Match each clinical presentation of postpartum hemorrhage to its most likely underlying etiology.
- Heavy bleeding after delivery of a macrosomic neonate; examination reveals a soft, boggy uterus palpated above the umbilicus.Uterine atony
- Continuous bright red bleeding following an operative vaginal delivery; examination reveals a firm, well-contracted uterus.Genital tract laceration
- Severe abdominal pain and hemorrhage following vigorous umbilical cord traction; a round, red mass is visible at the vaginal introitus with an absent fundus on abdominal palpation.Uterine inversion
- Persistent bleeding postpartum despite a firm uterus; inspection of the delivered placenta reveals ragged edges and a missing cotyledon.Retained products of conception
Answer
The presentations match as follows: a soft/boggy uterus indicates uterine atony; continuous bleeding with a firm uterus indicates a genital tract laceration; a protruding vaginal mass with an absent abdominal fundus indicates uterine inversion; and a placenta with missing cotyledons indicates retained products of conception.
Postpartum hemorrhage (PPH) etiologies are classically categorized by the '4 Ts': Tone, Trauma, Tissue, and Thrombin.
Additionally, uterine inversion is a rare but life-threatening complication (often categorized under Trauma) that presents with a visible vaginal mass and an absent uterine fundus on abdominal palpation, typically following excessive umbilical cord traction.
| Etiology (T) | Classic Findings | Common Risk Factors |
|---|---|---|
| Tone (Uterine atony) | Soft, boggy, enlarged uterus | Fetal macrosomia, polyhydramnios, prolonged labor |
| Trauma (Laceration) | Firm, contracted uterus with active bleeding | Operative vaginal delivery, precipitous labor |
| Tissue (Retained placenta) | Missing placental cotyledons, ragged edges | Placenta accreta, prior uterine surgery |
| Thrombin (Coagulopathy) | Oozing from IV sites, non-clotting blood | Severe preeclampsia, placental abruption, DIC |
Step-by-Step Solution
Key Concept
Identifying the etiology of postpartum hemorrhage (PPH) based on physical examination findings.