13/12/13 Postpartum Hemorrhage in Emergency Medicine Workup

Search Reference
Today
What would you like to print?
News
Print this section (Laboratory Studies)
Reference
[ CLOSE WINDOW ]
Print the entire contents of Postpartum Hemorrhage in Emergency Medicine Workup
Education
Log OutAbout
My Account
Medscape Reference
Dr. A Rahmani
Medscape's clinical reference is the most authoritative and accessible point-of-care medical
reference for physicians and healthcare professionals, available online and via all major mobile
devices. All content is free.

The clinical information represents the expertise and practical knowledge of top physicians and
pharmacists from leading academic medical centers in the United States and worldwide.

The topics provided are comprehensive and span more than 30 medical specialties, covering:

Diseases and Conditions

Print than 6000 evidence-based and physician-reviewed disease and condition articles are
More
Share to rapidly and comprehensively answer clinical questions and to provide in-depth
organized
Email Twitter in
information Facebook
support of diagnosis, treatment, and other clinical decision-making. Topics are richly
Feedback
illustrated with more than 40,000 clinical photos, videos, diagrams, and radiographic images.

Procedures
Postpartum Hemorrhage
More than 1000 clinical procedure articles providein
clear,Emergency
step-by-step instructions and include
instructional videos and images to allow clinicians to master the newest techniques or to improve
M edicine Workup
their skills in procedures they have performed previously.

Anatomy
Author: Maame Yaa A B Yiadom, MD, MPH; Chief Editor: Pamela L Dyne, MD more...
More than 100 anatomy articles feature clinical images and diagrams of the human body's major

Overview
Presentation
DDx
Workup
Treatment
Medication
Follow-up

Updated: May 2, 2012

Laboratory Studies
Laboratory Studies
Imaging Studies
Complete blood count (CBC)
Show All
The hemoglobin and hematocrit are helpful in estimating blood losses. However, in a patient with
References acute hemorrhage, several hours may pass before these levels change to reflect the blood loss
and platelet count.

emedicine.medscape.com/article/796785-workup 1/7
13/12/13 Postpartum Hemorrhage in Emergency Medicine Workup

If the white blood cell count is elevated, suspect endometritis or toxic shock syndrome.
Look for thrombocytopenia.
Coagulation laboratory studies: Elevations of the prothrombin time (PT), activated partial
thromboplastin time (aPTT), and international normalized ratio (INR) can indicate a present or
developing coagulopathy.
Electrolytes: Check for complicating electrolyte derangements such as a hypocalcemia, hypokalemia,
and hypomagnesemia. Use this first set as a baseline for comparison during and after fluid and/or blood
resuscitation.
BUN/creatinine: These measurements can be helpful in identifying renal failure as a complication of
shock. If the BUN level rises during or after resuscitation with blood products, consider red blood cell
hemolysis as a complication.
Type and crossmatch: Begin the process of finding appropriately matched blood for resuscitation in the
event that it is needed.
Fibrinogen level: Levels are normally elevated to 300-600 mg/dL in pregnancy. Normal or low values
raise concerns for a consumptive coagulopathy.
Liver function tests (LFTs), amylase, lipase: These studies can be helpful in considering other abdominal
pathology, such as HELLP syndrome, if there is abdominal pain in addition to, or instead of, uterine
tenderness.
Lactate: Consider ordering this if the initial electrolyte study shows an anion gap or septic or
hypovolemic shock is suspected as a concomitant diagnosis.

Next Section: Imaging Studies

Imaging Studies
Studies to be considered with vaginal bleeding and decreasing red blood cell counts in the postpartum patient
include ultrasonography (U/S), computed tomography (CT), or magnetic resonance imaging (MRI).

Ultrasonography is a fast and helpful modality for imaging pelvic structures and should be the first-line study
for pelvic pathology.

Ultrasonography

In a hemodynamically unstable patient, a bedside ultrasonography can be performed by an experienced

emergency medicine provider as an extension of the physical examination. In general, a dedicated pelvic
ultrasonography (transabdominal and/or transvaginal) is helpful in identifying large retained placental fragments,
hematomas, or other intrauterine abnormalities. Retained placenta and hematoma can look
ultrasonographically identical. Using a Doppler ultrasound to look for vascularity can help to differential
between the two, with clots being avascular and retained placenta often receiving persistent blood flow from
the uterus.

The abdominal views of the focused assessment with sonography in trauma (FAST) examination are helpful in
identifying fluid within the peritoneum that may be the result of hemorrhage. This study is designed to identify
intra-abdominal and pericardial fluid that requires early operative intervention in trauma patients. However, the
abdominal views are useful in any patient with suspected intra-abdominal free fluid. These include views of the
right upper quadrant (RUQ)/Morison's pouch area (the most dependent area of a supine patient's peritoneal
cavity), the left upper quadrant (LUQ) spleno-renal recess, and views of the pelvis (sagittal and coronal views
of the uterus and pouch of Douglas). This study can detect 250-500 mL of fluid in the peritoneum, but it is a
poor study for identifying retroperitoneal or paravaginal hemorrhage (extra-peritoneal bleeding).
emedicine.medscape.com/article/796785-workup 2/7
13/12/13 Postpartum Hemorrhage in Emergency Medicine Workup

Ultrasonography cannot reliably differentiate between blood, urine, or ascites; however, in the setting of
suspected hemorrhage, any fluid in the abdomen should prompt further investigation.

More stable patients can have their abdominal and/or pelvic ultrasonography confirmed with an official study
performed by a radiologist.

