Atonic Postpartum Haemorrhage in a Woman With Asthma and Pregnancy-Induced Hypertension
A 29-year-old woman, gravida 3 para 2, at 39 weeks undergoes category-1 caesarean delivery for prolonged fetal bradycardia under spinal anaesthesia. A 3.6 kg infant is delivered with Apgar 4 at one minute. Estimated blood loss is 700 mL at delivery and a further 1,200 mL by 20 minutes later. The uterus is soft and boggy with a steady trickle of blood and clots. She has received oxytocin 5 IU by slow IV injection and an infusion of 40 IU in 500 mL. Pulse 124/min, BP 96/58 mmHg, oxygen saturation 97% on air, and she is anxious and thirsty. Her history includes well-controlled asthma and pregnancy-induced hypertension; she takes no regular medication. Blood is being cross-matched, and a balloon tamponade device, a rapid infuser and a cell salvage set are all available. The consultant obstetrician is 15 minutes away.
1. Sequence your next ten minutes of management, naming the drugs you would use and the ones you would avoid in this specific patient, with reasons.
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Call for help and treat the physiology. Declare a postpartum haemorrhage and activate the massive haemorrhage protocol; allocate one person to blood, one to drugs, and one to recording. Two large-bore cannulae, warmed crystalloid to a minimum, cross-match, FBC, coagulation and fibrinogen.
Uterotonics, chosen around her comorbidities. Continue the oxytocin infusion, but do not give further rapid boluses - they cause hypotension, which she cannot afford. Avoid ergometrine: she has pregnancy-induced hypertension, and ergometrine raises blood pressure and provokes vomiting. Avoid or use only with extreme caution carboprost, a prostaglandin F2alpha analogue that causes bronchospasm - unacceptable in an asthmatic. Misoprostol 800 micrograms sublingually or 600 micrograms rectally is the safer third-line agent for her.
Tranexamic acid 1 g IV over 10 minutes, given within three hours of birth, repeated once after 30 minutes if bleeding continues.
Mechanical steps immediately. Bimanual uterine massage and compression, empty the bladder with a catheter, and inspect for genital tract trauma and retained placenta. If bleeding persists, insert the intrauterine balloon - do not wait for the consultant to arrive. Alert the anaesthetist, ICU and neonatology, and keep her warm.
2. State the thresholds at which you would escalate beyond drugs to tamponade and then to surgery, and justify the timeline you propose.
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Escalate on failure and on physiology, not on a fixed blood-loss figure alone. Practical triggers: blood loss exceeding 1,500 mL or ongoing loss above 200 mL every 15 minutes despite two adequate uterotonics; haemodynamic instability (systolic below 90 mmHg or heart rate above 130) despite blood products started; or a uterus that remains boggy after oxytocin, misoprostol and bimanual compression.
Tamponade first because it is the least invasive effective step and controls up to 85% of atonic bleeding. Balloon in, fill to the recommended volume, pack the vagina, and give a single dose of prophylactic antibiotic. Reassess in 15 minutes: if bleeding continues, if the balloon fills with blood, or if she remains unstable, the balloon has failed.
Then surgery, without a prolonged trial. Laparotomy with B-Lynch or vertical compression sutures, then stepwise devascularisation (uterine artery, then utero-ovarian), then hysterectomy. In an unstable patient, do not spend more than 30 minutes trialling the balloon; a balloon is a bridge to surgery, not a destination.
Call the consultant now and prepare theatre in parallel; the 15-minute arrival should not be on the critical path. Delay in the decision to operate - not the operation itself - is the commonest avoidable factor in deaths from postpartum haemorrhage.
3. She remains bleeding with a pulse of 132/min after the balloon is placed. Describe your transfusion and resuscitation strategy, including the parameters you target and the practices you avoid.
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Activate the massive transfusion protocol with a balanced ratio of packed red cells, fresh frozen plasma and platelets close to 1:1:1, and give cryoprecipitate or fibrinogen concentrate to keep fibrinogen above 1.5-2 g/L. In obstetric haemorrhage fibrinogen falls early and is the best single laboratory predictor of severity, so measure it and repeat it. Target haemoglobin above 7-8 g/dL, platelets above 50 x 10^9/L and INR below 1.5 in the actively bleeding patient; these are interim targets, not normal values.
Give calcium with every four units of blood, use warmed products through the rapid infuser, and keep the room warm - hypothermia, acidosis and dilution each worsen coagulopathy and compound the others.
Avoid large-volume crystalloid. It dilutes clotting factors, produces oedema and worsens outcome; keep it to the minimum needed to keep a line open until blood arrives. Avoid hypotonic fluids entirely.
Cell salvage is acceptable in obstetric haemorrhage provided a leucocyte-depletion filter is used; it is a valuable resource here.
After control: continue the oxytocin infusion for at least 24 hours, keep the balloon for 12-24 hours, monitor for Sheehan syndrome and transfusion reactions, and debrief. Record cumulative loss and running totals, because visual estimation underestimates true loss by up to half.