Postpartum Haemorrhage

Postpartum haemorrhage (PPH) is the single largest cause of maternal mortality in India and worldwide. It is a true obstetric emergency where minutes matter — a confident grasp of the 4 Ts, blood-loss thresholds, the uterotonic ladder, and the surgical step-up sequence will reliably fetch you single-best-answer marks in NEET PG.

Definition & Classification

Traditionally PPH is defined as blood loss ≥ 500 mL after vaginal delivery or ≥ 1000 mL after caesarean section, occurring within 24 hours of birth. Because visual estimation chronically underestimates blood loss by 30–50%, modern (ACOG 2017 / RCOG) definitions emphasise blood loss ≥ 1000 mL OR any blood loss accompanied by signs/symptoms of hypovolaemia, regardless of route of delivery.

Parameter	Primary (Early) PPH	Secondary (Late) PPH
Timing	Within 24 h of delivery	After 24 h up to 6 (some say 12) weeks postpartum
Commonest cause	Atony (~70–80%)	Retained products of conception (RPOC) and endometritis
Other causes	Trauma, retained tissue, coagulopathy	Subinvolution of placental site, sloughing of eschar after CS
Peak incidence	Immediate	7–14 days postpartum

PPH is also graded by severity: minor (500–1000 mL) vs major (>1000 mL); major is further split into moderate (1000–2000 mL) and severe (>2000 mL).

High-yield: The cut-offs are ≥500 mL (vaginal) and ≥1000 mL (CS). The commonest cause of primary PPH = uterine atony; commonest cause of secondary PPH = retained products + infection.

Etiology — The 4 Ts

A near-universal NEET PG framework. Memorise it as the mnemonic "4 Ts" and their relative frequency.

"T"	Mechanism	Approx. share	Key examples
Tone	Uterine atony	~70%	Over-distension (twins, polyhydramnios, macrosomia), prolonged/precipitate labour, high parity, chorioamnionitis, tocolytics, halothane, retained clots
Trauma	Genital tract injury	~20%	Cervical/vaginal/perineal lacerations, episiotomy extension, uterine rupture, uterine inversion, broad-ligament/vulval haematoma
Tissue	Retained placenta/products	~10%	Retained cotyledon/succenturiate lobe, morbidly adherent placenta (accreta spectrum)
Thrombin	Coagulopathy	~1%	Abruption, amniotic fluid embolism, HELLP, DIC, sepsis, inherited (von Willebrand), anticoagulants

High-yield: Risk factors for atony cluster around an over-stretched or over-worked uterus. Always palpate the fundus first — a soft, boggy, poorly contracted uterus = atony; a firm, well-contracted uterus with ongoing bleeding = trauma. This single distinction directs your entire management.

Pathophysiology

Haemostasis after delivery depends on myometrial contraction strangling the spiral arterioles in the placental bed ("living ligatures of Pinard") far more than on the clotting cascade. Hence tone is paramount — even a perfectly normal coagulation system cannot stop bleeding from an atonic uterus. When contraction fails, the ~600–700 mL/min uteroplacental blood flow at term continues unchecked, producing catastrophic loss within minutes. Massive transfusion and consumption then precipitate a dilutional + consumptive coagulopathy, completing a vicious cycle of bleeding.

Clinical Features

• Visible per-vaginal bleeding (may be concealed in inversion, haematoma, or rupture).
• Tachycardia is the earliest sign; hypotension is late because young, healthy parturients compensate well until ~25–30% volume is lost.
• Pallor, sweating, restlessness, air-hunger, oliguria.
• Soft boggy uterus rising above the umbilicus (filling with blood/clots) in atony.
• A mass at the introitus + sudden shock out of proportion to visible bleeding → suspect acute uterine inversion.

High-yield: In a young woman, shock may be the first obvious sign because blood pressure is preserved until late. Don't wait for hypotension — act on tachycardia + estimated loss.

Investigations

PPH is a clinical diagnosis — treatment must never wait for labs. However, send in parallel:

1. Group & cross-match (arrange at least 2 units; activate massive transfusion protocol early).
2. CBC, coagulation profile — PT/aPTT, fibrinogen (the most useful early predictor; level < 2 g/L strongly predicts severe PPH).
3. Renal/liver function, calcium, lactate, ABG for resuscitation guidance.
4. Ultrasound — particularly in secondary PPH to detect retained products of conception.
5. Bedside clot test (Wiener) if lab unavailable: failure to clot in 7–10 min suggests fibrinogen < 1 g/L.

