A 27-year-old woman, gravida 2 para 1, at 40 weeks gestation has a forceps-assisted vaginal delivery after pushing for 2 hours. She was diagnosed with preeclampsia with severe features on admission and is receiving a magnesium sulfate infusion. Her first pregnancy ended with a cesarean delivery at 39 weeks gestation for breech presentation. Temperature is 37.2 C (99 F), blood pressure is 150/100 mm Hg, and pulse is 112/min. Ten minutes after delivery, the placenta delivers with gentle traction, and the patient develops profuse vaginal bleeding. Bimanual massage reveals a firm, nontender uterus with the fundus at the level of the umbilicus. Pelvic examination shows a right vaginal sidewall defect. There is minimal bleeding from the cervical os, and the perineum is intact. Which of the following is the most likely cause of this patient's bleeding?

Question

A 27-year-old woman, gravida 2 para 1, at 40 weeks gestation has a forceps-assisted vaginal delivery after pushing for 2 hours.  She was diagnosed with preeclampsia with severe features on admission and is receiving a magnesium sulfate infusion.  Her first pregnancy ended with a cesarean delivery at 39 weeks gestation for breech presentation.  Temperature is 37.2 C (99 F), blood pressure is 150/100 mm Hg, and pulse is 112/min.  Ten minutes after delivery, the placenta delivers with gentle traction, and the patient develops profuse vaginal bleeding.  Bimanual massage reveals a firm, nontender uterus with the fundus at the level of the umbilicus.  Pelvic examination shows a right vaginal sidewall defect.  There is minimal bleeding from the cervical os, and the perineum is intact.  Which of the following is the most likely cause of this patient's bleeding?

Quizplus · Accepted Answer

11ec25c8_da64_35a3_bc81_790116003800_MD0003_00 This patient with profuse vaginal bleeding after delivery has a postpartum hemorrhage (PPH). The most common cause of PPH is uterine atony, which occurs due to insufficient uterine contractility and may be treated with bimanual uterine massage and uterotonic medications. Patients with uterine atony typically have heavy bleeding from the cervical os and an enlarged, boggy uterus palpable above the umbilicus (Choice D). bimanual uterine massage When the uterus is firm and the fundus is located at the level of the umbilicus (ie, no uterine atony), as in this patient, evaluation for other causes of PPH is required. Therefore, the next best step in management is to inspect for genital tract trauma (eg, lacerations of the cervix, vagina, perineum), particularly in patients who have undergone operative vaginal delivery (eg, forceps, vacuum). This patient's vaginal sidewall defect and minimal bleeding from the cervical os are consistent with a vaginal laceration. Because the vagina is supplied by branches of the uterine artery (which receives 30% of maternal cardiac output at delivery), patients with a vaginal laceration can have profuse bleeding. Treatment is with laceration repair. (Choice A) Endometritis may present with heavy vaginal bleeding postpartum. However, patients typically have fever and uterine tenderness, making the diagnosis unlikely in this patient. (Choice C) A prior cesarean delivery, as in this patient, increases the risk for placenta accreta and PPH due to retained products. Patients with placenta accreta typically require manual placental extraction; in contrast, this patient's placenta delivered with gentle traction. In addition, placenta accreta causes intrauterine bleeding leading to uterine enlargement and atony, which are not seen in this patient. placenta accreta (Choice E) Vaginal birth after cesarean delivery is a risk factor for uterine rupture, which can present with heavy vaginal bleeding. However, uterine rupture also typically causes severe abdominal pain (due to concomitant intraabdominal bleeding) and uterine tenderness. uterine rupture Educational objective: Genital tract trauma (eg, vaginal laceration) is a common cause of postpartum hemorrhage. Therefore, the cervix, vagina, and perineum are inspected thoroughly after vaginal delivery, particularly after operative vaginal delivery. References: Role of operative vaginal deliveries in prevention of cesarean deliveries. (http://www.ncbi.nlm.nih.gov/pubmed/25811126) Postpartum hemorrhage: prevention and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28409600)

A 27-Year-Old Woman, Gravida 2 Para 1, at 40 Weeks