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 esti- mations. 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.
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.
· What is the diagnosis and what are the likely causes?
· What is the sequence of management options you would employ in this situation?
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.
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 decompensa- tion 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:
· rub up a contraction by placing the dominant hand over the uterus and rubbing and squeezing firmly until the uterus becomes firm
· ensure two large-bore cannulae are inserted with cross-matched blood requested
· recheck full blood count and coagulation
· commence intravenous fluids for volume expansion
· give 500 μg 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, cer- vical laceration or retained placental tissue
· the doctor or midwife should continue bimanual compression until the clinical situa- tion is under control
· if the bleeding does not settle with the above measures then further options are uterine artery embolization or laparotomy with B-Lynch haemostatic suture, uterine artery lig- ation or hysterectomy.
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