Antepartum & Postpartum Hemorrhage, Placental Abruption & Uterine Atony
Comprehensive emergency protocol for third-trimester obstetric hemorrhage, peripartum collapse, and postpartum hemorrhage (PPH). Details the absolute prohibition of digital pelvic exams prior to ultrasound in third-trimester bleeding, the diagnostic differentiation of placenta previa vs. placental abruption, the stepwise pharmacological management of uterine atony (the 4 Ts), Bakri intrauterine balloon tamponade, and resuscitation of amniotic fluid embolism (AFE).
Resuscitation Quick Actions • First 2 Minutes
The Digital Exam Prohibition
NEVER perform digital cervical examination in third-trimester bleeding until ultrasound confirms absence of placenta previa
Concealed Abruption Trap
Twenty percent of placental abruptions have NO external bleeding; suspect in severe abdominal pain with 'woody' hypertonic uterus
First-Line PPH Resuscitation
Vigorous continuous bimanual uterine massage + empty bladder via Foley + Oxytocin 20-40 units in 1L NS IV at 250-500 mL/hr
Methergine vs Carboprost Contraindications
Methergine is CONTRAINDICATED in Hypertension/Preeclampsia. Carboprost (Hemabate) is CONTRAINDICATED in Asthma
PPH Tranexamic Acid
Administer TXA 1g IV over 10 minutes within 3 hours of delivery (WOMAN trial); repeat 1g in 30 min if bleeding persists
Bottom-Line Clinical Pearl
Never perform a digital pelvic examination in a patient presenting with third-trimester vaginal bleeding until placenta previa has been definitively ruled out by ultrasound; digital palpation of an unsuspected previa can lacerate placental sinusoids, producing fatal maternal and fetal exsanguination within minutes. In postpartum hemorrhage from uterine atony, initiate immediate bimanual uterine compression, administer IV Tranexamic Acid (1g within 3 hours), and execute the uterotonic ladder (Oxytocin -> Methergine [avoid in hypertension] -> Carboprost [avoid in asthma] -> Misoprostol).
Third-trimester vaginal bleeding (occurring after 20 weeks of gestation) affects 3-5% of pregnancies. Rapid differentiation between placenta previa and placental abruption is the foundation of emergency management:
| Diagnostic Feature | Placenta Previa | Placental Abruption (Abruptio Placentae) |
|---|---|---|
| Pathophysiology & Anatomy | Placental tissue implants over or within 2 cm of the internal cervical os (complete, partial, marginal, or low-lying). Lower uterine segment thinning in the third trimester shears placental attachments. | Premature detachment of a normally implanted placenta from the uterine wall before delivery. Decidual hemorrhage creates a retroplacental hematoma, destroying gas exchange surface. |
| Clinical Presentation | PAINLESS, BRIGHT RED VAGINAL BLEEDING: Often sudden and unprovoked, occurring while resting or sleeping. Uterus is soft, non-tender, and relaxed. Fetal heart tracing is initially normal. | PAINFUL, DARK RED VAGINAL BLEEDING: Severe, constant abdominal and back pain; hypertonic, rigid, 'woody' board-like uterus; high-frequency low-amplitude uterine contractions; marked uterine tenderness. |
| The 'Concealed' Hemorrhage Trap | Bleeding is always external and visible. | 20% of abruptions are completely CONCEALED: Retroplacental clot is trapped behind the fetal head or membranes with zero external vaginal bleeding! Severity of maternal shock and fetal distress is completely discordant with visible blood. |
| Fetal & Maternal Complications | Maternal hemorrhagic shock; preterm delivery. | Severe fetal distress/bradycardia (fetal mortality up to 20-30%); Disseminated Intravascular Coagulation (DIC) occurs in 10-20% due to massive release of placental tissue thromboplastin into maternal circulation. |
| Diagnostic Imaging | Transabdominal Ultrasound (TAUS) first, followed by careful Transvaginal Ultrasound (TVUS) if necessary (TVUS is safe and provides accurate measurement of distance from os). | Clinical diagnosis: ultrasound has poor sensitivity (< 25-50%) for placental abruption (acute retroplacental clot is isoechoic to the placenta). A negative ultrasound NEVER excludes abruption! |
Postpartum Hemorrhage is defined as cumulative blood loss >= 1,000 mL or bleeding accompanied by signs or symptoms of hypovolemia within 24 hours of delivery. Management is organized around the 4 Ts framework:
| Mnemonic Category | Incidence & Specific Etiology | Clinical Assessment & Physical Exam Findings |
|---|---|---|
| 1. Tone (Uterine Atony) | 70% to 80% of all PPH cases: Failure of myometrial muscle fibers to contract and constrict spiral arterioles following placental separation. | Soft, boggy, poorly contracted, enlarged uterus on abdominal palpation, often extending above the umbilicus. Bleeding is continuous, dark, and brisk with large clots. |
