A 24-year-old woman, gravida 1 para 1, is evaluated on labor and delivery for heavy vaginal bleeding. Thirty minutes earlier, the patient underwent a forceps-assisted vaginal delivery of a 4.4 kg (9 lb 11 oz) male infant at 41 weeks gestation. She feels dizzy and nauseated. The patient has asthma and has had to use her albuterol inhaler with increasing frequency throughout her pregnancy. Temperature is 36.1 C (97 F), blood pressure is 104/78 mm Hg, and pulse is 102/min. Oxygen saturation is 98%. The patient appears pale. The abdomen is soft and nontender, and the fundus is boggy and palpable above the umbilicus. Pelvic examination shows an intact perineal repair, no vaginal or cervical lacerations, and profuse vaginal bleeding with passage of large clots. Uterine massage and high-dose oxytocin do not resolve the bleeding. Which of the following is the best next step in management of this patient?
Postpartum uterine atony | |
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This patient with heavy vaginal bleeding and an enlarged, boggy uterus has uterine atony, the most common cause of postpartum hemorrhage. Uterine atony occurs due to insufficient uterine contractility after delivery, resulting in continued bleeding from open placental bed vessels. Risk factors include uterine overdistension (eg, macrosomia) and operative vaginal delivery, as in this patient.
First-line treatment for uterine atony includes bimanual uterine massage and high-dose oxytocin. If atony persists, additional medications are indicated, and the best next step in management is the administration of tranexamic acid. Tranexamic acid is an antifibrinolytic agent that prevents the breakdown of blood clots to achieve hemostasis, and its use reduces maternal mortality rates from hemorrhage.
(Choice A) Broad-spectrum antibiotics are not routinely administered after an operative vaginal delivery. They are indicated in patients with postpartum endometritis, which can present with heavy vaginal bleeding. However, endometritis also causes fever and uterine tenderness, which are not seen in this patient.
(Choice B) In patients whose uterine atony does not respond to bimanual uterine massage, high-dose oxytocin, and tranexamic acid, the next step is to administer second-line uterotonics such as carboprost tromethamine, a prostaglandin that increases uterine contractility. However, carboprost tromethamine can cause bronchospasm and, therefore, is contraindicated in patients with asthma.
(Choice C) If this patient's vaginal bleeding does not resolve with medical therapy and she continues to have massive hemorrhage, blood products (eg, fresh frozen plasma) may be required for patient stabilization.
(Choice E) Vaginal packing with sterile gauze can be used to apply pressure to bleeding vaginal mucosa temporarily (eg, after vaginal sulcal laceration repair) to allow for clot formation. However, it does not treat postpartum hemorrhage caused by uterine atony and may delay diagnosis in these patients.
Educational objective:
Uterine atony is the most common cause of postpartum hemorrhage, and first-line treatment includes bimanual uterine massage and high-dose oxytocin. In patients with persistent bleeding, the best next step in management is administration of tranexamic acid, an antifibrinolytic agent that prevents the breakdown of blood clots to achieve hemostasis.