High risk and low incidence diseases: Postpartum hemorrhage

Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide, with rising incidence in the United States. Diagnosis can be particularly challenging in the emergency department (ED), where time-sensitive decisions are required and maternal physiologic adaptations may obscure early warning signs. Emergency physicians must be equipped to recognize subtle presentations, initiate resuscitation, and coordinate care across specialties.

This review highlights the pearls and pitfalls of PPH, including presentation, diagnosis, and management in the ED based on current evidence.

PPH presents variably, and patients can deteriorate rapidly, with pregnancy-related physiologic changes often masking early signs of blood loss. Emergency physicians should consider this diagnosis in appropriate clinical scenarios, recognizing that hypotension is a late finding and subtle symptoms may represent early hemorrhage. Initial evaluation begins with resuscitation, followed by identifying the etiology using the "4 Ts" framework: tone (uterine atony), tissue (retained placenta), trauma (tears, lacerations, uterine inversion), and thrombin (coagulation abnormalities). Pelvic examination is essential, with laboratory studies and ultrasound serving as adjuncts to confirm retained tissue, uterine rupture, or intra-abdominal bleeding. Timely recognition and targeted intervention are critical to preventing morbidity and mortality.

Emergency physicians must remain prepared to rapidly identify and treat PPH, as early recognition and intervention are vital to survival. Applying the "4 Ts" framework and engaging a multidisciplinary team are keys to reducing morbidity and mortality in this high-risk condition.