If there is no response, additional considerations would include associated RPOC, adherent placentation, or even uterine inversion, and in these situations, imaging may be helpful. About 1% of third trimester deliveries are complicated by RPOC [11] and is the second most common etiology for PPH after uterine atony; although, this is typically seen in the delayed PPH population. The diagnosis of RPOC is helpful to the clinician in determining whether surgical intervention is warranted. Trauma-related hemorrhage may be due to lacerations, uterine rupture, or incision extensions. Imaging may be helpful to delineate the extent of intra-abdominal hemorrhage, whereas infralevator or perineal hemorrhage may be evaluated on visual inspection. Coagulopathy, either inherited or acute related to amniotic fluid embolism, placental abruption, severe pre-eclampsia or HELLP syndrome, is less common but potentially life threatening. There is a long list of risk factors associated with uterine atony, which is not within the scope of this document. CT Abdomen and Pelvis In the setting of hemorrhage, the primary role of CT is to determine whether active ongoing hemorrhage is present, to localize the bleeding, and to identify the source, which is best accomplished with a CT with IV contrast. There is little clinical utility in a noncontrast CT or CT with and without IV contrast in the setting of active ongoing hemorrhage. In hemodynamically stable patients, when conventional medical treatment has been unsuccessful in terminating hemorrhage, multiphasic CT can be useful in localizing the source of extravasation for targeted therapy [12,29], particularly in suspected intra-abdominal hemorrhage [12]. Although uterine atony is a clinical diagnosis, CT can be helpful by detecting focal or diffuse arterial or venous oozing and/or hematoma within the cavity of an enlarged uterus [13]. RPOC can be difficult to differentiate from blood products even on multiphase CT [12].
Postpartum Hemorrhage. If there is no response, additional considerations would include associated RPOC, adherent placentation, or even uterine inversion, and in these situations, imaging may be helpful. About 1% of third trimester deliveries are complicated by RPOC [11] and is the second most common etiology for PPH after uterine atony; although, this is typically seen in the delayed PPH population. The diagnosis of RPOC is helpful to the clinician in determining whether surgical intervention is warranted. Trauma-related hemorrhage may be due to lacerations, uterine rupture, or incision extensions. Imaging may be helpful to delineate the extent of intra-abdominal hemorrhage, whereas infralevator or perineal hemorrhage may be evaluated on visual inspection. Coagulopathy, either inherited or acute related to amniotic fluid embolism, placental abruption, severe pre-eclampsia or HELLP syndrome, is less common but potentially life threatening. There is a long list of risk factors associated with uterine atony, which is not within the scope of this document. CT Abdomen and Pelvis In the setting of hemorrhage, the primary role of CT is to determine whether active ongoing hemorrhage is present, to localize the bleeding, and to identify the source, which is best accomplished with a CT with IV contrast. There is little clinical utility in a noncontrast CT or CT with and without IV contrast in the setting of active ongoing hemorrhage. In hemodynamically stable patients, when conventional medical treatment has been unsuccessful in terminating hemorrhage, multiphasic CT can be useful in localizing the source of extravasation for targeted therapy [12,29], particularly in suspected intra-abdominal hemorrhage [12]. Although uterine atony is a clinical diagnosis, CT can be helpful by detecting focal or diffuse arterial or venous oozing and/or hematoma within the cavity of an enlarged uterus [13]. RPOC can be difficult to differentiate from blood products even on multiphase CT [12].