Computed tomography

In the event that ultrasonography is not diagnostic, CT is a helpful follow-up study. This may also be the first-
line study when a pelvic hematoma or abscess is suspected, which may be missed with a sonogram. The
traditional teaching is that pelvic CT is a less than ideal study for pelvic structures, due to artifact from the
surrounding pelvic bones that reduces the image quality. However, this is generally not the case with modern
multidetector CT studies. When enhanced with intravenous (I+) and intra-intestinal (O/R+...either oral or
rectal contrast), CT can detail pelvic hematomas, cesarean delivery wound dehiscence, and retained placental
tissue.

Magnetic resonance imaging

MRI is a time consuming study that is rarely performed from the ED in these patients. It can be helpful in
delineating tissue planes to determine if a fluid collection (hematoma or abscess) is intrauterine or extrauterine
when this is not clear from ultrasonography or CT. It can also help to distinguish a placenta accreta from
simple retained products of conception.

Limited literature is available on abdominopelvic imaging in postpartum hemorrhage since the presentation of
significant bleeding prompts rapid resuscitation and immediate intervention based on the clinical picture rather
than documented imaging. Nonetheless, all 3 imaging modalities can assist in the evaluation of a bleeding
source, but ultrasonography is usually sufficient for emergent situations.
Proevcieoeuds to Treatment & Management

Contributor Information and Disclosures

Author
Maame Yaa A B Yiadom, MD, MPH Staff Physician, Department of Emergency Medicine, Cooper
University Hospital, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical
School

Maame Yaa A B Yiadom, MD, MPH is a member of the following medical societies: Alpha Omega
Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians,
American Medical Association, American Public Health Association, National Medical Association, and
Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)
Daniela Carusi, MSc, MD Instructor, Obstetrics and Gynecology and Reproductive Biology, Harvard
Medical School; Consulting Physician, Department of Obstetrics and Gynecology, Medical Director,
Department of General Ambulatory Gynecology, Brigham and Women's Hospital

Daniela Carusi, MSc, MD is a member of the following medical societies: American College of
emedicine.medscape.com/article/796785-workup 3/7
13/12/13 Postpartum Hemorrhage in Emergency Medicine Workup

Obstetricians and Gynecologists, Association of Reproductive Health Professionals, and Massachusetts

Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Assaad J Sayah, MD Chief, Department of Emergency Medicine, Cambridge Health Alliance

Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS
Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical
Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson
Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of
Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS Associate Professor of Medicine, Harvard Medical School, Beth Israel
Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard
Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical
Center

John D Halamka, MD, MS is a member of the following medical societies: American College of
Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for
Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor
Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los
Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine,
Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency
Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors
Special thanks to Dr. Donnie Bell for his assistance with the "Imaging" section for this topic.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous

emedicine.medscape.com/article/796785-workup 4/7
13/12/13 Postpartum Hemorrhage in Emergency Medicine Workup

author, Michael P Wainscott, MD, to the development and writing of this article.

References

1. Minino AM, Heron MP, Murphy SL, Kochanek KD, et al. National Vital Statistic Reports:
Deaths 2004. US Department of Health and Human Services and the Center for Disease Control
and Prevention; August 21, 2007. 120. [Full Text].

2. World Health Organization. World Health Report 2005: Make Every Mother and Child Count.
Available at http://www.who.int/whr/2005/whr2005_en.pdf. Accessed September 10, 2008.

3. USAID (United States Agency for International Development). Postpartum Hemorrhage

Prevention. USAID Postpartum Hemorrhage Prevention Initiative (POPPHI). Available at
http://www.pphprevention.org/briefs_newsletters.php. Accessed September 9, 2008.

4. PATH. Saving Mother's Lives: Initiative promotes proven strategy for preventing postpartum
hemorrhage. PATH: Preventing Postpartum Hemorrhage. Available at
http://www.path.org/projects/preventing_postpartum_hemorrhage.php. Accessed September 9,
2008.

5. Miller S, Lester F, Hensleigh P. Prevention and treatment of postpartum hemorrhage: new

advances for low-resource settings. J Midwifery Womens Health. Jul-Aug 2004;49(4):283-92.
[Medline]. [Full Text].

6. Menitove JE, McElligott MC, Aster RH. Febrile transfusion reaction: what blood component
should be given next?. Vox Sang. 1982;42(6):318-21. [Medline].

View Table List

Read more about Postpartum Hemorrhage in Emergency Medicine on Medscape

Related Reference Topics Related News and Articles

Hemolytic Uremic It Is Not the Ride: Inter-hospital Transport Is Not an Independent Risk
Syndrome in Factor for Intraventricular Hemorrhage Among Very Low Birth Weight
Emergency Medicine Infants
Vitreous Hemorrhage Advancing Maternal Survival in the Global Context
in Emergency Twitter Introduces Alert System for Emergencies, Disasters
Medicine
Epidural Hematoma in
Emergency Medicine

Medscape Reference © 2011 WebMD, LLC

emedicine.medscape.com/article/796785-workup 5/7
13/12/13 Postpartum Hemorrhage in Emergency Medicine Workup

About Medscape Reference

About Medscape
Privacy Policy
Terms of Use
WebMD
MedicineNet
eMedicineHealth

emedicine.medscape.com/article/796785-workup 6/7
13/12/13 Postpartum Hemorrhage in Emergency Medicine Workup

RxList
WebMD Corporate
Help

All material on this website is protected by copyright, Copyright © 1994-2013 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.
DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by
qualified physicians and other medical professionals. The information contained herein should NOT be used as a
substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The
information provided here is for educational and informational purposes only. In no way should it be considered as
offering medical advice. Please check with a physician if you suspect you are ill.

Close

emedicine.medscape.com/article/796785-workup 7/7