Abnormalities of the Third Stage of Labor chorioamnionitis

I. INTRODUCTION Uterine distortion/ Fibroids

A. POSTPARTUM HEMORRHAGE (PPH) abnormality Placenta previa
1. ACOG definition: cumulative blood loss of > 1 L with Beta mimetics
Uterine relaxing
signs and symptoms of hypovolemia Magnesium sulfate
medication
2. Traditional definition: blood loss of Anesthetics
1. > 500 mL in vaginal delivery Bladder distention which Halogenated anesthetics
2. > 1 L in CS delivery may prevent uterine
contraction* Nitroglycerin
3. Blood loss of > 500 mL in the first 24 hours after delivery
* from 2020 trans, not in the lecture
4. 10% decrease in hemoglobin and hematocrit level from
baseline
B. TISSUE
5. There is a need for transfusion (clinical estimation is
frequently inaccurate) Etiologic category and process Clinical risk factors
6. Treacherous feature: Failure of the pulse rate and blood Accreta
pressure to undergo more than moderate alterations until - placenta grows too deeply into the
uterine wall
large amounts of blood has been lost
Increta
7. Best definition should combine clinical presentation - placenta attaches itself even more
with objective data Prior uterine surgery,
deeply into the muscle wall of
placenta previa,
uterus
Table 1. Severity of blood loss and corresponding manifestations
multiparity
Percreta
Estimated % Blood - placenta attaches itself and grows
Heart Signs and
blood loss volume SBP through the uterus, sometimes
rate symptoms
(mL) lost extending to nearby organs, such
500-1000 10–15 < 100 Normal
None as the bladder
Vasoconstriction, Manual placental
Slight removal,
weakness, Retained placental membrane
1000-1500 15–25 100-120 decrease succenturiate/
sweating
Restlessness, accessory lobe
1500-2000 25–35 120-140 80-100 pallor, oliguria
Anuria, altered C. TRAUMA of the genital tract
2000-3000 35–45 > 140 60-80 consciousness Etiologic category and
Clinical risk factors
process
B. LATE POSTPARTUM HEMORRHAGE Precipitous labor
8. Bleeding after 24 hours of delivery Macrosomia
9. Crystalloid and blood are promptly given for suspected Laceration of cervix, vagina Shoulder dystocia
hypovolemia or perineum Operative delivery
10. The following are predisposed to hemorrhage due to low Episiotomy (especially
mediolateral)
baseline blood volume
Deep engagement
1. Small women (less than 5 ft) Extensions and lacerations
at CS Malposition
2. Severe preeclampsia/eclampsia (generalized Malpresentation
vasoconstriction in the body; small increase in blood Uterine Rupture Prior Uterine Surgery
volume) Fundal placenta
3. Chronic renal failure Uterine Inversion Grandmultiparity
Excessive umbilical cord traction
D. THROMBIN (abnormalities of coagulation)
Etiologic category and
Clinical risk factors
II. RISK FACTORS FOR PPH (4Ts) process
1. Tone – failure of uterus to contract after placental delivery Preexisting clotting
2. Tissue – retained placental tissue or blood clot abnormalities (e.g.
History of hereditary
3. Trauma – genital tract lacerations or hematomas hemophilia, von Willebrand
coagulopathy or liver disease
4. Thrombin – coagulopathy disease,
hypofibrinogenemia)
Acquired in pregnancy
A. TONE
Etiologic category and - Idiopathic Sepsis
Clinical risk factors thrombocytopenic Bruising*
process
purpura* Elevated BP*
Polyhydramnios
- DIC*
Multiple gestation
Overdistention of uterus DIC Intrauterine demise
Macrosomia
Retained clots HELLP (hemolysis, elevated
Hemorrhage
Rapid labor liver enzymes, low platelet)
Anticoagulation History of thrombotic disease*
Uterine muscle Prolonged labor
Gestational hypertensive Elevated BP*
exhaustion (fatigue) Labor augmentation (e.g. oxytocin) disorder of pregnancy with - Fetal demise
Prior PPH adverse conditions* - Fever + neutrophil
Intraamniotic infection/ Prolonged ROM - Dead fetus in utero abnormality

