The Confidential Enquiry into Maternal Deaths (UK) identified 'Four Ts' as the classification of postpartum hemorrhage aetiology. In a patient who delivered vaginally 30 minutes ago with 1200 mL blood loss, a firm uterine fundus, no cervical/vaginal lacerations, but with coagulopathy (INR 2.8, fibrinogen 80 mg/dL), the most likely aetiology is:
- A Tone (uterine atony)
- B Tissue (retained placenta)
- C Thrombin (coagulopathy) ✓
- D Trauma (genital tract injury)
Correct answer: C. Thrombin (coagulopathy)
Explanation
The Four Ts of PPH aetiology are Tone (uterine atony, 80% of cases), Trauma (genital tract lacerations), Tissue (retained placenta/membranes), and Thrombin (coagulopathy). In this patient, the uterus is well-contracted (ruling out atony), there are no lacerations identified (ruling out trauma), and no retained tissue; the clinical picture with markedly abnormal coagulation indices (low fibrinogen, elevated INR) points to Thrombin as the primary aetiology. Fibrinogen <200 mg/dL in the context of PPH predicts severe haemorrhage.
Reference: Williams Obstetrics, 26th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.