Case 15 A 37-year-old woman with heavy bleeding per vaginum following a forceps delivery

 Case 15 A 37-year-old woman with heavy

bleeding per vaginum following a

forceps delivery

Mrs Brown, a 37-year-old para 5, delivered by rotational

forceps, was noted to have steady heavy bleeding per

vaginum while in the recovery, 1hour 30minutes after

delivery. You have been called to assess her.

What differential diagnosis would you

be considering as a cause for

postpartum haemorrhage (PPH)?

• Uterine atony

• Traumatic cause – vaginal or cervical tear

• Retained placenta or placental tissue

• Disseminated intravascular coagulation

• Uterine rupture

• Uterine inversion

What other relevant information would

you wish to obtain?

• Was the placenta complete?

• What was the weight of the baby?

• Had labour been prolonged?

Mrs Brown has had five spontaneous vaginal deliveries in

the past. There had been no complications in the previous

pregnancies and deliveries.

In the current pregnancy there had been no problems

antenatally, labour was induced at 40 weeks +12 days.

Labour was augmented with oxytocin because of slow

progress in the first stage and a rotational forceps delivery

was performed in theatre for a prolonged second stage and

occipito-transverse fetal position. The baby weighed 4.17kg.

Placenta and membranes were delivered completely and the

episiotomy was sutured in layers. The total blood loss at the

end of the procedure was 450mL.

What features would you look for in

your examination?

• Signs of pallor, pulse and BP

• On abdominal examination – level of the uterus in

relation to umbilicus, tone of uterus (atonic or

contracted)

• Assessment of the vaginal bleeding

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.

KEY POINT

Primary postpartum haemorrhage (PPH) is defined as loss

of more than 500mL blood from the genital tract within

24hours of delivery. Secondary PPH is vaginal bleeding of

more than 500mL after 24hours and up to 6 weeks after

delivery. Massive PPH is blood loss of more than 1.5L.

What specific questions would you ask?

• What has the total blood loss since delivery been?

• What oxytocics have been administered so far?

• What are her pulse and blood pressure (BP)

recordings?

Mrs Brown had lost about 400mL blood vaginally while in

recovery, with a steady trickle continuing. The total blood

loss since delivery is estimated to be 850mL. Her pulse rate

is 96beats/minute and her BP is 121/78mmHg. She had

syntometrine in the third stage of labour.

KEY POINT

Active management of the third stage of labour reduces

the risk of atonic PPH. Ergometrine 500μg with 5units

oxytocin is given by intramuscular injection immediately

after the baby is delivered. Alternatively, 10units oxytocin

alone may be given by intramuscular injection if

ergometrine is inappropriate as in cases of pre-eclampsia

or cardiac disease.104 Part 2: Cases

PART 2: CASES

Box 15.1 Predisposing factors for postpartum

haemorrhage

• Uterine overdistention – multiple pregnancy,

polyhydramnios, big baby

• Prolonged labour

• Antepartum haemorrhage – placenta previa, abruption

• Grand multiparity (parity >5)

• General anaesthesia

Table 15.1 Clinical findings in obstetric haemorrhage.

Blood volume loss Blood pressure (systolic) Symptoms and signs Degree of shock

500–1000mL (10–15%) Normal Palpitations, tachycardia, dizziness Compensated

1000–1500mL (15–25%) Slight fall (80–100mmHg) Weakness, tachycardia, sweating Mild

1500–2000mL (25–35%) Moderate fall (70–80mmHg) Restlessness, pallor, oliguria Moderate

2000–3000mL (35–50%) Marked fall (50–70mmHg) Collapse, air hunger, anuria Severe

After ACOG educational bulletin. Hemorrhagic shock. Int J Gynaecol Obstet (1997) 57: 219–226.

Mrs Brown appears comfortable. There is no obvious pallor,

her pulse is 96beats/minute and her BP 121/78mmHg. The

uterus is palpable till the umbilicus and does not appear to

be well contracted. A vaginal pad is fully soaked with blood

and there is a persistent trickle continuing (Table 15.1).