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 - Severe infection  Diarrhea (most common)
- Antepartum hemorrhage
- Abruption  Hypertension
- Sudden collapse
- Amniotic fluid embolus  Vomiting
* from 2020 trans, not in the lecture  Fever
 Flushing
III. ABC  Tachycardia (least common)
11. Prompt recognition and treatment is CRITICAL  PG E2 Dinoprostone
 20 mg suppository per rectum/vagina, q2h
1. A (Assessment)
 Not available in PH yet; but marketed for cervical ripening
 Constant awareness of patient’s hemodynamic status
at a 0.5mg dosage (Ilarde, 2019)
 Evaluate to determine cause of bleeding
 PG E1 Misoprostol
2. B (Breathing)
 Effective for uterine contraction BUT is illegal in the PH
 Oxygen supplementation
(still being sold in Quiapo as an abortifacient)
3. C (Circulation)
 IV access (double line-large bore catheter)
 Adequate circulating blood volume through crystalloids and If bleeding is unresponsive to uterotonics
blood products 1. Bimanual uterine compression
 Easily done and controls most cases of continuing
IV. UTERINE ATONY hemorrhage
12. The most frequent cause of obstetrical hemorrhage  Not simply fundal massage
13. Failure of the uterus to sufficiently contract after delivery  Posterior uterine wall is massaged by one hand on the
abdomen, while the other hand is made into a fist and placed
and to arrest bleeding from vessel at the placental
into the vagina
implantation site (some bleeding is inevitable)  The fist kneads the anterior uterine wall through the
anterior vaginal wall
A. RISK FACTORS  Concurrently, the uterus is also compressed between the two
14. Primiparity or high parity hands
15. Prior PPH
16. Retained clots
17. Overdistended uterus
1. Large fetus
2. Multiple fetus
3. Hydramnios
18. Labor abnormalities
1. Rapid labor
2. Prolonged labor
3. Augmented labor
4. Chorioamnionitis
19. Labor induction/augmentation (with Figure 2. Bimanual uterine compression
prostaglandins/oxytocin)
20. Anesthesia/analgesia 2. Immediately mobilize the emergent-care obstetrical team to
1. Halogenated agents the delivery room and call for whole blood or packed red cells
2. Conduction analgesia with hypotension 3. Request urgent help from the anesthesia team
4. Secure at least two large-bore IV catheters
 Crystalloid with oxytocin is continued simultaneously with
B. PHYSICAL EXAMINATION blood products (one bore for uterotonics, one bore for blood;
21. Identified as a soft and boggy uterus by bimanual exam accdg to Doc Ilarde usually Gauge 18 ang ginagamit sa OB)
1. Uterus is usually stone-hard after delivery 5. Insert an indwelling Foley catheter for continuous urine
22. Expression of clots during uterine massage output monitoring
23. Fundus is always palpated after placental delivery to 6. Begin volume resuscitation with rapid intravenous infusion of
confirm contracted uterus crystalloid
1. If not contracted yet – fundal massage + 7. With sedation, analgesia, or anesthesia established and now
uterotonics should be initiated with optimal exposure, once again manually explore the
uterine cavity for retained placental fragments and for uterine
C. MANAGEMENT abnormalities, including lacerations or rupture; inspect cervix
Uterotonics and vagina
1. Oxytocin (first line)
 Pure oxytocin – IM Non-Surgical Procedures
 Diluted oxytocin – IV  Uterine packing or balloon tamponade
 Should not be given as an undiluted IV bolus since it may  Gauze (not used as much since it can be left behind and
cause serious hypotension and cardiac arrythmias cause infection)
2. Ergot Derivatives
 Foley catheter (for low income settings)
 Methylergonovine (Methergine) & Ergonovine
 Given IM  Condom catheter (for low income settings)
 Not for patients with preeclampsia since it may cause  Sengstaken-Blakemoore (has indications for esophageal and
dangerous hypertension, especially when given through IV uterine hemorrhage)
3. E- and F-series Prostaglandins  Rusch balloons
 PG F2α Carboprost tromethamine  Bakri postpartum balloons (specially for uterine use; not
 250 ug IM, q15-90 mins (max. 8 doses) common in PH) or BT cath
 Side effects:

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  Remains inflated for 12-24 if responsive, remove within the 1. Inspect placenta after delivery for completeness
next 24-48 h (Ilarde, 2019) (done routinely)
2. Defect: uterus is manually explored then fragment is
removed
31. Retained succenturiate lobe
1. Accessory lobes of placenta located at a distance
from the main placenta
32. Manual exploration of uterine cavity for removal
33. Membranes adhered to uterine lining separated by gentle
traction with ring forceps

