History
A 32-year-old woman is brought into the delivery suite by ambulance 6 days following a vaginal delivery at 39 weeks’ gestation. The pregnancy and labour had been unremark-able and the placenta was delivered by controlled cord traction. Following delivery the woman had been discharged home after 6 h. She reported that the lochia had been heavy for the first 2 days but that it had then settled to less than a period. However today she had suddenly felt crampy abdominal pain and felt a gush of fluid, fol-lowed by very heavy bleeding. The blood has soaked through clothes and she had passed large clots, which she describes as the size of her fist. She feels dizzy when she stands up and is nauseated.
Examination
She is pale with cool and clammy extremities. She is also drowsy. Her blood pressure is 105/50 mmHg and heart rate is 112/min. On abdominal palpation there is minimal tender-ness but the uterus is palpable approximately 6 cm above the symphysis pubis. Speculum examination reveals large clots of blood in the vagina. When these are removed, the cervix is seen to be open.
Questions
• What is the diagnosis?
• What is your immediate and subsequent management?
• Should an ultrasound scan be requested?
Medicine
The diagnosis is secondary postpartum haemorrhage.
Immediate management
This woman is in hypovolaemic shock and needs immediate resuscitation. Two wide-bore cannulae should be inserted and blood sent for full blood count, urea and electrolytes, clotting and crossmatch of 4 units, with further red cells, platelets or fresh-frozen plasma requested depending on further evaluation and blood results. Immediate intravenous fluid should be administered, usually colloid as volume expansion to maintain cardiac output. The uterus should be rubbed suprapubically, and if this fails then bimanually, pending administration of 500 μg ergometrine and commencing a syntocinon infusion. These meas-ures stem the blood loss and aid immediate resuscitation while the diagnosis is investigated.
A urinary catheter should be inserted to allow close fluid balance monitoring and renal function.
The anaesthetist and senior obstetrician should be called urgently. Subsequent management The fact that the cervix is open is pathognomonic of retained tissue, and evacuation of retained products of conception should be arranged once the woman has been resuscitated and blood is available. In view of the haemodynamic instability, general anaesthetic is preferred. Intravenous antibiotics should be given. The woman should be monitored initially in a high-dependency setting until clinically and haematologically stable. Although she is likely to have had a coagulopathy at admission, she is still at high risk of venous thromboembolism as she is probably septic, postpartum and has undergone anaesthetic.
Thromboembolic stockings and heparin should therefore be administered postoperatively. Ultrasound scan Ultrasound scan would not be indicated in this scenario. First, an open cervix implies retained products and it would therefore be superfluous. Second, an examination under anaesthetic is warranted anyway to establish any other cause of bleeding, such as vaginal or perineal trauma. Third, retained products may be confused with blood clot on post-partum ultrasound.
KEY POINTS
• Postpartum women with retained products of conception become very ill very quickly. Once the diagnosis is made they need intravenous antibiotics and urgent evacuation of the uterus.
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