Case 88: Postpartum bleeding

 CASE 88: POSTPARTUM BLEEDING

History

A 39-year-old woman in her first pregnancy delivered twin sons 2 h ago. There were no significant antenatal complications. She had been prescribed ferrous sulphate and folic acid during

the pregnancy as anaemia prophylaxis, and her last haemoglobin was 10.9 g/dL at 38 weeks.

The fetuses were within normal range for growth and liquor volume on serial scan estimations. A vaginal delivery was planned and she went into spontaneous labour at 38 weeks and

4 days. Due to decelerations in the cardiotocograph (CTG) for the first twin, both babies were

delivered by ventouse after 30 min active pushing in the second stage. The midwife recorded

both placentae as appearing complete.

As this was a twin pregnancy, an intravenous cannula had been inserted when labour was

established and an epidural had been sited. The lochia has been heavy since delivery but the

woman is now bleeding very heavily and passing large clots of blood.

On arrival in the room you find that the sheets are soaked with blood and there is also

approximately 500 mL of blood clot in a kidney dish on the bed.

Examination

The woman is conscious but drowsy and pale. The temperature is 35.9°C, blood pressure

120/70 mmHg and heart rate 112/min. The peripheries feel cool. The uterus is palpable to the

umbilicus and feels soft. The abdomen is otherwise soft and non-tender. On vaginal inspection there is a second-degree tear which has been sutured but you are unable to assess further

due to the presence of profuse bleeding.

The midwife sent blood tests 30 min ago because she was concerned about the blood loss at

the time.

INVESTIGATIONS

Normal range for

pregnancy

Haemoglobin 7.2 g/dL 11–14 g/dL

Mean cell volume 99.0 fL 74.4–95.6 fL

White cell count 3.2×109/L 6–16×109/L

Platelets 131×109/L 150–400×109/L

International normalized ratio (INR) 1.3 0.9–1.2

Activated partial thromboplastin time (APTT) 39 s 30–45 s

Sodium 138 mmol/L 130–140 mmol/L

Potassium 3.5 mmol/L 3.3–4.1 mmol/L

Urea 5.2 mmol/L 2.4–4.3 mmol/L

Creatinine 64 mmol/L 34–82 mmol/L

Questions

• What is the diagnosis and what are the likely causes?

• What is the sequence of management options you would employ in this situation?100 Cases in Obstetrics and Gynaecology

248

ANSWER 88

The diagnosis is primary postpartum haemorrhage (PPH), defined as the loss of more than

500 mL of blood in the first 24 h following delivery. This classification applies even if the

blood is lost at caesarean section or while awaiting placental delivery.

! Causes of and risk factors for postpartum haemorrhage

• Uterine atony (multiple pregnancy, grand multiparity, polyhydramnios, prolonged

labour)

• Antepartum haemorrhage

• Uterine sepsis (chorioamnionitis)

• Retained placenta

• Lower genital tract trauma (perineal or cervical tears)

• Coagulopathy (heparin treatment, inherited bleeding disorders)

• Previous PPH

This woman’s major risk factor is multiple pregnancy and with the high uterus, the cause is

likely to be uterine atony (inability of the uterus to contract adequately). Blood loss is often

underestimated, the ‘high’ uterus may contain a large volume of concealed blood and the

blood pressure in young fit women remains relatively normal until decompensation occurs.

Therefore this woman is in fact extremely sick and at risk of cardiac arrest if immediate management is not employed.

The sequence of management strategies is:

• bimanually compress the uterus (with one hand abdominally compressing and the

other hand compressing from the vagina) to expel any clots and stimulate the uterus

to contract

• ensure two large-bore cannulae are inserted with crossmatched blood requested

• recheck full blood count and coagulation

• commence intravenous fluids for volume expansion

• give 500 mg ergometrine intramuscularly or intravenously to enhance uterine

contraction

• start a syntocinon infusion to maintain uterine contraction

• consider other uterotonics such as misoprostol or carboprost

• transfer to theatre for examination under anaesthetic to assess for vaginal trauma,

cervical laceration or retained placental tissue

• the doctor or midwife should continue bimanual compression until the clinical situation is under control

• an inflatable intrauterine balloon should be inserted once traumatic causes of bleeding have been excluded

• if the bleeding does not settle with the above measures, and with correction of any

coagulopathy, then further options are uterine artery embolization or laparotomy

with B-Lynch haemostatic suture, uterine artery ligation or hysterectomy.Case 88: Postpartum bleeding

249

KEY POINTS

• Uterine compression from the abdomen or bimanually is the first and immediate management strategy for postpartum haemorrhage and should be continued

until the clinical situation has settled.

• Clinicians usually underestimate blood loss and in assessing haemodynamic status

may forget to take account of concealed loss (into the uterus) and the ability of

healthy women to compensate.