B. PLACENTA ACCRETA SYNDROME

Figure 3. Balloons used for control of postpartum hemorrhage
Surgical Procedures
 Uterine compression sutures (brace compression sutures)
- parang suspenders
 B-lynch, Hayman & Cho multiple squares suture
 Uterus is tested by the surgeon first before application of
sutures
 Pelvic vessel ligation (uterus sparing)
 Uterine artery ligation
 Internal Iliac / Hypogastric artery ligation
 Decrease BP by 85%; decreases peripheral pulse rate
 More difficult to do but has better effect (Ilarde, 2019)
 Angiographic embolization
 Hysterectomy
34. Accret, ac + crescere; to grow from adhesion or
coalescence, to adhere, to become attached to
35. Abnormally firm adherence of the placenta to
myometrium due to partial/total absence of the decidua
basalis, imperfect development of Nitabuch layer
36. Closely linked to prior uterine surgery  incidence is ↑
(caesarean scar pregnancy)
1. Following accrete, subsequent pregnancies have
increased risk for previa, uterine rupture, recurrent
accrete, and hysterectomy
37. Leading cause of intractable PPH and emergency
peripartum hysterectomy
38. Histological diagnosis cannot be made from the placenta
alone, and the uterus or curettings with myometrium are
necessary for histopathological confirmation
Variations of Placenta Accreta Syndrome

NOTE:
When the patient is old, management is usually aggressive
When the patient is young, management is usually conservative

D. ACTIVE MANAGEMENT OF THE THIRD STAGE OF Placental villi Placental villi Placental villi
LABOR (AMTSL) attached to invade the penetrate
1. Routine administration of uterotonic (Oxytocin) immediately myometrium myometrium through the
after delivery of the baby; IM 10 u 1 amp myometrium
and to/through
2. Delayed cord clamping (beyond 1-3 minutes from delivery
the serosa
or until pulsations stop)
3. Controlled cord traction to deliver the placenta (support is
applied on top)  In all three varieties, abnormal adherence may involve:
E. EXPECTANT MANAGEMENT  ALL lobules = TOTAL
24. Conservative/physiologic management
 FEW to SEVERAL cotyledons = PARTIAL
25. Signs of placental separation are awaited
 All or part of a SINGLE lobule = FOCAL
26. Placenta delivered spontaneously or with aid of gravity,
maternal pushing, or nipple stimulation
27. Uterotonics not routinely administered
Risk Factors
 Associated previa in the current pregnancy
 Prior cesarean delivery
F. SEQUELAE
28. Hemorrhage
29. Risk for: Maternal Complications
1. Infection  Massive hemorrhage
2. Recurrent PPH  Disseminated Intravascular Coagulopathy (DIC)
3. Hysterectomy  Visceral injury
4. Sheehan’s syndrome  Acute Respiratory Distress Syndrome (ARDS)
5. Multi-organ failure  Renal failure
 Infection
V. TISSUE-RETAINED PRODUCTS OF CONCEPTION  Death
A. RETAINED PLACENTAL MEMBRANE
30. Retained placental fragments Fetal Complications

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 Adverse perinatal outcome from preterm delivery and restricted
fetal growth

Management
 Ideally should be diagnosed antepartum
 Best outcome: planned delivery in a tertiary hospital
 Adhered placenta during the third stage of labor  hemorrhage
 Percreta and Increta – almost always mandates hysterectomy
 Conservative management – reserved for hemodynamically
stable patients
 Leaving the placenta in situ
 After the fetus has been delivered, it may be possible to
trim the umbilical cord and repair the hysterectomy
incision but leave the placenta in situ Figure 4. Progressive degrees of uterine inversion
After the fundus begins and continues to invert (1, 2), it would not be visible
 This may be wise for women in whom abnormal
externally until at the level of the introitus (3) or completely inverted (4)
placentation was not suspected before CS delivery and in
whom uterine closure stops bleeding
Risk Factors
 After this, she can be transferred to a higher-level facility
 Fundal placental implantation
for definitive management
 Delayed-onset or inadequate uterine contractility after delivery
 Methotrexate therapy (to dilute placenta; entails close
of the fetus (i.e. uterine atony)
monitoring for sepsis and necrosis)
 Cord traction applied before placental separation
 Wedge resection - focal accreta
 Abnormally adhered placentation (e.g. accrete syndromes)

