Postpartum Haemorrhage with Retained Placenta and Coagulopathy
A 28-year-old woman, G2P1, delivered a 4.2 kg baby spontaneously 30 minutes ago. She had a prolonged second stage and received oxytocin augmentation. The placenta has not delivered. She is now pale, anxious, and has a heart rate of 120 bpm, blood pressure 90/60 mmHg, and estimated blood loss of 800 mL. The uterus is soft and fundal height is above the umbilicus. Intravenous access is in place with a 16G cannula, and she has received 10 IU oxytocin IM. She is Rh positive. The unit has a blood bank and a consultant on call.
1. What is your immediate management of this postpartum haemorrhage with a retained placenta?
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Resuscitation: ABCDE approach. Call for help (senior obstetrician, anaesthetist, haematologist, porters). Ensure two large-bore IV lines, take blood for full blood count, coagulation screen, fibrinogen, U&E, cross-match 4 units. Start crystalloid and initiate blood transfusion if indicated (likely with ongoing bleeding and signs of shock). Keep her warm, monitor urine output, and consider catheterisation.
Uterine massage and pharmacological: Bimanual uterine massage. Give uterotonics: oxytocin infusion (e.g., 40 IU in 500 mL over 4 hours), ergometrine 0.5 mg IM (if no hypertension), carboprost 250 mcg IM every 15 min (max 8 doses) or misoprostol 800 mcg sublingually. Avoid ergometrine if hypertensive.
Retained placenta: With signs of shock and heavy bleeding, manual removal of placenta in theatre is indicated. Do not wait for spontaneous delivery. Perform under anaesthesia with antibiotic cover. If placenta is adherent (accreta), be prepared for possible hysterectomy and call for senior help.
Coagulopathy: Monitor coagulation; if fibrinogen <2 g/L or signs of DIC, give fresh frozen plasma, cryoprecipitate, and platelets as guided by haematology. Tranexamic acid 1 g IV if not already given.
Escalation: If bleeding continues, consider balloon tamponade, uterine artery embolisation, or laparotomy with B-Lynch suture or hysterectomy. Document all steps.
2. Two hours later, the placenta has been manually removed. The patient is now stable but has ongoing oozing from venepuncture sites and her fibrinogen is 1.2 g/L. What is the diagnosis and how do you manage it?
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The diagnosis is disseminated intravascular coagulation (DIC) secondary to postpartum haemorrhage and retained placenta. Ongoing oozing and low fibrinogen (<2 g/L) support this.
Management:
- Treat the cause: Ensure uterus is contracted, no retained products, and infection is treated. Continue uterotonics as needed.
- Supportive: Monitor vital signs, urine output, and bleeding. Repeat coagulation profile, fibrinogen, platelets, and D-dimer.
- Blood products: Give fresh frozen plasma (FFP) 15–20 mL/kg to replace clotting factors, cryoprecipitate (if fibrinogen <1.5 g/L) to raise fibrinogen, and platelets if platelet count <50 x 10^9/L with bleeding. Target fibrinogen >2 g/L, platelets >50, and PT/APTT near normal.
- Tranexamic acid: Consider 1 g IV if not already given.
- Haematology input: Involve haematologist for guidance.
- Avoid over-transfusion: Use point-of-care testing if available (e.g., ROTEM).
- Monitor for complications: Renal failure, respiratory distress, and thromboembolism (use thromboprophylaxis once bleeding controlled).
After stabilisation, debrief the patient and provide contraception advice and follow-up.