A 32 year old woman calls 911 for heavy vaginal bleeding. She reports that she had a normal vaginal delivery 2 days ago. Her delivery was reportedly uncomplicated. She says that she had an infection during labor called chorioamnionitis. Since delivery, she had had bleeding like a heavy period. She was discharged from the hospital this morning. Starting about an hour ago, she began soaking through a pad in 15 minutes and passing clots. She began to feel dizzy, so her partner called 911.
She has no chronic medical problems.
On examination, she is alert and oriented, but appears pale. She is sitting on a towel that is saturated with blood. Her vital signs are HR 115, BP 92/63, RR 18, O2 saturation 100% on RA.
This patient is two days postpartum presenting with a secondary postpartum hemorrhage. Secondary postpartum hemorrhage is defined as excessive bleeding between 24 hours and 12 weeks after delivery. (1) Any patient with postpartum hemorrhage should be transported immediately to the hospital for evaluation.
Santa Clara: Gynecological and Obstetrical Emergencies 700-A18
For BLS, routine medical care should be initiated (700-S04) including oxygen titration as appropriate. Her vital signs should be monitored frequently and she should be treated for signs and symptoms of shock (700-A10).
For ALS transport, vascular access should be obtained.
San Mateo: Adult Medical Treatment Protocols, Vaginal Bleeding
Routine medical care should be initiated including oxygen titration as appropriate. Her vital signs should be monitored frequently and she should be placed on a cardiac monitor. Vascular access should be obtained. The receiving facility should be notified.
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.