What would be your initial

management?

• IV access – two large (14 G) cannulae should be

inserted

• Blood for full blood count (FBC), urea and electrolytes

(U & E), coagulation screen, group and save and ask for

at least 2 units of cross - matched blood

• Volume replacement with crystalloids followed by

colloids

• Nasal oxygen 8 – 10 L/minute

• Catheterize the bladder

• Massage the uterus and perform bimanual compression (Fig. 15.1 )

• Involve the senior obstetrician, anaesthetist and senior

midwife at an early stage

A bolus of 500μg ergometrine should be administered

IV. A total of 1 mg ergometrine can be given if there is

continued atony.

Give 5 – 10 units oxytocin as an IV bolus and oxytocin

infusion (40 units oxytocin in 500 mL normal saline at a

rate of 125 mL/hour) should be commenced IV.

Figure 15.1 Bimanual compression.

If the uterus remains atonic with persistent bleeding

despite the above measures, 250μg carboprost IM could

be administered and repeated after 15 minutes, depending on the response to a maximum dose of 2 mg (eight

doses).

Following administration of ergometrine, give an oxytocin bolus and oxtyocin infusion.

Mrs Brown’s uterus is well contracted, but there is still

continued vaginal bleeding. The placenta appears complete.

By now she has lost 1.6L blood. Her pulse is 112beats/

minute, her BP is 96/50mmHg and she appears pale. Her

haemoglobin is 96g/L and the coagulation profile is normal.

What is the next line of management?

• Head - down tilt

• Oxygen 8 – 10 L/minute by mask

• Hartman solution 2 L IV, Gelofusine 1.5 L IV

• Cross - match 6 units, O - negative blood if cross - match

not readyCase 15 105

PART 2: CASES

vaginal tears are sutured and haemostasis secured. Total

blood loss by the end of EUA is 3.2L. She receives 4units

blood and 1unit of fresh frosen plasma. Prophylactic

intravenous augmentin is administered (Figs 15.2 and 15.3;

Box 15.4).

What would be your postoperative

management?

• Monitoring of pulse, BP, respiratory rate, oxygen saturation and temperature every 15 minutes

• Monitoring of hourly urine output

• Watch for vaginal bleeding

• Thromboembolic disease stockings and dalteparin if

platelets and clotting are normal

Box 15.2 Management of retained placental • Repeat FBC, clotting profile and U & E

tissue

If the placenta has not been delivered before the onset of

PPH, an attempt should be made to deliver it with cord

traction and uterine countertraction. Care must be taken

because the risk of uterine inversion is greater if the uterus

remains poorly contracted. Manual removal should be

performed under anaesthesia if the placenta is not easily

delivered or the cord is avulsed.

If the placenta has been previously delivered, then

exploration of the uterus is indicated if the uterus

continues to relax when bimanual compression and

massage are stopped despite the administration of

uterotonics.

Inverted uterus

The uterus is said to be inverted if it turns inside-out

during delivery of the placenta. Repositioning the uterus

should be performed immediately.

Box 15.3 Management of genital tract trauma

Genital tract trauma is the most likely cause if bleeding

persists despite a well-contracted uterus. EUA with

suturing of vaginal or cervical laceration using absorbable

suture material is indicated.

Lower genital tract haematomas are usually managed by

incision and drainage, although expectant management is

acceptable if the lesion is not enlarging. Any bleeding

vessels are tied off, and oozing areas may be oversewn.

Broad ligament and retroperitoneal haematomas can be

initially managed expectantly if the patient is stable and

the lesions are not expanding. Ultrasound, CT scanning

and MRI can all be used to assess the size and progress of

these haematomas. Selective arterial embolization may be

the treatment of choice if intervention is required in these

patients.

