A 39-year-old woman, gravida 7 para 7, is evaluated for increased vaginal bleeding. Twenty minutes ago, the patient underwent a vacuum-assisted vaginal delivery for fetal heart rate abnormalities of a 4.1-kg (9-lb) infant over an intact perineum. The placenta delivered spontaneously and was intact on inspection. Estimated blood loss for the delivery was 425 mL. This pregnancy was complicated by gestational hypertension for which the patient underwent induction of labor. Her 6 previous pregnancies were uncomplicated. The patient has no chronic medical problems and has had no surgeries. She takes a prenatal vitamin daily. She does not use tobacco, alcohol, or illicit drugs. The patient is now experiencing heavy vaginal bleeding with large blood clots. Blood pressure is 140/80 mm Hg, pulse is 106/min, and respirations are 20/min. On abdominal examination, the uterine fundus is soft and palpated 3 cm above the umbilicus. The perineal pad is saturated with blood, and there are fist-sized blood clots extruding from the vagina. Which of the following is the best next step in management of this patient?

Question

A 39-year-old woman, gravida 7 para 7, is evaluated for increased vaginal bleeding.  Twenty minutes ago, the patient underwent a vacuum-assisted vaginal delivery for fetal heart rate abnormalities of a 4.1-kg (9-lb) infant over an intact perineum.  The placenta delivered spontaneously and was intact on inspection.  Estimated blood loss for the delivery was 425 mL.  This pregnancy was complicated by gestational hypertension for which the patient underwent induction of labor.  Her 6 previous pregnancies were uncomplicated.  The patient has no chronic medical problems and has had no surgeries.  She takes a prenatal vitamin daily.  She does not use tobacco, alcohol, or illicit drugs.  The patient is now experiencing heavy vaginal bleeding with large blood clots.  Blood pressure is 140/80 mm Hg, pulse is 106/min, and respirations are 20/min.  On abdominal examination, the uterine fundus is soft and palpated 3 cm above the umbilicus.  The perineal pad is saturated with blood, and there are fist-sized blood clots extruding from the vagina.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c035_46f8_8f63_354c00609cfd_MD0005_00 Postpartum hemorrhage (PPH), defined as ≥1,000 mL of blood loss or bleeding with associated hypovolemia within the first 24 hours after delivery, is an obstetric emergency and a leading cause of maternal mortality. Risk factors include grand multiparity, fetal macrosomia, and operative vaginal delivery. PPH can result in rapid exsanguination, so the cause of the hemorrhage must be determined quickly so that appropriate treatment can be implemented. This patient has heavy vaginal bleeding and a soft, enlarged uterus palpated above the umbilicus, a presentation consistent with uterine atony, the most common cause of PPH. Hemostasis after placental separation is achieved when the uterus contracts and compresses the intrauterine blood vessels that supplied the placenta. Uterine atony occurs when the uterus fails to contract after placental separation. The first steps in management are uterine massage and oxytocin, which increase uterine contraction. Second-line uterotonic medications (eg, methylergonovine, carboprost, misoprostol) are indicated if atony is unresponsive to oxytocin and massage. (Choice A) If PPH does not respond to initial management with uterine massage and uterotonic medications, alternate etiologies are evaluated. Retained placental fragments occur when the placenta delivers incompletely and a portion of it remains inside the uterus, preventing effective uterine contraction. Retained placental fragments are associated with manual placental extraction and placenta accreta. This patient's placenta was intact on examination, making this etiology unlikely. placenta accreta (Choice B) Genital tract lacerations (eg, cervix, vagina) are common after operative vaginal delivery. Examination for lacerations can be performed if bleeding is unresponsive to initial management. However, genital tract lacerations are not associated with a soft, enlarged uterus, like this patient's. (Choice C) Uterine artery embolization is indicated for stable patients with persistent bleeding unresponsive to first- or second-line treatments. It is used as a temporizing measure until definitive surgical management (eg, hysterectomy) can be performed. (Choice E) Uterine balloon tamponade, which involves placing an inflated balloon inside the uterus to compress blood vessels and promote clotting, is indicated when first- and second-line uterotonic agents fail to manage PPH. Educational objective: The most common cause of postpartum hemorrhage is uterine atony, failure of the uterus to contract after placental separation. First-line management for uterine atony is bimanual uterine massage and oxytocin infusion. References: Prevention and management of postpartum hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/17390600)

A 39-Year-Old Woman, Gravida 7 Para 7, Is Evaluated for Increased