High-yield: Fibrinogen is the coagulation factor that falls first and most steeply in obstetric haemorrhage; a level < 2 g/L is the best laboratory predictor of progression to severe PPH.

Management — Stepwise Approach

Run resuscitation and identification of cause simultaneously (the "two clocks" rule).

A. Initial resuscitation (HAEMOSTASIS / "ABC")

Call for help → two wide-bore (14–16 G) IV cannulae → bloods + crossmatch → warmed crystalloid + blood → catheterise bladder → keep patient warm → identify cause.

Use the HAEMOSTASIS mnemonic for the full sequence:

• H — Ask for Help
• A — Assess (vitals, blood loss) and resuscitate
• E — Establish aetiology, Ensure uterotonics, Ensure blood availability
• M — Massage the uterus (bimanual)
• O — Oxytocin infusion / prostaglandins
• S — Shift to theatre, bimanual compression / aortic compression
• T — Tamponade (balloon) or uterine packing
• A — Apply compression sutures (B-Lynch)
• S — Systematic pelvic devascularisation (uterine/internal iliac ligation)
• I — Interventional radiology (uterine artery embolisation), if available/stable
• S — Subtotal/total hysterectomy

B. Uterotonic ("medical") ladder for atony

Drug	Dose / Route	Mechanism	Caution / Contraindication
Oxytocin (first line)	10 IU IM or 5 IU slow IV, then infusion 40 IU in 500 mL	↑ contraction frequency & force	Avoid rapid IV bolus → hypotension
Methylergometrine	0.2 mg IM/IV (slow)	Sustained tetanic contraction	Contraindicated in hypertension / pre-eclampsia / cardiac disease
Carboprost (15-methyl PGF2α)	250 µg IM/intramyometrial, q15 min, max 8 doses (2 mg)	Prostaglandin contraction	Contraindicated in asthma; causes bronchospasm, diarrhoea, fever
Misoprostol (PGE1)	800–1000 µg per rectum (or sublingual)	Prostaglandin contraction	Pyrexia, shivering; useful where injectables/cold-chain unavailable
Tranexamic acid	1 g IV over 10 min, repeat once after 30 min if bleeding continues	Antifibrinolytic	Give early (within 3 h) per WOMAN trial

High-yield (frequently tested drug pearls):

• First-line uterotonic = oxytocin.
• Methylergometrine is CONTRAINDICATED in hypertension/pre-eclampsia.
• Carboprost (PGF2α) is CONTRAINDICATED in bronchial asthma.
• Misoprostol = the prostaglandin of choice in low-resource / asthmatic settings.
• Tranexamic acid 1 g IV early reduces death from bleeding (WOMAN trial); give within 3 hours.

C. Mechanical / surgical step-up (when medical therapy fails)

The classic NEET PG escalation sequence:

Bimanual uterine compression → uterine tamponade (Bakri/condom balloon) → B-Lynch (brace) compression suture → stepwise uterine devascularisation (uterine artery ligation → ovarian/utero-ovarian → anterior division of internal iliac artery ligation) → uterine artery embolisation (if stable & available) → hysterectomy (definitive, last resort).

• Condom catheter / Bakri balloon tamponade — quick, often definitive; the "tamponade test": if bleeding stops after inflation, laparotomy may be avoided.
• B-Lynch suture (described by Christopher B-Lynch, 1997) — vertical brace sutures that mechanically compress the uterus; ideal when atony responds to bimanual compression. Other compression sutures: Hayman, Cho.
• Uterine artery ligation (O'Leary stitch) — ligates ~90% of uterine blood supply; safe and effective first surgical vascular step.
• Internal iliac (hypogastric) artery ligation — ligate the anterior division, distal to the posterior division, to preserve gluteal supply; reduces pulse pressure (converts arterial to venous-type flow). Technically demanding.
• Peripartum hysterectomy — life-saving definitive procedure; preferred over conservative measures when there is placenta accreta spectrum or uncontrollable atony. Subtotal hysterectomy is faster and usually adequate unless the cause is in the lower segment/cervix.

High-yield: For morbidly adherent placenta (accreta/increta/percreta), do NOT attempt forcible removal — proceed to planned/peripartum hysterectomy (leaving placenta in situ ± methotrexate is an alternative conservative approach in selected fertility-preserving cases).