Management
 Immediate recognition for quick resolution and good outcome
 Once any degree of uterine inversion is recognized, several
steps must be implemented urgently and simultaneously;
 Immediate assistance
 Immediate assistance is summoned (obstetrical and
anesthesia personnel)
 Blood
 Brought to the delivery suite in case it may be needed
 Large bore intravenous system
 Px is evaluated for emergency general anesthesia
 Large-bore intravenous infusion systems are secured 
VI. TRAUMA begin rapid crystalloid infusion to treat hypovolemia (while
39. Genital Tract Trauma awaiting arrival of blood for transfusion)
1. Second most common cause of postpartum  Prompt replacement of the uterus
 Inverted uterus has not contracted and completely
bleeding
retracted + placenta has already separated  uterine
2. Lacerations to the perineum, vagina, cervix, or replacement by pushing up on the inverted fundus with
uterus the palm of the hand and fingers in the direction of the
3. Bleeding despite a contracted uterus long axis of the vagina
 Should be careful not to puncture the uterus (especially
common if uterus is too soft)

A. UTERINE INVERSION
40. One of the classic hemorrhagic disasters encountered in
obstetrics
41. Completely inverted – protrusion of a bluish gray mass
from the vagina
42. Incompletely inverted – absent uterine fundus or
obvious defect of fundus on abdominal examination and
palpation
43. Evidence of shock Figure 5. Johnson maneuver – manual reduction (not in the lecture but was
mentioned during the case discussion)
 Leave placenta
 If placenta is still attached, it is not removed until infusion
systems are operational and a uterine relaxant drug
administered
 Once repositioned, give uterotonics
 Uterus restored to its normal configuration  tocolysis is
stopped  infuse oxytocin (other uterotonics may be
given, as well)

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  Fundus is maintained in its normal anatomical position
while applying bimanual compression to control further
hemorrhage until the uterus is well
Surgical Intervention
 When bimanual compressions fail:
 Huntington procedure – application of atraumatic clamps to
each round ligament and upward traction
 Haultain incision – if the constriction ring still prohibits
repositioning, a longitudinal surgical cut is made posteriorly
through the ring to expose the fundus and permit reinversion
 Hysterectomy – last resort
B. LACERATIONS/GENITAL TRACT TRAUMA
 Second most common cause of postpartum bleeding
 Lacerations of perineum, cervix, vagina, or uterus
 Suspect if (+) bleeding despite contracted uterus
 Vulvovaginal
 Small, superficial anterior vaginal wall tears – no need for
repair
 Extensive tears – intrauterine exploration for possible
uterine tears
 Suture repair with effective analgesia
 Blood replacement
 Capable assistance
 Cervical
 Superficial – occur in more than half of vaginal deliveries
(<0.5 cm)
 Seldom require repair unless extending to upper third of
vagina
 Diagnosed with visual inspection with adequate exposure
 Colporrhexis – total or partial avulsion of the cervix from the
vagina, usually from difficult deliveries (e.g. forceps
extraction)
 Other cervical injuries
 Anterior cervical lip ischemia
 Annular/circular detachment of cervix (entire vaginal
portion of cervix is avulsed)
C. PUERPERAL HEMATOMA
 Most often associated with a laceration, episiotomy, or an
operative delivery
 Spontaneous rupture of blood vessels
 Excruciating pain
 Vulvar – vestibular bulb or branches of the pudendal artery
(inferior rectal, perineal, and clitoral arteries)
 Vulvovaginal
 Paravaginal – descending branch of the uterine artery
 Retroperitoneal
 Tense, fluctuant, tender, swelling of varying site even covered
by discolored skin
 Symptoms:
 Pelvic pressure (hallmark symptom)
 Pain or inability to void
 Change in vital signs disproportionate to blood loss
 Supralevator extension  the hematoma extends upward in the
paravaginal space and between the leaves of the broad
ligament
 If undetected: it can be palpated abdominally or until
hypovolemia develops
 Ideally should be diagnosed antepartum to provide major
decision and concerns on timing and ideal facility
 Sonography – identifies abnormal placental ingrowth
antepartum
 Other diagnostics – 3D Sonography with Power Doppler, MRI
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Management
 Managed according to size, duration of delivery and expansion
 Blood loss with puerperal hematoma is nearly always
considerably more than the clinical estimate
 Smaller vulvar hematoma
 Expectant, observation
 Severe pain or hematoma continues to enlarge
 Surgical exploration
 Embolization – primarily or secondarily if surgical attempts for
homeostasis have failed
 Incision is made at point of maximal distention  blood clot
evacuated  ligation  cavity is obliterated with absorbable
suture
D. UTERINE RUPTURE
 Primary – previously intact or unscarred uterus
 Most common risk factor is multiparity
 Secondary – preexisting myometrial incision, injury, or anomaly
 Most often site: thinned out lower uterine segment
Table 2. Causes of Uterine Rupture
Preexisting Uterine Injury or Anomaly
 Caesarian delivery or hysterectomy
 Previously repaired uterine rupture
Surgery
 Myomectomy incision through or to the
Involving
endometrium
the
Myometrium  Deep cornual resection of interstitial
fallopian tube
 Metroplasty
Coincidental  Abortion with instrumentation – sharp or
Uterine suction curette, sounds
Trauma  Silent rupture in previous pregnancy
 Pregnancy in underdeveloped uterine horn
Congenital  Defective connective tissue – Marfan or
Ehlers-Danlos Syndrome
Uterine Injury or Abnormality Incurred in Current
Pregnancy
 Persistent, intense, spontaneous contractions
 Labor stimulation – oxytocin, prostaglandins
 Intraamnionic instillation – saline,
prostaglandins
Before  Perforation by internal uterine pressure
Delivery catheter
 External trauma – sharp, blunt
 External version
 Uterine overdistension – hydramnios,
multifetal pregnancy
 Internal version second twin
During  Difficult forceps delivery
Delivery  Rapid tumultuous labor and delivery
 Difficult manual removal of the placenta
 Placental accrete syndromes
 Gestational trophoblastic neoplasia
Acquired
 Adenomyosis
 Sacculation of entrapped retroverted uterus
Classic Signs and Symptoms
 Fetal distress (during labor)- decelerated heart rate
 Diminished baseline uterine pressure
 Abdominal pain
 Loss of uterine contractility or hyperstimulation
 Abnormal labor or failure to progress
 Hemorrhage and shock
 Recession of presenting part (from engaged to -2 or -3)
 Fetal prognosis depends on degree of placental separation and
magnitude of placental bleeding and hypovolemia  should be
delivered within 18 mins
 Hypoxia or anoxia, acidosis, depressed APGAR scores,
admission to NICU, perinatal death
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 Maternal consequence intra-op, you diagnosed her with placenta increta.
 Bladder injury, severe blood loss or transfusion, hypovolemic Management?
shock, need for hysterectomy, and death Bonus 2 Give two risk factors for uterine inversion.

