Bimanual massage of the uterus is performed, and 2 large-bore intravenous lines are placed due to ongoing bleeding. Blood pressure is 100/60 mm Hg, pulse is 112/min, and respirations are 18/min. Which of the following is the best next step in management of this patient?

Question

Bimanual massage of the uterus is performed, and 2 large-bore intravenous lines are placed due to ongoing bleeding.  Blood pressure is 100/60 mm Hg, pulse is 112/min, and respirations are 18/min.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da61_ebb1_bc81_fdad3e3998bf_MD0003_00 Postpartum hemorrhage (PPH) is defined as an estimated blood loss ≥1,000 mL or bleeding with signs/symptoms of hypovolemia. The management of PPH due to uterine atony occurs in a stepwise approach: Initial management includes the placement of 2 large-bore intravenous lines for volume resuscitation. Bimanual uterine massage and bladder catheterization are performed to improve uterine tone. High-dose oxytocin, the first-line uterotonic agent, is administered.If uterine atony persists, the best next step in management is tranexamic acid, an antifibrinolytic agent that prevents the breakdown of blood clots to achieve hemostasis; its use reduces maternal mortality from hemorrhage.Patients with continued bleeding are administered second-line uterotonic medications, including carboprost tromethamine, methylergonovine, and misoprostol. Carboprost tromethamine is contraindicated in patients with asthma due to the risk of bronchospasm. Methylergonovine is contraindicated in patients with hypertension (regardless of the patient's current blood pressure) due to an increased risk of stroke (Choices A and D).If PPH does not resolve with medical therapy, an intrauterine balloon tamponade can be used to compress placental bed blood vessels for hemostasis (Choice C).Finally, patients with PPH refractory to medical and minimally invasive techniques require either uterine artery embolization or surgical management with laparotomy (and possible hysterectomy). Initial management includes the placement of 2 large-bore intravenous lines for volume resuscitation. Bimanual uterine massage and bladder catheterization are performed to improve uterine tone. High-dose oxytocin, the first-line uterotonic agent, is administered. Initial management includes the placement of 2 large-bore intravenous lines for volume resuscitation. Bimanual uterine massage and bladder catheterization are performed to improve uterine tone. High-dose oxytocin, the first-line uterotonic agent, is administered. Bimanual uterine massage If uterine atony persists, the best next step in management is tranexamic acid, an antifibrinolytic agent that prevents the breakdown of blood clots to achieve hemostasis; its use reduces maternal mortality from hemorrhage. If uterine atony persists, the best next step in management is tranexamic acid, an antifibrinolytic agent that prevents the breakdown of blood clots to achieve hemostasis; its use reduces maternal mortality from hemorrhage. Patients with continued bleeding are administered second-line uterotonic medications, including carboprost tromethamine, methylergonovine, and misoprostol. Carboprost tromethamine is contraindicated in patients with asthma due to the risk of bronchospasm. Methylergonovine is contraindicated in patients with hypertension (regardless of the patient's current blood pressure) due to an increased risk of stroke (Choices A and D). Patients with continued bleeding are administered second-line uterotonic medications, including carboprost tromethamine, methylergonovine, and misoprostol. Carboprost tromethamine is contraindicated in patients with asthma due to the risk of bronchospasm. Methylergonovine is contraindicated in patients with hypertension (regardless of the patient's current blood pressure) due to an increased risk of stroke (Choices A and D). If PPH does not resolve with medical therapy, an intrauterine balloon tamponade can be used to compress placental bed blood vessels for hemostasis (Choice C). If PPH does not resolve with medical therapy, an intrauterine balloon tamponade can be used to compress placental bed blood vessels for hemostasis (Choice C). intrauterine balloon tamponade Finally, patients with PPH refractory to medical and minimally invasive techniques require either uterine artery embolization or surgical management with laparotomy (and possible hysterectomy). Finally, patients with PPH refractory to medical and minimally invasive techniques require either uterine artery embolization or surgical management with laparotomy (and possible hysterectomy). (Choice B) Dilation and curettage is indicated for PPH due to retained products of conception (eg, placenta, membranes). Although this patient's placenta was extracted in pieces, an ultrasound revealed no evidence of retained products of conception (eg, a thin endometrial stripe). (Choice F) Vaginal packing with sterile gauze can be used to apply pressure to bleeding vaginal mucosa (eg, after vaginal sulcal laceration repair) to allow for clot formation. However, vaginal packing is extrauterine and therefore does not compress the bleeding placental bed blood vessels. In addition, packing may delay the evaluation and diagnosis of PPH. Educational objective: Postpartum hemorrhage is defined as an estimated blood loss ≥1,000 mL or bleeding with signs/symptoms of hypovolemia. The management of postpartum hemorrhage due to uterine atony occurs in a stepwise approach. Initial treatment includes administration of high-dose oxytocin, the first-line uterotonic agent. References: Postpartum hemorrhage: prevention and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28409600) Tranexamic acid for preventing postpartum haemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/26079202)

Bimanual Massage of the Uterus Is Performed, and 2 Large-Bore