occurs in labor
      • Surgical emergency with high maternal morbidity & potential fetal demise
      • Imaging rarely performed
    • Delayed rupture presents with pain, bleeding
      • Look for defect in myometrium
      • Often clot in the defect in continuity with intrauterine fluid
  • Endometritis
    • Generally a clinical diagnosis based on combination of fever, pelvic pain, elevated white cell count, & tender “boggy uterus” in a patient with PPH
    • Imaging findings of endometritis are nonspecific and overlap with normal postpartum state & RPOC
      • Uterus often large
      • Increase flow on Doppler typical, but not always present (lack of flow does not rule out endometritis)
      • Mixed echogenicity material in cavity (may have coexistent RPOC)
      • Bright echoes in cavity from gas
      • May appear normal & still have clinical endometritis
    • More common after C-section than after vaginal birth
    • May be complicated by ovarian vein thrombosis
Helpful Clues for Rare Diagnoses
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Aug 10, 2016 | Posted by in OBSTETRICS | Comments Off on Postpartum Hemorrhage

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