A 34-year-old woman, gravida 3 para 2, has a precipitous spontaneous vaginal delivery of a 4.2-kg (9 lb 5 oz) boy at 39 weeks gestation. After 15 minutes of gentle umbilical cord traction and fundal massage, the placenta is not delivered. Umbilical cord traction is continued; the umbilical cord abruptly avulses, and the patient suddenly develops severe abdominal pain. Blood pressure is 70/40 mm Hg and pulse is 62/min. On abdominal examination, the uterine fundus is not palpable at the umbilicus. There is copious vaginal bleeding with bright red blood and passage of large clots. On removal of the blood clots, a firm, rounded mass is visualized protruding from the vagina. Which of the following is the most likely cause of this patient's symptoms?

Question

A 34-year-old woman, gravida 3 para 2, has a precipitous spontaneous vaginal delivery of a 4.2-kg (9 lb 5 oz) boy at 39 weeks gestation.  After 15 minutes of gentle umbilical cord traction and fundal massage, the placenta is not delivered.  Umbilical cord traction is continued; the umbilical cord abruptly avulses, and the patient suddenly develops severe abdominal pain.  Blood pressure is 70/40 mm Hg and pulse is 62/min.  On abdominal examination, the uterine fundus is not palpable at the umbilicus.  There is copious vaginal bleeding with bright red blood and passage of large clots.  On removal of the blood clots, a firm, rounded mass is visualized protruding from the vagina. Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d995_4d7a_bc81_bb5fab9a6ca9_MD0003_00 This patient's postpartum hemorrhage and vaginal mass are concerning for uterine inversion, an obstetric emergency. Risk factors may include fetal macrosomia, rapid labor and delivery, and placenta accreta. Uterine inversion likely occurs due to excessive fundal pressure and traction on the umbilical cord prior to placental separation, which can lead to cord avulsion, as in this patient. The excessive traction causes the fundus to collapse into the endometrial cavity and prolapse through the cervix, resulting in a firm, rounded mass protruding through the vagina. As a result, the fundus is no longer palpable transabdominally. Patients with uterine inversion typically have severe abdominal pain and heavy vaginal bleeding with possible hemorrhagic shock (eg, hypotension). Neurogenic shock, due to the traction effect on the surrounding peritoneum, may also occur, resulting in a paradoxical bradycardia. (Choice A) Placenta previa, in which the placenta covers the cervix, can cause heavy vaginal bleeding; however, bleeding occurs antenatally, not postpartum, and is typically painless. Placenta previa (Choice B) A prolapsing fibroid may appear as a firm, rounded mass protruding into the vagina; however, it is not typically associated with severe abdominal pain or hypotension. In addition, the uterine fundus would remain palpable transabdominally. prolapsing fibroid (Choice D) Uterine rupture, or disruption of the uterine wall, can present with severe abdominal pain and heavy bleeding; however, it is not associated with a vaginal mass. In addition, uterine rupture is rare in patients without prior uterine surgery (eg, myomectomy). Uterine rupture (Choice E) Vaginal hematoma is a cause of postpartum hemorrhage that can appear as a firm, rounded vaginal mass. However, blood loss is typically hidden in the paravaginal space (ie, occult bleeding with no passage of large clots), and the uterine fundus remains palpable transabdominally. Educational objective: Uterine inversion, in which the uterine fundus inverts and prolapses through the cervix or vagina after delivery, typically appears as a firm, rounded mass protruding through the cervix or vagina. Patients can have severe abdominal pain, heavy vaginal bleeding, and a nonpalpable uterine fundus on abdominal examination. References: Total and acute uterine inversion after delivery: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/25326075) Acute complete uterine inversion after controlled cord traction of placenta following vaginal delivery: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/27386133)

A 34-Year-Old Woman, Gravida 3 Para 2, Has a Precipitous