Uterine atony vs Trauma, tissue, and thrombin postpartum hemorrhage causes
How to tell Uterine atony and Trauma, tissue, and thrombin postpartum hemorrhage causes apart when a board question makes them look alike.
Tone is boggy atony; trauma bleeds despite firm uterus; tissue is retained placenta; thrombin is coagulopathy.
Side by side
Uterine atony is the most common postpartum hemorrhage cause and presents with a boggy enlarged uterus that fails to contract after delivery.
Trauma causes laceration or hematoma with firm uterus; tissue is retained placenta; thrombin is coagulopathy such as DIC.
Failure of myometrial contraction prevents compression of spiral arteries at the placental bed.
Bleeding can also come from genital tract injury, retained products preventing contraction, or impaired clot formation.
Boggy uterus, risk from overdistension or prolonged labor, and response to uterotonics support atony.
Firm uterus with ongoing bleeding supports trauma; ultrasound or missing cotyledon supports retained tissue; abnormal coagulation labs support thrombin.
The trap
Postpartum hemorrhage causes are remembered as the 4 T's, but they have very different management assess in order: (1) TONE: uterine atony (boggy soft uterus, the MOST common cause, about 70 to 80 percent of PPH) first-line treatment is bimanual uterine massage plus oxytocin; second-line is methylergonovine (avoid in hypertension or preeclampsia), carboprost (15-methyl PGF2-alpha, avoid in asthma), or misoprostol; tranexamic acid within 3 hours; balloon tamponade if medication fails; (2) TRAUMA: bleeding despite a firm uterus suggests cervical or vaginal laceration inspect and repair; (3) TISSUE: retained placenta manually extract or D&C; (4) THROMBIN: coagulopathy (preeclampsia/HELLP, amniotic fluid embolism, sepsis, congenital coagulopathy, DIC) treat with FFP, platelets, cryoprecipitate, and address the underlying cause.
The repair move
For postpartum hemorrhage, start with the four Ts and assess uterine tone first.
Try a free question
CoreA 28-year-old G1 P1 has prolonged 22-hour labor with macrosomic fetus and brisk vaginal bleeding (estimated 1500 mL) 20 minutes after delivery. Bimanual exam reveals a boggy enlarged uterus that fails to firm with massage. The placenta appears intact. Speculum exam shows no lacerations. Which cause of postpartum hemorrhage is most likely?
Show answer and explanation
Answer: A. Uterine atony. Uterine atony is the most common cause of postpartum hemorrhage (about 70-80%); risk factors include prolonged labor, macrosomia, multiparity, and overdistension; treatment is uterine massage plus uterotonics (oxytocin, methylergonovine, carboprost).
Why the other choices are tempting
- B. Genital tract trauma bleeds despite a firm contracted uterus and visible lacerations on speculum exam.
- C. Retained placenta is suggested by incomplete delivery or ultrasound showing retained products.
- D. Coagulopathy bleeds at multiple sites with abnormal PT/PTT, fibrinogen, and platelet values.
- E. Uterine inversion presents with a mass at the introitus and severe pain; the uterus is not boggy in this scenario.
Flashcards
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What is the most common postpartum hemorrhage cause?
Uterine atony is the most common postpartum hemorrhage cause.
What exam finding supports atony?
A soft boggy enlarged uterus supports uterine atony.
Quick answers
What is the fastest way to tell Uterine atony from Trauma, tissue, and thrombin postpartum hemorrhage causes?
Tone is boggy atony; trauma bleeds despite firm uterus; tissue is retained placenta; thrombin is coagulopathy.
What is the key clue for Uterine atony?
Uterine atony is the most common postpartum hemorrhage cause and presents with a boggy enlarged uterus that fails to contract after delivery.
What is the key clue for Trauma, tissue, and thrombin postpartum hemorrhage causes?
Trauma causes laceration or hematoma with firm uterus; tissue is retained placenta; thrombin is coagulopathy such as DIC.
What is the common trap with Uterine atony vs Trauma, tissue, and thrombin postpartum hemorrhage causes?
Postpartum hemorrhage causes are remembered as the 4 T's, but they have very different management assess in order: (1) TONE: uterine atony (boggy soft uterus, the MOST common cause, about 70 to 80 percent of PPH) first-line treatment is bimanual uterine massage plus oxytocin; second-line is methylergonovine (avoid in hypertension or preeclampsia), carboprost (15-methyl PGF2-alpha, avoid in asthma), or misoprostol; tranexamic acid within 3 hours; balloon tamponade if medication fails; (2) TRAUMA: bleeding despite a firm uterus suggests cervical or vaginal laceration inspect and repair; (3) TISSUE: retained placenta manually extract or D&C; (4) THROMBIN: coagulopathy (preeclampsia/HELLP, amniotic fluid embolism, sepsis, congenital coagulopathy, DIC) treat with FFP, platelets, cryoprecipitate, and address the underlying cause.