Management Answers
1-2. Oxytocin, bimanual compression
 Definitive management for the fetus: immediate abdominal *Pwede na rin daw ABC, call for help (hahaha)
delivery 3-5. Carboprost, dinoprostine, methergine, ergonovine
 Conservative surgical management: uterine repair 6. Balloon tamponade
7-9. Compression sutures, pelvic vessel ligation, embolization
 Young women still want to give birth 10. Hypogastric/internal iliac
 Not extensive and (-) extension of rupture 11. Uterine rupture
 Applicable for those who still has 12. Hysterectomy (because multiple lacerations)
13. Colporrhexis
 desire for childbearing 14-15. Associated previa, previous CS
 hemodynamically stable, no evidence of evolving Bonus 1 Hysterectomy
coagulopathy Bonus 2 Fundal placenta, uterine atony, cord traction applied before
placental separation, abnormally adhered placentation
 low transverse with no extensions, easily controllable
 Hysterectomy – intractable uterine bleeding, multiple,
longitudinal or low lying rupture sites. CASE
33-year-old G4P1 (1-0-2-1) was referred by a local health
 Rupture of previous scars – revise edges and primary closure
center due to elevated BP. Her first pregnancy was a molar
pregnancy wherein she underwent suction curettage; second
REFERENCES pregnancy was delivered spontaneously at home with a
Lecture midwife; her third pregnancy was a miscarriage but no
2020 Trans curettage was done. Patient was diagnosed with gestational
Cunningham, F.G. et al. Williams Obstetrics, 25th Ed. McGraw-Hill hypertension during her early third trimester during one of her
Education: USA, 2018 checkups and she was maintained on Methyldopa 250 mg BID.
She has had 5 total prenatal checkups at a local health center.
Her menses occur monthly lasting for 4-7 days using 3 pads per
QUIZ day with occasional associated dysmenorrhea. Her last normal
PRE-TEST menstrual period was December 9, 2018.
1. Correct OB score of the patient (case)
2. Initial impression
3-5. DDx At the ER around 2:30 pm, patient's vital signs were as
6. AOG follows: BP = 160/90 mmHg, PR = 97 bpm, RR = 20 cpm,
7-10. 4Ts afebrile. She had clear breath sounds and centering on the
abdomen, it was globular with fundic height of 28 cm, with fetal
heart tones appreciated best at the left lower quadrant at 140's
Answers
1. G4P1 (1-0-2-1) bpm. Internal examination done revealed a 9 cm dilated fully
2. Hypovolemic shock secondary to postpartum hemorrhage secondary effaced cervix, no bag of waters, at station 0. She subsequently
to uterine inversion delivered within 30 minutes to a term cephalic, live birth baby
3-5. Uterine atony, uterine rupture, puerperal hematoma, POP, accrete girl with birth weight of 3.5 kg AGA for 39 weeks. A third-degree
syndrome, uterine inversion laceration was noted, and repair was done. At 4 pm, the patient
6. 39 weeks
was still at the delivery table when there was note of profuse
7-10. Tone, tissue, trauma, thrombin
vaginal bleeding after the placenta was delivered and a
presence of a violaceous 7 x 7 cm protuberant mass at the
POST-TEST
vaginal introitus. BP dropped to 80/50 mmHg and HR was
1-2. A case of a 19-year-old med student, G1P1 (1-0-0-1), noted to be 135 bpm.
post-NSD for 25 minutes, presenting with profuse
bleeding (after baby/placenta out). How will you
manage the patient?
3-5. What other medications can you give for this patient
(other uterotonics) if what you gave (1st line) in
number 1 or 2 did not work?
6. If the uterotonics still didn’t work, what other methods
can you do? Examples are condom catheter, Foley
catheter, and gauze.
7-9. Since the patient is only 19, what conservative, non-
surgical interventions can you do?
10. What is the vessel that you can ligate to decrease the
pulse pressure by 85%?
11. Camille, 30 years old, G2, was involved in a vehicular
accident. She was brought to the ER presenting with
severe abdominal pain and decreased fetal heart
tone. What is your initial impression?
12. Camille underwent CS. After baby out, you noted
multiple longitudinal lacerations all over the uterus.
What will you do next?
13. What do you call complete/partial avulsion of the
cervix from the vagina?
14-15. What are the most important risk factors for accrete?
Bonus 1 Faith, undergoing her 2nd CS due to placenta previa;

