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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Postpartum hemorrhage is excessive bleeding after birth; uterine atony is the most common cause
- Four Ts: Tone, Trauma, Tissue, Thrombin
- First steps: call for help, uterine massage, IV access, labs/type-cross, oxytocin, quantify blood loss
- Methylergonovine is contraindicated in hypertension; carboprost is contraindicated in asthma
- Tranexamic acid should be given early for significant PPH, ideally within 3 hours
Overview
Postpartum hemorrhage is a leading cause of preventable maternal death. Modern definitions emphasize cumulative blood loss >=1000 mL or bleeding with hypovolemia, but treatment should start earlier for brisk bleeding or instability.
Epidemiology
Risk increases with uterine overdistension, prolonged labor, chorioamnionitis, magnesium sulfate, high parity, operative delivery, retained placenta, previa/accreta, and coagulopathy. Many cases occur without risk factors.
Clinical Features
Symptoms
Heavy vaginal bleeding after delivery
Lightheadedness, syncope, dyspnea, chest discomfort
Severe pelvic pain suggests hematoma or rupture
Persistent bleeding despite firm uterus suggests laceration/tissue/coagulopathy
Delayed bleeding days-weeks postpartum suggests retained products/subinvolution
Signs
Boggy enlarged uterus = atony
Firm uterus with bleeding = trauma, tissue, thrombin
Tachycardia, hypotension, pallor, altered mental status
Expanding vulvovaginal hematoma
Oozing from IV sites suggests DIC
Investigations
First-line
Quantified blood loss and vitalsMonitor HR, BP, oxygen saturation, mental status, urine output
Focused bedside examAssess uterine tone, placenta completeness, lacerations, hematoma
CBC, type/crossmatch, coags, fibrinogenGuide transfusion and detect DIC
Second-line
Bedside ultrasoundAssess retained products or intrauterine clot
ABG/lactateConsider in shock or massive transfusion
CMP and calciumMonitor metabolic complications during massive transfusion
Specialist
Massive transfusion protocolActivate early for ongoing major hemorrhage
IR or operative evaluationUterine artery embolization in selected stable patients; laparotomy/hysterectomy if uncontrolled
1
Immediate response
- Call obstetric hemorrhage team
- Fundal massage and bimanual compression for atony
- Two large-bore IVs, oxygen as needed, Foley, labs/type-cross
- Start oxytocin and resuscitate with fluids/blood products
2
Uterotonics
- Oxytocin first-line
- Methylergonovine IM; avoid in hypertension/preeclampsia
- Carboprost IM; avoid in asthma
- Misoprostol as adjunct or where other agents unavailable
3
Adjuncts/escalation
- Tranexamic acid 1 g IV early, ideally within 3 hours
- Remove retained tissue/clots
- Repair lacerations
- Balloon tamponade for persistent atony
- Compression sutures, artery ligation, embolization, or hysterectomy if persistent
4
Coagulopathy
- Activate massive transfusion for severe bleeding
- Replace RBCs, plasma, platelets, fibrinogen/cryoprecipitate as needed
- Treat DIC from abruption, sepsis, fetal demise, or HELLP
Complications
- Hemorrhagic shock: Can progress rapidly after delivery
- DIC: Especially with abruption, sepsis, fetal demise, HELLP
- Sheehan syndrome: Pituitary infarction causing failure to lactate and amenorrhea
- Transfusion complications: Hypocalcemia, hypothermia, coagulopathy
- Emergency hysterectomy: Life-saving but causes infertility
USMLE Step 2 CK Exam Tips
- 1Most common cause of PPH = uterine atony
- 2Boggy uterus = massage + oxytocin
- 3Firm uterus with bleeding = laceration until proven otherwise
- 4Four Ts: Tone, Trauma, Tissue, Thrombin
- 5Methylergonovine contraindication = hypertension
- 6Carboprost contraindication = asthma
- 7Failure to lactate after severe PPH = Sheehan syndrome
- 8TXA most useful within 3 hours
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