Reproductive · Year 2 · from Reproductive
Case 1: Postpartum Hemorrhage Due to Uterine Atony
Clinical Image
Source: Wikipedia - Postpartum bleeding - CC BY-SA 4.0
Case Presentation
A 32-year-old G4P4 woman has just delivered a 4.1 kg infant vaginally after oxytocin augmentation for a prolonged labor lasting 18 hours. The placenta delivers spontaneously 10 minutes after delivery. Within 30 minutes postpartum, the nurse notes heavy vaginal bleeding with clots. Estimated blood loss is already 800 mL. The uterus is palpated and found to be soft and "boggy" above the umbilicus rather than firm and contracted. Vital signs show heart rate 105 bpm and blood pressure 100/65 mmHg. The diagnosis is postpartum hemorrhage secondary to uterine atony. Bimanual uterine massage is initiated immediately. Oxytocin infusion is increased, and methylergonovine (Methergine) 0.2 mg IM is administered (after confirming the patient is not hypertensive). The uterus remains poorly contracted. Misoprostol 800 mcg is given rectally. Tranexamic acid 1 gram IV is administered. With aggressive uterotonic therapy and continued massage, the uterus becomes firm. Total blood loss is estimated at 1500 mL. The patient receives 2 units of packed red blood cells. Hemoglobin the following day is 8.5 g/dL. She is discharged on day 2 with oral iron supplementation and does well at her postpartum visit.
Key Learning Points
- Uterine atony is the most common cause of postpartum hemorrhage (PPH), accounting for approximately 70% of cases; risk factors include overdistension (macrosomia, polyhydramnios, multiple gestation), prolonged labor, chorioamnionitis, and oxytocin use
- The "4 T's" framework for PPH causes: Tone (atony), Tissue (retained products), Trauma (lacerations), and Thrombin (coagulopathy)
- First-line management includes uterine massage and uterotonic agents: oxytocin, methylergonovine (contraindicated in hypertension), carboprost (contraindicated in asthma), and misoprostol
- Tranexamic acid given within 3 hours of delivery reduces PPH-related mortality and should be considered early in management