| 2. Trauma (Lacerations & Inversion) | 15% to 20% of PPH: Cervical lacerations, vaginal vault tears, expanding vulvovaginal hematomas, uterine rupture, or acute uterine inversion. | Persistent brisk arterial vaginal bleeding despite a firm, well-contracted uterus. Uterine inversion presents with a dark blue-gray mass protruding from the vagina and sudden neurogenic shock. |
| 3. Tissue (Retained Products) | 5% to 10% of PPH: Retained cotyledon, succenturiate placental lobe, or placenta accreta spectrum (placenta accreta, increta, percreta). | Inspect the delivered placenta: missing cotyledons or torn vessels crossing membranes. Ongoing bleeding with a subinvoluted uterus. |
| 4. Thrombin (Coagulopathies) | < 1% to 2% of PPH: Consumptive coagulopathy from severe abruption, amniotic fluid embolism (AFE), sepsis, gestational thrombocytopenia, or von Willebrand disease. | Oozing from peripheral IV puncture sites, hematuria, absence of clot formation in shed vaginal blood. |
| Step/Agent | Dosing & Administration Route | Critical Rules & Specific Contraindications |
|---|---|---|
| Step 1: Mechanical Decompression | 1. Bimanual Uterine Compression: Insert gloved right hand into vagina, form a fist in anterior fornix, and compress anterior uterine wall against external left hand pressing posteriorly through abdominal wall. 2. Bladder Decompression: Insert Foley catheter (a distended bladder mechanically inhibits uterine contraction). | Maintain continuous bimanual compression while second provider initiates pharmacotherapy. |
| Step 2: Tranexamic Acid (TXA) | Tranexamic Acid 1.0 gram IV in 100 mL NS infused over 10 minutes. Administer within 3 hours of delivery (WOMAN trial). May repeat 1.0g IV if bleeding continues after 30 minutes. | Reduces death due to bleeding by 30% without increasing thromboembolic complications. |
| Step 3: First-Line Uterotonic: Oxytocin (Pitocin) | Oxytocin 20 to 40 units in 1 Liter crystalloid infused at 250 to 500 mL/hr OR 10 units IM. | FIRST-LINE DRUG: Causes rhythmic upper myometrial contractions. Never administer rapid undiluted IV bolus (causes severe hypotension, chest pain, and cardiac arrest). |
| Step 4: Second-Line Uterotonics: Methergine vs. Carboprost | 1. Methylergonovine (Methergine) 0.2 mg IM every 2 to 4 hours (sustained tetanic contraction). 2. Carboprost Tromethamine (Hemabate/PGF2a) 250 mcg (0.25 mg) deep IM every 15 to 90 minutes (max 8 doses). | CRITICAL CONTRAINDICATIONS: - Methergine is CONTRAINDICATED in HYPERTENSION, PREECLAMPSIA, or CAD (produces catastrophic peripheral vasoconstriction and stroke). - Carboprost is CONTRAINDICATED in ASTHMA (causes severe, refractory bronchospasm). |
| Step 5: Prostaglandin E1: Misoprostol (Cytotec) | Misoprostol 800 to 1,000 mcg rectally or sublingually. | Rapid onset (3-5 min sublingual); highly effective alternative when IV access is tenuous or second-line drugs are contraindicated. |
| Step 6: Intrauterine Balloon Tamponade (Bakri Balloon) | Insert Bakri Intrauterine Tamponade Balloon through cervical os into uterine cavity under ultrasound guidance. Inflate balloon with 300 to 500 mL sterile saline via large syringe until resistance is met. Apply gentle traction. | Applies direct hydrostatic pressure against bleeding myometrial venous sinuses. The 'Tamponade Test': if bleeding arrests from the drainage port, balloon tamponade is successful (maintain for 12-24h). If bleeding continues briskly around balloon, proceed immediately to laparotomy (B-Lynch sutures, uterine artery embolization, or emergency hysterectomy). |
Third-Trimester Vaginal Bleeding: The Absolute Prohibition on Digital Pelvic Exams
In any pregnant patient beyond 20 weeks of gestation presenting with vaginal bleeding, A DIGITAL PELVIC EXAMINATION IS STRICTLY FORBIDDEN. If the patient has an undiagnosed placenta previa, introducing a examining finger through the internal cervical os will puncture the low-lying placenta or shear placental vessels off the cervical stroma. This can produce catastrophic, uncontrollable arterial exsanguination within seconds, resulting in maternal cardiac arrest and fetal death. The physical examination must be limited to visual inspection of the external genitalia only until the placental location has been definitively mapped as normal by ultrasound. Only after ultrasound confirms that the placenta is safely remote from the internal os may a sterile speculum examination be performed to evaluate for cervical lacerations or dilation.
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