A 34-year-old woman, gravida 2 para 2, is evaluated on the postpartum floor for nausea and lightheadedness. The patient developed these symptoms when she tried to ambulate to the bathroom, forcing her to immediately lie down. Earlier today, she underwent a repeat cesarean delivery at 39 weeks gestation; she is taking scheduled NSAIDs for incisional pain. The patient is fatigued and feels like she can barely keep her eyes open. She has no chronic medical conditions and takes no daily medications. Blood pressure is 80/50 mm Hg, pulse is 124/min, and respirations are 18/min. The patient appears pale and has cold skin. The uterine fundus is firm at the umbilicus, and the abdomen is tender but has no increased bleeding from the incision site. On pelvic examination, there is minimal lochia and no clots. Which of the following is the best next step in management of this patient?

Question

A 34-year-old woman, gravida 2 para 2, is evaluated on the postpartum floor for nausea and lightheadedness.  The patient developed these symptoms when she tried to ambulate to the bathroom, forcing her to immediately lie down.  Earlier today, she underwent a repeat cesarean delivery at 39 weeks gestation; she is taking scheduled NSAIDs for incisional pain.  The patient is fatigued and feels like she can barely keep her eyes open.  She has no chronic medical conditions and takes no daily medications.  Blood pressure is 80/50 mm Hg, pulse is 124/min, and respirations are 18/min.  The patient appears pale and has cold skin.  The uterine fundus is firm at the umbilicus, and the abdomen is tender but has no increased bleeding from the incision site.  On pelvic examination, there is minimal lochia and no clots.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This postpartum patient with hypotension, tachycardia, and signs of decreased end-organ perfusion (eg, fatigue, lightheadedness, cold skin) most likely has hypovolemic shock due to postpartum hemorrhage. Postpartum hemorrhage typically occurs within hours of delivery; uterine atony is the most common cause. Therefore, initial evaluation requires bimanual examination to assess for an enlarged, boggy uterus and heavy vaginal bleeding consistent with atony. In contrast, post-cesarean delivery patients with hemorrhagic shock and no signs of uterine atony (such as this patient) most likely have intraabdominal bleeding from uterine artery injury. Because pregnancy increases uterine artery blood flow, an intrapartum uterine artery injury can lead to rapid and massive blood loss with subsequent hemodynamic instability. This patient's bleeding is most likely located in the retroperitoneum (ie, retroperitoneal hematoma), which is a rare but life-threatening cause of postpartum hemorrhage that typically presents with no incisional bleeding and minimal abdominal or back pain, as the retroperitoneum has a vast potential space for blood accumulation before built-up pressure causes peritoneal stretching and pain. Hemodynamically unstable patients with a suspected retroperitoneal hematoma require emergency laparotomy. (Choice A) A prolonged postoperative ileus or mild small bowel obstruction can be managed with antiemetics and serial examinations. These patients typically have vomiting and abdominal distension, which are not seen in this patient. In addition, postoperative gastrointestinal complications typically present several days to weeks after surgery unlike postpartum hemorrhage, which occurs within hours of delivery. (Choice B) CT scan of the abdomen and pelvis can confirm the diagnosis of a retroperitoneal hematoma but is only appropriate for hemodynamically stable patients. Stable patients may then undergo arterial embolization for control of bleeding. (Choice D) Oxytocin infusion and fundal massage are used to treat uterine atony, but this patient's fundus is firm and her lochia minimal, making this diagnosis unlikely. fundal massage (Choice E) Transvaginal ultrasound can diagnose postpartum hemorrhage due to a retained placenta; however, patients typically have heavy vaginal bleeding, which is not seen in this patient. Educational objective: Retroperitoneal hematomas may occur postpartum due to uterine artery injury, leading to massive blood loss and hemodynamic instability despite minimal abdominal pain and no obvious source of bleeding. Hemodynamically unstable patients with a suspected retroperitoneal hematoma require emergency laparotomy. References: Risk factors for relaparotomy after cesarean delivery. (http://www.ncbi.nlm.nih.gov/pubmed/22921276) Return to the operation theatre: an analysis of repeat surgeries in operative obstetrics. (http://www.ncbi.nlm.nih.gov/pubmed/27651589) Selective arterial embolisation: life-saving intervention in the management of retroperitoneal haematoma in obstetrics. (http://www.ncbi.nlm.nih.gov/pubmed/21417659)

A 34-Year-Old Woman, Gravida 2 Para 2, Is Evaluated on the Postpartum