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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