Case Details

Test test

Paramedics begin patient transport and obtain vascular access on the way to the nearest medical center.  Repeat vital signs are HR 125, BP 80/40, RR 22, O2 saturation 99% on RA. The patient begins to feel increasingly dizzy and lightheaded.

This patient is showing vital sign abnormalities concerning for hypovolemic shock from her hemorrhage.  

Santa Clara: Gynecological and Obstetrical Emergencies 700-A18, Vaginal Bleeding (Postpartum)
Attempt fundal massage to try to improve uterine tone and decrease the hemorrhage.

San Mateo: A second IV should be placed.  Her systolic blood pressure is now less than 90, so a 500 mL normal saline bolus should be given.  Consider contacting base hospital for medical direction.

Postpartum hemorrhage is the #1 cause of maternal death worldwide. In the United States, postpartum hemorrhage affects approximately 3% of deliveries and is a significant cause of pregnancy-related morbidity and mortality (2).  According to the American College of Obstetricians and Gynecologists (ACOG), primary postpartum hemorrhage refers to 1000 mL or more of blood loss with signs or symptoms of hypovolemia within 24 hours of delivery.  (3). Delayed, or secondary postpartum hemorrhage is significant uterine bleeding between 24 hours to 12 weeks after delivery.

The paramedics provided initial resuscitation for this patient’s hypovolemic shock.  Following the emergency department’s medical management, including initiating a blood transfusion (and TXA?), the OB/GYN took the patient to the operating room for a dilation and curettage.  She was noted to have a small segment of retained placenta in her uterus, which was removed. Her heavy bleeding resolved. She was discharged home the next day.

1. Alexander J, Thomas P, Sanghera J. Treatments for secondary postpartum haemorrhage. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: PMID: 11869640.
2. Reale SC, Easter SR, Xu X, Bateman BT, Farber MK. Trends in Postpartum Hemorrhage in the United States From 2010 to 2014. Anesthesia & Analgesia. 2019 Sep 18.
3. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 183, October 2017: Postpartum Hemorrhage. Obstetrics and gynecology. 2017 Oct;130(4):e168.

1. Alexander J, Thomas P, Sanghera J. Treatments for secondary postpartum haemorrhage. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: PMID: 11869640.
2. Reale SC, Easter SR, Xu X, Bateman BT, Farber MK. Trends in Postpartum Hemorrhage in the United States From 2010 to 2014. Anesthesia & Analgesia. 2019 Sep 18.
3. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 183, October 2017: Postpartum Hemorrhage. Obstetrics and gynecology. 2017 Oct;130(4):e168.