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Summary Table

Feature	Detail
Risk Factors	Overdistended uterus (multiple gestation, polyhydramnios, fetal macrosomia), prolonged labor, precipitous labor, chorioamnionitis, use of tocolytics (e.g., magnesium sulfate), high parity, prior history of uterine atony, general anesthesia (halogenated agents), retained placental fragments
Etiology	Failure of the myometrium to contract adequately after delivery of the placenta, leading to uncontrolled hemorrhage from the open spiral arteries at the placental implantation site
Patient Presentation	Postpartum hemorrhage (blood loss >1000 mL or signs/symptoms of hypovolemia) occurring within the first 24 hours after delivery, most commonly immediately after placental delivery
Classic Physical Exam	A soft, "boggy," enlarged, poorly contracted uterus on bimanual palpation; fundus is often above the expected level; continuous vaginal bleeding despite placental delivery
Key Diagnostic Results	Clinical diagnosis based on physical exam findings; CBC shows dropping hemoglobin/hematocrit; coagulation panel (PT, aPTT, fibrinogen) to rule out coagulopathy; bedside ultrasound may show retained products
Management	Bimanual uterine massage (first step), uterotonic agents (oxytocin, methylergonovine, carboprost, misoprostol), tranexamic acid, intrauterine balloon tamponade, surgical intervention if refractory (B-Lynch suture, uterine artery ligation, hysterectomy as last resort)
Keywords	"Boggy uterus," "soft uterus," "postpartum hemorrhage," "fundal massage," "bleeding after delivery of placenta," "failure to contract"

1. Pathophysiology

During pregnancy, blood flow to the uterus increases dramatically, reaching approximately 500 to 700 mL per minute at term. After delivery of the placenta, the primary mechanism of hemostasis is mechanical contraction of the myometrial fibers. These interlacing smooth muscle bundles, sometimes referred to as "living ligatures" or the physiologic sutures of the uterus, compress the spiral arteries that previously supplied the placental bed. When the myometrium contracts effectively, this compression occludes the vessels and prevents hemorrhage.

In uterine atony, the myometrium fails to generate adequate contractile force. Without this mechanical compression, the spiral arteries at the placental site remain open and bleed freely. This is the single most common cause of primary postpartum hemorrhage (PPH), accounting for roughly 70 to 80 percent of all cases.

The connection between risk factors and pathophysiology is direct. An overdistended uterus (from twins, polyhydramnios, or a large fetus) has overstretched muscle fibers that cannot contract efficiently. Prolonged labor leads to myometrial fatigue, while chorioamnionitis causes inflammation that impairs coordinated contraction. Magnesium sulfate, used for preeclampsia or tocolysis, is a calcium antagonist that directly inhibits smooth muscle contraction. Halogenated anesthetic agents (such as sevoflurane) used in general anesthesia also cause dose-dependent uterine relaxation.

Understanding this mechanism explains why the first-line intervention is always aimed at restoring uterine tone: if you can get the muscle to contract, you stop the bleeding.

2. Classification and Clinical Manifestation

Uterine atony falls under the broader classification of postpartum hemorrhage. The widely taught framework for PPH etiology is the "Four T's":

Category	Cause	Frequency	Key Feature
Tone	Uterine atony	~70-80% of PPH	Boggy, soft uterus; most common cause
Trauma	Lacerations, hematomas, uterine rupture, uterine inversion	~20%	Firm uterus with continued bleeding; visible injury on inspection
Tissue	Retained placenta or placental fragments	~10%	Incomplete placenta on inspection; uterus cannot fully contract due to retained tissue
Thrombin	Coagulopathy (DIC, von Willebrand disease, anticoagulant use)	~1%	Diffuse oozing, no clot formation, abnormal coagulation studies

The clinical manifestation of uterine atony can be graded by severity based on estimated blood loss and hemodynamic response:

Class	Estimated Blood Loss	Heart Rate	Blood Pressure	Symptoms
Compensated	500-1000 mL	Mild tachycardia (90-100)	Normal	Dizziness, palpitations
Mild	1000-1500 mL	100-120	Mild hypotension	Weakness, diaphoresis
Moderate	1500-2000 mL	120-140	Systolic 80-90 mmHg	Restlessness, oliguria, pallor
Severe	>2000 mL	>140 or bradycardia	Systolic <80 mmHg	Altered consciousness, anuria, collapse

A critical teaching point: blood loss in the postpartum period is often underestimated visually by up to 30 to 50 percent. Quantitative measurement of blood loss (using calibrated drapes or gravimetric weighing of materials) is more accurate than visual estimation.

