How should I manage a 9‑day postpartum woman who suddenly has a large gush of bright‑red blood soaking four pads with a sizable non‑fibrous clot?

Management of Secondary Postpartum Hemorrhage at 9 Days Postpartum

This patient requires immediate evaluation for genital tract trauma (cervical or vaginal laceration) or retained placental tissue, as these are the most likely causes of delayed hemorrhage with large non-fibrous clots at 9 days postpartum, and she should receive tranexamic acid 1 g IV immediately if bleeding is ongoing. 1

Immediate Assessment and Stabilization

Initial Clinical Evaluation

• Assess uterine tone first by palpating the fundus. If the uterus is firm and well-contracted, uterine atony is effectively ruled out, and genital tract trauma becomes the leading cause of bleeding. 2
• Perform systematic visual inspection under adequate lighting of the cervix, vaginal walls, perineum, and periurethral area to identify lacerations. Consider examination under anesthesia if the patient cannot tolerate adequate inspection. 2
• Verify complete placental delivery and assess for retained products of conception if no laceration is identified. 2

Immediate Pharmacologic Intervention

• Administer tranexamic acid 1 g IV over 10 minutes immediately if bleeding is ongoing, regardless of the underlying cause. Effectiveness decreases by approximately 10% for every 15-minute delay, and administration beyond 3 hours may be harmful. 1, 3
• Administer oxytocin 5-10 IU slow IV or IM to ensure uterine contraction, even though atony is less likely at 9 days postpartum. 1, 4
• Initiate fluid resuscitation with physiologic electrolyte solutions while assessing the severity of blood loss. 1

Diagnostic Workup

Laboratory Studies

• Obtain full blood count (hemoglobin), coagulation studies (PT/PTT, fibrinogen), group and screen, and venous blood gas for rapid hemoglobin measurement and lactate (>2 mmol/L indicates shock). 5
• Fibrinogen is the single most important parameter to monitor because it declines rapidly during active bleeding and is the most common factor deficiency in postpartum hemorrhage. 1
• Point-of-care testing is preferred over laboratory testing due to faster turnaround time during active hemorrhage. 5

Imaging Studies

• Perform transvaginal ultrasound with Doppler if no laceration is found and retained placental tissue is suspected. Retained products of conception complicate approximately 1% of third-trimester deliveries and are the second most common cause of postpartum hemorrhage after atony. 2
• CT with IV contrast may be useful in hemodynamically stable patients to localize bleeding sources, particularly for intra-abdominal hemorrhage. 2, 3

Etiology-Specific Management

If Genital Tract Laceration is Identified

• Perform immediate surgical repair with absorbable suture under adequate anesthesia and lighting. 2
• Use figure-of-eight sutures for arterial bleeders to ensure hemostasis. 2
• Consider packing if diffuse oozing from multiple small lacerations is present. 2

If Retained Placental Tissue is Suspected

• Manual removal of placenta should NOT be routinely performed except in cases of severe and uncontrollable postpartum hemorrhage, as it may worsen bleeding. 1
• Consider uterine evacuation if ultrasound confirms retained products and bleeding persists despite medical management. 6

If Uterine Atony is Present (Soft, Boggy Uterus)

• Perform vigorous bimanual uterine massage to stimulate contraction. 2
• Administer additional uterotonics if massage and oxytocin are insufficient. Note that methylergonovine 0.2 mg IM is contraindicated in hypertensive patients (>10% risk of severe hypertension) and should be avoided in women with asthma due to bronchospasm risk. 1
• Consider misoprostol 800-1000 mcg rectally as second-line therapy, though be aware it can cause high fevers (>40°C) with autonomic effects including tachycardia and disorientation. 7

Blood Product Management

Transfusion Thresholds and Strategy

• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL. 1
• Transfuse packed RBCs, fresh frozen plasma, and platelets in a 1:1:1 ratio during massive transfusion. 5, 1
• Do not delay transfusion waiting for laboratory results in severe bleeding. 1
• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage. 1

Coagulation Management

• If bleeding continues without coagulation results available and <4 units RBC have been given, withhold FFP until 4 units of RBC have been transfused to avoid overtransfusion. 5, 1
• After 4 units of RBC, administer 4 units of FFP and maintain 1:1 ratio until coagulation results are available. 5, 1
• Administer cryoprecipitate or fibrinogen concentrate if fibrinogen <2-3 g/L with ongoing bleeding. 5, 1, 3
• Platelet transfusion is rarely needed unless blood loss exceeds 5,000 mL or platelet count <75 × 10⁹/L. 1, 3

Tranexamic Acid Dosing

• A second dose of tranexamic acid 1 g IV can be given if bleeding continues after 30 minutes or restarts within 24 hours. 1

Mechanical and Surgical Interventions

Non-Surgical Options

• Implement intrauterine balloon tamponade before proceeding to surgery or interventional radiology if medical management fails. 1
• Consider pelvic pressure packing for acute uncontrolled hemorrhage stabilization; it can remain for 24 hours. 1

Interventional Radiology

• Uterine artery embolization is particularly useful when no single bleeding source is identified and the patient is hemodynamically stable. 1, 3
• Embolization requires hemodynamic stability for transfer to the angiography suite. 1

Surgical Options

• Uterine compression sutures (B-Lynch or similar) can be used to control bleeding if other measures fail. 1
• Hysterectomy is reserved as the last resort when all other measures have failed. 3

Supportive Care

Essential Measures

• Maintain normothermia by warming all infusion solutions and blood products and using active skin warming, as clotting factors function poorly at lower temperatures. 1
• Administer oxygen to achieve arterial oxygen saturation ≥95% in severe postpartum hemorrhage. 1
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL. 1
• Continue hemodynamic monitoring for at least 24 hours post-delivery due to significant fluid shifts. 1

Common Pitfalls to Avoid

• Do not assume atony is the cause without assessing uterine tone. A firm uterus effectively rules out atony, and genital tract trauma becomes the leading diagnosis. 2
• Do not delay tranexamic acid administration. Its effectiveness decreases by 10% for every 15 minutes of delay, and it should be given within 3 hours of bleeding onset. 1, 3
• Do not overtransfuse FFP early in atonic or traumatic bleeds. Withhold FFP until 4 units of RBC have been given unless early coagulopathy is documented. 5, 1
• Do not perform manual removal of placenta routinely, as it may worsen bleeding except in severe uncontrollable hemorrhage. 1
• Do not use methylergonovine in hypertensive or asthmatic patients due to risks of severe hypertension and bronchospasm. 1