D. Specific scenarios

• Retained placenta → manual removal under anaesthesia; if morbid adherence, hysterectomy.
• Genital tract trauma → identify and suture lacerations; evacuate and drain haematomas.
• Acute uterine inversion → immediate manual replacement (Johnson manoeuvre) before the constriction ring forms; do NOT remove the placenta first; give uterotonics only after replacement. Tocolytics (terbutaline/MgSO₄) or halothane may relax the ring; hydrostatic (O'Sullivan) method if manual fails.
• Coagulopathy → replace with FFP, cryoprecipitate (for fibrinogen), platelets; maintain fibrinogen > 2 g/L, platelets > 50,000.

Prevention — Active Management of Third Stage of Labour (AMTSL)

The single most effective PPH-prevention strategy. Components:

1. Prophylactic uterotonic — oxytocin 10 IU IM within 1 minute of delivery (drug of choice). Heat-stable carbetocin is a WHO-recommended alternative where cold-chain is poor.
2. Controlled cord traction (with counter-traction on the uterus — Brandt-Andrews).
3. Delayed cord clamping + uterine massage after placental delivery.

High-yield: The most important component of AMTSL is the prophylactic uterotonic (oxytocin); AMTSL reduces PPH risk by ~60%.

Complications

• Hypovolaemic shock, acute kidney injury (acute tubular necrosis).
• DIC from consumption + dilution.
• Sheehan syndrome — postpartum pituitary necrosis from hypotension; presents with failure of lactation (earliest), amenorrhoea, hypothyroidism, adrenal insufficiency.
• Transfusion reactions, TRALI, hypothermia, hypocalcaemia ("citrate toxicity").
• ARDS, multi-organ dysfunction; maternal death.
• Loss of fertility after hysterectomy; psychological sequelae.

Key Differentials

Presentation	Likely cause	Discriminator
Soft boggy uterus, brisk bleed	Atony	Uterus relaxes; responds to massage/uterotonics
Firm uterus, continuous trickle bright-red	Trauma (laceration)	Well-contracted fundus; visible tear on inspection
Shock disproportionate to visible loss + mass at introitus	Uterine inversion	Fundus not palpable abdominally
Bleeding with non-clotting blood, oozing from puncture sites	Coagulopathy/DIC	Low fibrinogen, deranged PT/aPTT
Bleeding day 7–14, fever, tender uterus	Secondary PPH (RPOC/endometritis)	USG shows retained products
Delivered placenta but bleeding persists	Retained cotyledon / succenturiate lobe	Inspect placenta for missing pieces / torn vessels

Recently asked / exam angle

• Single-best-answer on the uterotonic ladder: "Which is contraindicated in an asthmatic with PPH?" → Carboprost. "Contraindicated in pre-eclampsia?" → Methylergometrine.
• Management sequence questions: given failed oxytocin + ergometrine, next step → carboprost; failed medical therapy → balloon tamponade / B-Lynch before vascular ligation; hysterectomy is last.
• Definition/threshold MCQs: ≥500 mL vaginal, ≥1000 mL CS.
• Drug of choice for prophylaxis in AMTSL → oxytocin (carbetocin where cold chain fails).
• WOMAN trial / tranexamic acid — give within 3 hours, 1 g IV.
• Internal iliac ligation — ligate the anterior division; mechanism = reduces pulse pressure.
• Sheehan syndrome as a delayed complication — earliest feature = failure of lactation.
• Uterine inversion — replace before removing placenta; Johnson manoeuvre.
• Commonest cause: primary = atony; secondary = retained products.
• Fibrinogen as the best lab predictor of severe PPH.

Rapid revision

1. PPH thresholds: ≥500 mL vaginal, ≥1000 mL CS, within 24 h = primary.
2. 4 Ts: Tone (70%, commonest) > Trauma > Tissue > Thrombin.
3. Soft boggy uterus = atony; firm uterus + bleeding = trauma.
4. First-line uterotonic = oxytocin; prophylaxis in AMTSL = oxytocin 10 IU IM.
5. Methylergometrine contraindicated in hypertension/pre-eclampsia.
6. Carboprost (PGF2α) contraindicated in asthma.
7. Tranexamic acid 1 g IV within 3 h (WOMAN trial) cuts bleeding deaths.
8. Surgical step-up: bimanual compression → balloon tamponade → B-Lynch → uterine artery (O'Leary) → internal iliac (anterior division) → embolisation → hysterectomy.
9. B-Lynch = brace compression suture (1997); good for atony responsive to compression.
10. Placenta accreta → do not pull; proceed to hysterectomy.
11. Uterine inversion → replace first (Johnson manoeuvre), uterotonics after, never remove placenta first.
12. Delayed complication of hypovolaemic PPH = Sheehan syndrome (failure of lactation first); secondary PPH (day 7–14) commonest cause = retained products + endometritis.