• Communicate with the senior midwife, senior obstetrician, anaesthetist, haematologist, blood transfusion

service and porter

• Continuous pulse/BP/oximeter

• Examination under anaesthesia (EUA) in theatre to

rule out cervical, vaginal laceration and retained placental remnants (Boxes 15.2 & 15.3 )

Mrs Brown has an EUA under general anaesthetic which

shows bleeding from a cervical and vaginal tear. The uterus

is contracted and found to be empty. A central venous

pressure line is inserted by the anaesthetist. Cervical and

Ovarian ligament Fallopian tube Round ligament

Broad

ligament

(a) Anterior view (b) Posterior view (c) Anterior view

Figure 15.2 Insertion of the B-Lynch suture. (a) and (b) demonstrate the anterior and posterior views of the uterus showing the application

of the B-Lynch Brace suture; (c) shows the anatomical appearance after competent application.106 Part 2: Cases

PART 2: CASES

Mrs Brown recovers very well. Her observations are stable

with good urine output and minimal lochia. The repeat

haemoglobin is 88g/L, platelets 187 × 10−9/L, with normal

U&E and clotting. She receives dalteparin until she is fully

mobile and is started on 200mg ferrous sulphate twice

daily. She goes home on the fourth post-delivery day with

follow-up arranged with the community midwife. The

puerperium is uncomplicated until day 12 when she begins

to feel unwell with some lower abdominal pain and

increased lochia. The bleeding becomes heavier the

following day and is also associated with a fever which

brings her into the hospital.

What is the diagnosis and what do

you think are the possible causes of

the problem?

The diagnosis is secondary PPH. The two most common

causes of secondary PPH are retained products of conception and intrauterine infection (endometritis).

What are the important features on

history and examination?

A review of the hospital notes and delivery records to

confirm completeness of the placenta, etc. Signs of pallor,

pulse, temperature and BP should be checked.

On abdominal examination, the level of the uterus in

relation to the umbilicus, signs of peritonism and uterine

tenderness should be looked for. The vaginal loss should

be assessed and a speculum examination carried out to

see if the cervical os is open.

Mrs Brown’s pulse is 88beats/minute, BP 100/70mmHg,

temperature 38.1°C, her abdomen is soft and she has

moderate vaginal loss. The uterus was well involuted, tender

and the cervix closed.

What is the most likely cause for PPH

here and what investigations would

you perform?

The diagnosis is endometritis as the uterus is involuted

but tender and the cervix is closed and therefore retained

placental remnants are unlikely in this case.

Blood should be taken for FBC, clotting profile, U & E,

C - reactive protein, group and save, and 2 units of blood

at least cross - matched.

An endocervical swab, high vaginal swab and blood

cultures should also be taken.

What are the most likely organisms

responsible for secondary PPH and what

antibiotics would you administer?

The most likely organisms are anaerobes including

bacteroids and peptostreptococci and the enteropharyngeal group which includes Escherichia coli and

streptococci.

Antibiotics (intravenous while she remains pyrexial)

may need to include metronidazole to cover anaerobes,

aminoglycoside for Gram - negative organisms and cefuroxime to cover Gram - positive organisms.

Mrs Brown’s haemoglobin level is 88g/L, her white cell

count 19.2 × 109/L, platelets 332 × 109/L, CRP 253mg/L, and

U&E and clotting are normal. The high vaginal swab grows

Streptococcus viridans sensitive to augmentin. She responds

well to antibiotics, her bleeding settles and she makes a

good recovery.

Figure 15.3 Bakri intrauterine balloon.

Box 15.4 Management of coagulopathy

If manual exploration has excluded genital tract trauma or

retained placental fragments, bleeding from a wellcontracted uterus is most commonly caused by a defect in

haemostasis. Coagulation screen results clarify this

diagnosis. Replacement with blood products is indicated.

Cryoprecipitate may be useful along with fresh frozen

plasma because of the markedly depressed fibrinogen

levels. Cryoprecipitate provides a more concentrated form

of fibrinogen and other clotting factors (VIII, XIII, von

Willebrand factor).Case 15 107

PART 2: CASES

Box 15.5 Surgical methods of managing atonic postpartum haemorrhage

If there is continued bleeding despite aggressive medical

management, surgical management should be considered

early.