3. Diagnostic Workup

Test	Purpose	Findings in Uterine Atony
Bimanual palpation (Best Initial Test)	Assess uterine tone	Soft, boggy, enlarged uterus; fundus above expected level
Inspection of placenta	Rule out retained tissue	Complete placenta and membranes (if incomplete, consider "Tissue" as cause)
Genital tract inspection	Rule out lacerations	No cervical, vaginal, or perineal tears identified
CBC	Baseline and serial monitoring	Dropping hemoglobin and hematocrit
Coagulation panel (PT, aPTT, fibrinogen)	Rule out coagulopathy	Normal in isolated atony; fibrinogen <200 mg/dL suggests developing DIC
Type and crossmatch	Prepare for transfusion	Standard preparation
Point-of-care ultrasound	Evaluate for retained products or hematoma	Empty uterine cavity; no retained fragments

Uterine atony is fundamentally a clinical diagnosis. The best initial test is simply placing your hands on the uterus. On bimanual exam, the uterus feels soft, boggy, and poorly defined rather than the expected firm, contracted, "grapefruit-sized" globular shape it should assume after delivery.

The diagnostic sequence matters for exam purposes. When a vignette describes postpartum bleeding, your first job is to identify the source using the Four T's framework. Palpate the uterus (Tone), inspect the birth canal (Trauma), examine the placenta (Tissue), and check coagulation labs (Thrombin). If the uterus is boggy, you have your diagnosis without needing imaging or invasive testing.

Laboratory studies are supportive, not diagnostic. A fibrinogen level is particularly high-yield because it is the earliest coagulation parameter to become abnormal in evolving DIC. A fibrinogen below 200 mg/dL in the postpartum setting is concerning and should prompt aggressive factor replacement. Note that fibrinogen is normally elevated in pregnancy (400 to 600 mg/dL), so a value that appears "normal" for a non-pregnant patient may actually represent a significant decline.

There is no "gold standard" confirmatory test for uterine atony. The diagnosis is confirmed by the clinical response: if uterotonic therapy restores tone and stops bleeding, the diagnosis is confirmed retrospectively.

4. Management and Treatment

Step	Intervention	Details
1. Initial	Bimanual uterine massage	Immediate; one hand on the fundus abdominally, one hand in the vagina compressing the uterus between both hands
2. First-line uterotonic	Oxytocin (Pitocin)	10-40 units in 1 L normal saline IV infusion; or 10 units IM
3. Second-line uterotonics	Methylergonovine (Methergine)	0.2 mg IM every 2-4 hours; contraindicated in hypertension/preeclampsia
	Carboprost (Hemabate / 15-methyl PGF2-alpha)	0.25 mg IM every 15-90 minutes (max 8 doses); contraindicated in asthma
	Misoprostol (PGE1)	600-1000 mcg sublingual, buccal, or rectal
4. Adjunct	Tranexamic acid (TXA)	1 g IV over 10 minutes; give within 3 hours of delivery; may repeat once
5. Tamponade	Intrauterine balloon (e.g., Bakri balloon)	Inflate with 300-500 mL saline; provides direct pressure on the placental bed
6. Surgical	B-Lynch compression suture	Uterine compression suture if balloon fails
	Uterine artery ligation / Internal iliac artery ligation	Reduces pulse pressure to the uterus
	Hysterectomy	Last resort, definitive treatment for life-threatening refractory hemorrhage
Supportive	Massive transfusion protocol	pRBC : FFP : Platelets in 1:1:1 ratio; activate early if hemorrhage is severe

Step-by-step approach:

The absolute first intervention for a boggy uterus is bimanual uterine massage. This is both therapeutic and diagnostic. You physically compress the uterus between your hands to stimulate contraction. On exams, if the vignette says "boggy uterus" and asks for the next best step, the answer is fundal massage, not medications.

Simultaneously, oxytocin is initiated as the first-line pharmacologic agent. It can be given as a dilute IV infusion (10 to 40 units in 1 liter of crystalloid) or as a 10-unit IM injection. A high-yield point: oxytocin should not be given as an undiluted IV bolus because it can cause profound hypotension and cardiovascular collapse.

