What is the role of ultrasonography in the diagnosis of postpartum hemorrhage (PPH)?

Updated: Jan 02, 2018
  • Author: Maame Yaa A B Yiadom, MD, MPH; Chief Editor: Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE  more...
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Answer

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).

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.


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