OB/GYN
A 36-year-old primigravida woman just delivered spontaneously baby girt weighing 4.4 kg.
After 5 minutes placenta is delivered complete and intact. Massaging of the uterine is performed along with 20 units of oxytocin in 1000 mL of lactated Ringers fast drip. After careful inspection of the genital tract, a second-degree laceration was identified and a 2-cm left lateral vaginal wall laceration, suturing is difficult because of brisk bleeding from above the site of laceration. Physical examination reveals a soft, boggy uterine fundus. Blood pressure 164/92 mmHg, Heart rate 130 /min, Respiratory rate 18 /min, Temperature 37 °C. Which of the following is the next best step in management?
Explanation
Core Concept: Postpartum hemorrhage (PPH) most commonly results from uterine atony (a "boggy" uterus). When first-line therapy (uterine massage and oxytocin) fails, second-line uterotonic agents are required.
Clinical Presentation:
- Excessive vaginal bleeding post-delivery.
- Soft, boggy, and poorly contracted uterine fundus.
- Tachycardia and hypotension if bleeding is severe.
- Complications: Hypovolemic shock, coagulopathy (DIC), and Sheehan syndrome.
Diagnosis:
- First-line diagnostic tool: Clinical assessment of blood loss and uterine tone.
- Most accurate (gold standard) test: Clinical diagnosis; quantitative blood loss measurement and coagulation profile if coagulopathy is suspected.
Management:
- Acute management: Bimanual uterine massage, IV fluids, and second-line uterotonics. Methylergonovine is contraindicated here due to hypertension (BP 164/92). Prostaglandin F2-alpha (Carboprost/Hemabate) is the drug of choice (contraindicated in asthma).
- Definitive management: Intrauterine balloon tamponade, uterine artery embolization, or exploratory laparotomy with hysterectomy if medical management fails.