Conservative measures

• Packing of uterus: packing the uterus with sterile gauze

could be attempted, with the end of the pack fed

through the cervix into the vagina

• Balloon tamponade: ‘Bakri SOS’ balloon, Sengstaken–

Blakemore oesophageal catheter and the Rusch urological

hydrostatic balloon are options for tamponade. The

balloon is inflated with 100–300mL warm 0.9% sodium

chloride until enough counter-pressure is exerted to stop

bleeding from uterine sinuses. The balloon tamponade is

left in place for 6–8hours to allow time for blood

transfusion and coagulopathy correction. Once vital

parameters are within acceptable limits, the balloon is

deflated in two stages – half the 0.9% sodium chloride is

withdrawn, and if there is no significant bleeding after

30minutes, the remaining volume is withdrawn to deflate

and remove the balloon.

Laparotomy

• B-Lynch suture: this involves opening the lower segment

and passing a suture through the posterior uterine wall

and then over the fundus to be tied anteriorly.

• Uterine artery ligation

• Internal iliac artery ligation

• Hysterectomy: this is curative for bleeding arising from the

uterus or cervix While subtotal hysterectomy may be

performed faster and be effective for bleeding caused by

uterine atony, it may not be effective for controlling bleeding

from the lower segment, cervix or vaginal fornices.

Uterine artery embolization

Interventional radiology should be considered in the

management of PPH when surgical options have been

exhausted, in managing haematomas, and with continued

bleeding following hysterectomy.

CASE REVIEW

Mrs Brown was a grand multipara which increased her risk

of atonic PPH and had a rotational forceps delivery which

also put her at a higher risk of traumatic PPH. She received

supportive care to maintain her circulating blood volume

and oxygenation and treatment with oxytocics (ergometrine and oxytocin) which controlled the uterine atonicity.

However, as the bleeding continued she had an EUA in

theatre, both to see if there were tears of the cervix, vagina

or uterus causing the continuing bleed and also to confirm

an empty uterus without any retained remnants of placenta. The EUA revealed cervical and vaginal tears that

were repaired and haemostasis achieved.

She presented some days later with a secondary PPH

which was clinically and on investigation likely to be

caused by an endometritis. This responded well to antibiotics. In view of her grand multiparity, Mrs Brown is at a

higher risk of PPH in subsequent pregnancies.

Obstetric haemorrhage remains a problem both in

terms of maternal mortality and severe morbidity. The

incidence of severe bleeding in childbirth is estimated

to be 5 per 1000 maternities. Dealing with an ill bleeding

woman requires skilled teamwork between obstetric and

anaesthetic teams with appropriate help from other specialists including haematologists, vascular surgeons and

radiologists. Senior staff should be involved as early as

possible.

Maternal tachycardia, severe abdominal pain and tenderness are important early features of genital tract sepsis.

High - dose broad - spectrum intravenous antibiotics should

be started immediately sepsis is suspected, without waiting

for microbiology results. Disseminated intravascular coagulation and uterine atony are common in genital tract

sepsis and often cause life - threatening PPH.108 Part 2: Cases

PART 2: CASES

KEY POINTS

• Primary PPH can be caused by uterine atony, trauma to

the genital tract, problems with coagulation or a

combination of these. Secondary PPH may be brought

about by endometritis and/or retained placental remnants

• With a significant PPH, resuscitation of the mother,

supportive care, good communication with other

specialities including anaesthetics and haematologists, and

appropriate investigation and intensive monitoring is vital

• With a uterine atony, completeness of the placenta must

be confirmed and measures instituted including

administration of oxytocics and bimanual massage of the

uterus

• When bleeding continues despite aggressive medical

management, surgical management should be considered

early. An EUA to rule out retained placental remnants or

trauma of the genital tract should be undertaken in the

first instance with recourse to other measures including

ballon tamponade of the uterus, laparotomy and B-Lynch

suture, as required

• With secondary PPH, management includes appropriate

resuscitation, antibiotic treatment and evacuation of the

uterus, if indicated