Causes of Post-Partum Hemorrhage - Differential Diagnosis Algorithm
Blood Loss: >500mL post vaginal delivery OR >1000 mL post Caesarean section
Uterine Atony (70%):
• Uterine fatigue (e.g. prolonged/induced labor, rapid labor, grand multiparity)
• Overdistension of uterus (e.g. multiple gestation, polyhydramnios, fetal macrosomia)
• Bladder distension
• Uterine infection (e.g. chorioamnionitis)
• Functional/anatomic distortion of uterus
• Drugs — Uterine relaxants (e.g. nifedipine, magnesium sulfate, NSAlDs)
Trauma (20%):
• Perineal laceration (e.g. episiotomy)
• Vaginal laceration / hematoma
• Cervical laceration (e.g. forceps/vacuum delivery)
• Uterine rupture
• Uterine inversion
Remnant Tissue (10%):
• Retained blood clots
• Retained cotyledon or succenturiate lobe
• Abnormal placentation (placenta accreta, increta, or percreta)
Thrombin (1%):
• Thrombocytopenia
• Idiopathic thrombocytopenic purpura (ITP)
• Thrombotic thrombocytopenic purpura (TTP)
• HELLP syndrome
• Disseminated intravascular coagulation (DIC)
• Anti-coagulation agents (e.g. heparin)
• Pre-existing coagulopathy (e.g. von Willebrand's disease, Hemophilia A)
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