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Give the case’s pertinent data.
Pertinent Positives
 (+) Elevated BP (160/90
mmHg)
 (+) Hx of molar pregnancy,
suction curettage
 (+) Hx of miscarriage, no
curettage
 (+) Gestational hypertension
 (+) 3rd degree laceration
 (+) Profuse vaginal bleeding
after delivery of placenta
 (+) Violaceous 7x7cm
protuberant mass at vaginal
introitus
 (+) Decrease in BP (80/50
mmHg)
 (+) Increase in HR (135 bpm)
Pertinent Negatives
 (-) High risk maternal age
 (-) Tachycardia/bradycardia
before delivery
 (-) Tachypnea/bradypnea
before delivery
 (-) Fever
 (-) Fetal heart rate
deceleration
 Delivery of term cephalic,
live birth baby girl with birth
weight of 3.5 kg (AGA for 39
weeks)
 No history of coagulopathies
 (-) Pain
 Normal delivery of placenta – takes place within 30 minutes
(maximum) after fetal delivery
 Prolonged placental delivery of the patient may suggest
abnormalities (e.g. abnormally adhered placenta)
 Uterine inversion
What is the final diagnosis? What are the patient’s risk factors
for your diagnosis?
 Postpartum hemorrhage secondary to uterine inversion
 Risk factors
 Previous uterine surgery (curettage)
 Increased risk for abnormally adherent placenta
 Uterine atony (though no clear mention if uterus was
soft/boggy, upon palpation)
How will you manage the case?
 (See management of uterine inversion)

What is your initial impression? What are the possible sequelae?

A 33 y/o, female, G4P2 (2-0-2-2) postpartum with hypovolemic  Hemorrhage
shock, secondary to postpartum bleeding secondary to complete  Shock
uterine inversion, to rule out placenta accreta, gestational HTN vs.  Consequence of uterine inversion
preeclampsia, prolonged 3rd stage of labor.  Hemorrhage
 Sheehan syndrome
What are the differential diagnoses?  Decreased blood supply to the pituitary gland due to
 Puerperal hematoma massive blood loss
 Uterine rupture  Amenorrhea
 Uterine atony
 Pelvic organ prolapse (sa gyne pa raw to) Provide an algorithm as to how to manage cases such as this
 Accrete syndrome (hi carlo ginamit ko algorithm mo hahahaha)

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