Postpartum hemorrhage: Clinical

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Postpartum hemorrhage: Clinical

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A 30-year-old woman, gravida 3 para 2, is admitted to the labor and delivery unit in active labor. This pregnancy was complicated by gestational diabetes mellitus, which was managed with metformin. An hour after admission, the patient delivers a healthy baby weighing 4100 g (9 lb 1 oz). Thirty minutes after the placenta is delivered, blood starts flowing profusely from the vaginal vault. Placental examination reveals it is fully intact. The patient’s temperature is 37.0°C (98.6°F), pulse is 102/min, respirations are 20/min, and blood pressure is 80/60 mmHg. On physical examination, the uterus is soft and boggy. A large-bore IV catheter is inserted, followed by fluid and blood resuscitation. Which of the following is the most appropriate step in management?  


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Postpartum hemorrhage is worrisome when more than 500 milliliters of blood are lost after a vaginal delivery, or more than 1000 milliliters of blood are lost after a C-section.

Postpartum hemorrhage usually occurs in the 24 hours following delivery, in which case it’s called early, or primary postpartum hemorrhage.

But in rare situations, it happens later than 24 hours after delivery, and that’s where it’s called late, or secondary postpartum hemorrhage.

Postpartum hemorrhage, like any ongoing bleeding, can be classified according to the degree of hypovolemia and vital signs status.

Stage 1 is when 500 to 1000 milliliters of blood have been lost. Blood pressure is usually normal, but there may be palpitations, tachycardia and slight dizziness.

Stage 2 is when 1000 to 1500 milliliters have been lost. Systolic blood pressure drops to 80 to 100 mmHg, tachycardia is obvious, and there may be weakness and sweating.

Stage 3 is when 1500 to 2000 milliliters have been lost. Systolic blood pressure drops between 70 and 80 mmHg, and there may be restlessness, pallor and low urine output.

Finally, stage 4 is when more than 2000 milliliters have been lost, systolic blood pressure is less than 70 mmHg, and symptoms may include cardiovascular and respiratory collapse, loss of consciousness and and anuria.

Now, before elucidating the cause, some immediate measures should be taken in order to compensate the blood loss. These follow an A-B-C pattern.

A stands for airway, so you’ll want to protect the airway, especially when there’s loss of consciousness.

B stands for breathing, so you’ll want to administer Oxygen through a non-rebreather mask.

C stands for circulation - meaning measuring vital signs and establishing the degree of hypovolemia, inserting two large caliber peripheral IV catheters - of at least 14 gauge or even larger-gauge -, and starting fluid resuscitation immediately, with 500 milliliters of normal saline or lactated Ringer’s solution given over 30 minutes.


Postpartum hemorrhage is defined as blood loss of more than 500 mL for a vaginal delivery, or more than 1000 mL for cesarean delivery, within the first 24 hours following childbirth. Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breath rate.

Risk factors for PPH include prolonged labor, a large baby, placenta complications, an infection, or underlying medical conditions. Treatment for PPH depends on the cause and can range from uterine massage to a blood transfusion. Prevention strategies include proper prenatal care, labor monitoring, and active management of the third stage of labor.


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