If oxytocin and massage fail, second-line uterotonics are added. The contraindication profiles are heavily tested:

Methylergonovine is an ergot alkaloid that causes sustained myometrial contraction through direct smooth muscle stimulation. It is contraindicated in patients with hypertension or preeclampsia because it causes systemic vasoconstriction and can precipitate hypertensive crisis or stroke.

Carboprost (15-methyl PGF2-alpha) is a prostaglandin analog. It is contraindicated in asthma because PGF2-alpha causes bronchoconstriction. The dose is 0.25 mg IM, repeatable every 15 to 90 minutes up to a maximum of 8 doses.

Misoprostol (a PGE1 analog) has the fewest contraindications and can be given by multiple routes (sublingual, buccal, rectal). It is often used when the other agents are contraindicated or unavailable.

Tranexamic acid (an antifibrinolytic) should be administered within 3 hours of delivery onset. The WOMAN trial demonstrated reduced death from bleeding when TXA was given early. The dose is 1 g IV over 10 minutes, with a second dose if bleeding continues after 30 minutes.

If medical management fails, the escalation follows a predictable surgical ladder: intrauterine balloon tamponade first (less invasive), then compression sutures (B-Lynch), then vascular ligation, and finally hysterectomy as the definitive, life-saving last resort. Do not delay hysterectomy in a hemodynamically unstable patient who has failed all other measures.

Throughout all of this, resuscitation runs in parallel: large-bore IV access, crystalloid infusion, activation of massive transfusion protocol with a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Genital tract laceration	Presents with postpartum bleeding, can be profuse	Uterus is firm and well-contracted on palpation; bleeding continues despite good tone; visible laceration on direct inspection
Retained placental tissue	Postpartum bleeding, uterus may feel somewhat enlarged	Placental inspection reveals missing cotyledons or incomplete membranes; ultrasound shows echogenic material in the uterine cavity
Uterine inversion	Sudden postpartum hemorrhage with hemodynamic instability	Fundus is not palpable abdominally; a mass is felt or visible at the introitus; associated with excessive cord traction
Coagulopathy / DIC	Ongoing postpartum bleeding refractory to uterotonics	Uterus is firm; bleeding is diffuse (oozing from IV sites, mucosal surfaces); abnormal coagulation studies (elevated PT/aPTT, low fibrinogen, thrombocytopenia)
Uterine rupture	Hemorrhage, hemodynamic instability, may occur intrapartum or postpartum	History of prior cesarean section or uterine surgery; sudden loss of fetal station; abdominal pain; cessation of contractions during labor
Placenta accreta spectrum	Hemorrhage at the time of placental delivery	Placenta fails to separate from the uterine wall; known risk factors include prior cesarean and placenta previa

The exam distinguishes these conditions primarily through two findings: (1) the tone of the uterus on palpation and (2) the completeness of the placenta on inspection. If the uterus is boggy, it is atony. If the uterus is firm but bleeding continues, look elsewhere (laceration, coagulopathy, or retained tissue with ultrasound).

6. Traps and High-Yield Pearls

The most common way students lose points on uterine atony questions is by skipping the physical exam finding and jumping to pharmacologic management. When a postpartum patient is bleeding and the vignette tells you the uterus is soft and boggy, the next best step is bimanual uterine massage, not oxytocin. Medications are given simultaneously or immediately after, but the tested "next step" is always massage first.

The second major trap involves contraindications to second-line uterotonics. If the vignette describes a patient with preeclampsia who has postpartum hemorrhage refractory to oxytocin, methylergonovine is the wrong answer. If the patient has asthma, carboprost is the wrong answer. These contraindication pairings (methylergonovine and hypertension, carboprost and asthma) appear repeatedly and are designed to test whether you memorize drug profiles or truly understand their pharmacology.

A third trap is the patient who continues to bleed despite a firm uterus. Students anchored on "postpartum hemorrhage equals atony" will keep selecting uterotonics when the real answer is genital tract inspection for a laceration or coagulation studies for DIC. Always reassess the uterine tone in the vignette before choosing your answer.

Finally, remember that uterine atony is not just a postpartum diagnosis. It can also be tested in the context of risk factor identification before delivery. A question may describe a patient with polyhydramnios, twins, and prolonged oxytocin augmentation, then ask what complication she is most at risk for after delivery. The answer is postpartum hemorrhage due to uterine atony.

The core competency being tested is your ability to recognize a boggy uterus as the cause of hemorrhage, initiate the correct stepwise management, apply drug contraindications under pressure, and escalate appropriately when conservative measures fail.

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