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Question

Difficulty: EasyLabor, Delivery, and Puerperium

Match each etiology of primary postpartum hemorrhage with its classic physical examination finding or clinical presentation.

  • Uterine atonyBoggy, enlarged, and poorly contracted uterus on abdominal palpation
  • Genital tract lacerationFirm, well-contracted uterus with a steady trickle of bright red vaginal bleeding
  • Retained products of conceptionIncomplete placenta with missing cotyledons on gross inspection
  • Uterine inversionSmooth, round mass protruding from the vagina with an absent fundus on abdominal palpation

Answer

Uterine atony matches with a boggy uterus; genital tract lacerations match with a firm uterus and steady bleeding; retained products match with missing placental cotyledons; and uterine inversion matches with a visible mass and absent abdominal fundus.
Primary postpartum hemorrhage is systematically evaluated using the '4 Ts'. Tone (uterine atony) presents with a soft, boggy uterus. Trauma (lacerations) presents with a firm uterus and active bleeding. Tissue (retained placenta) presents with missing cotyledons on inspection. Uterine inversion is a mechanical collapse presenting with an absent abdominal fundus and a vaginal mass.

Step-by-Step Solution

1
Evaluate the presenting symptom.
Identify that the patient is experiencing primary postpartum hemorrhage.
Establishing the overarching diagnosis focuses the differential on the '4 Ts' (Tone, Trauma, Tissue, Thrombin).
2
Differentiate based on uterine tone.
A boggy uterus points to atony (Tone), whereas a firm uterus shifts suspicion toward a laceration (Trauma).
Uterine tone is the most critical first step in determining the etiology of postpartum bleeding.
3
Assess additional anatomical and gross inspection findings.
Missing placental cotyledons indicate retained tissue (Tissue), while an absent abdominal fundus with a vaginal mass confirms uterine inversion.
Specific physical findings uniquely differentiate the remaining causes of postpartum hemorrhage.

Key Concept

The etiologies of primary postpartum hemorrhage and their distinct physical examination findings.
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Topics

Labor, Delivery, and Puerperium

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