🔑 Key Learning

  • Defined as blood loss > 500 mL after vaginal delivery or > 1000 mL after caesarean section.
  • Primary PPH occurs within 24 hours; secondary PPH occurs between 24 hours and 12 weeks postpartum.
  • Common causes summarised as the four Ts: Tone, Trauma, Tissue, Thrombin.
  • Management includes resuscitation, uterotonic agents, and possible surgical intervention.

🧬 Primary PPH

👀 Clinical Features

  • Heavy vaginal bleeding within 24 hours postpartum.
  • Uterus may feel soft or ‘boggy’.
  • Signs of hypovolaemia: pallor, hypotension, tachycardia.
  • Symptoms may arise during or shortly after third stage of labour.

💥 Causes: The Four Ts

  • Tone: Uterine atony (most common)
  • Trauma: Perineal or vaginal tears
  • Tissue: Retained placenta
  • Thrombin: Coagulopathy (e.g. DIC)

🧪 Investigations

  • Clinical diagnosis based on visible blood loss and maternal observations.
  • FBC, coagulation screen, group and save or crossmatch.
  • Consider bedside clot observation (for coagulopathy).
  • USS if retained tissue suspected.

💊 Management

  • A–E approach and immediate resuscitation.
  • Mechanical: bimanual uterine massage.
  • Medical:
    • IV oxytocin
    • IV ergometrine (avoid in hypertension)
    • IM carboprost (avoid in asthma)
    • Sublingual misoprostol
    • Tranexamic acid (if < 3 hours since bleeding started)
  • Surgical:
    • Intrauterine balloon tamponade
    • Uterine artery embolisation or ligation
    • Hysterectomy if bleeding uncontrolled

🧬 Placenta Accreta

Implantation of the placenta beyond the endometrium, and into the myometrium resulting in great difficulty separating the placenta during delivery --> PPH

👀 Clinical Features

  • Difficult placental delivery
  • Significant PPH unresponsive to routine management
  • Known risk factors: previous caesarean section, placenta praevia

🧪 Diagnosis

  • Antenatal detection via transvaginal ultrasound

💊 Management

  • Planned caesarean section
  • Uterus-preserving surgery or hysterectomy

💧 Secondary PPH

👀 Clinical Features

  • Vaginal bleeding occurring from 24 hours to 12 weeks after delivery
  • May be associated with:
    • Fever
    • Uterine tenderness
    • Foul-smelling lochia

💥 Causes

  • Endometritis
    • Suggested by foul-smelling discharge, PV bleeding, abdominal pain, fever
  • Retained products of conception

🧪 Investigations

  • Pelvic ultrasound to assess for retained products
  • High vaginal/cervical swabs
  • FBC and CRP if infection suspected

💊 Management

  • Empirical antibiotics for suspected endometritis
  • Surgical evacuation if retained products are confirmed

📝 Exam Clues & Clinchers

  • Sudden heavy bleeding after delivery → think uterine atony.
  • Boggy uterus on palpation → massage + IV oxytocin.
  • Delayed bleeding + offensive lochia + fever → suspect endometritis.
  • Placenta accreta suspected in woman with prior caesarean and difficult placenta separation.

🔗 Useful Links and References

RCOG Green-top Guideline No. 52. Prevention and Management of PPH. https://obgyn.onlinelibrary.wi...