CC. JUANICO, CLAREEN MAE T.

07/30/2020

ALL THE OPTIONS

Normally, after the delivery of the fetus, myometrium contracts to mechanically compress the
blood vessels supplying the placental bed to stop the bleeding after delivery. The failure of the uterus to
contract after delivery is called uterine atony which leads to Postpartum Hemorrhage and if not
managed properly, may cause mortality to the mother.

Today, the clinical clerks were presented by a case of a 35 yr old mother with an OB score of G4P3
(3003) at 38 5/7 weeks AOG who came in due to labor pains. Patient came in with uterine contractions
every 5 minutes and was hypertensive at 160/90. Patient’s past medical history, family history and
personal social history were unremarkable. OB history revealed no infection or complication during the
past pregnancies and patient delivered her children via NSVD. PE was unremarkable except for her
Abdominopelvic exam which revealed she has gravid uterus, Fundic height of 33 cm; fetal heart beat
130s; EFW of 3410 g; L1- breech L2- maternal right; L3 cephalic engaged; and L4- n/a. Patient had
preeclampsia with severe features. Patient was admitted with her cervix 4 cm fully effaced, Station-1,
cephalic in presentation and with intact bag of water. Plans for patient was to control her BP then
monitor progress of labor. It took 10 hours for the patient to labor and failure of descent was declared
thus resulting and patient to undergo Emergency CS. Intraoperative findings revealed patient delivered a
live full term baby girl in cephalic presentation with birth weight 3080 grams with no abruptio and her
ovaries and fallopian tubes were grossly normal. Estimated blood loss was 3 litres. Uterine massage was
first done. Then uterotonics were also provided: Oxytocin was given then Carboprost for 3 times.
Tranexamic acid was also given to prevent further bleeding. However, bleeding did not stop thus
Hysterectomy and Bilateral Tubal ligation were done but the right ureter was noted to be bulging and
bleeding. Thus, Surgery department was then called for Ureteroneocystostomy Right with Psoas hitch
technique and Ureteral Stent on the Right. Patient stayed for 13 days in the hospital postoperatively.
Patient was also taking antibiotics pre-operatively, intra operatively and post-operatively. In the ward,
patient developed ventilator associated pneumonia as bibasal crackles and rhonchi were noted. Patient
was also transfused 5 units of blood to correct anemia.

In this case, step by step management used before patient finally undergoes hysterectomy was
emphasized to the clinical clerks. The 3 litre-blood loss of the patient is indicated as Hemorrhage class 4.
This means that the patient is already in profound shock as patient is also hypotensive, which requires
immediate stopping of bleeding. The management done by the residents showed us a step by step
process which was also described in the clinical practice guidelines by POGS in 2010. The residents first
applied uterotonics with Oxytocin 10u IM as the first line treatment after the bleeding did not stop, the
third line medicine, 3 units of Carboprost 250mg IVTT was used. The second line medication,
ergometrine was not used as it was contraindicated in hypertensive patients which the patient was.
Uterine massage was also performed in the patient which is done if uterotonics cannot control the
bleeding. Hemostatics are also used as adjunct based on the CPG by POGS. The residents used
tranexamic acid 1g IVTT until postoperative days. After uterine massage, bleeding did not stop,
peripartum hysterectomy was done. According to CPG by POGS, other nonsurgical options such as the
use of bimanual uterine compression and Balloon tamponade are only temporary techniques to stop the
bleeding but surgical interventions must be performed. Surgical procedures such as brace suturing
(performing the B lynch, Hayman and Cho Square sutures are the most commons brace sutures done)
and vaso occlusive procedures may be bypassed and outright hysterectomy can be done. Hysterectomy
is considered immediately if patient is hemodynamically unstable; hysterectomy is the only way to
immediately alleviate the condition; if patient has completed her family and if reproductive function is
no longer an issue. Patient was hemodynamically unstable thus, doing the hysterectomy was indeed the
right thing to do. It was also mentioned in the conference that uterine artery ligation and Internal iliac
artery ligation are done if uterus has to be preserved but in the case, it was not considered as the
patient was already in hypovolemic shock. Ureteroneocystostomy was done because it was also
mentioned in the conference that one of peripartum hysterectomy’s complication is ureteral injury. It is
also important to give the patient antibiotics not only pre-operatively and post-operatively but should
be given intraoperatively for several times especially that the duration of operation was 10 hours.

This case showed the importance of co-management of a patient with different departments
specifically Internal medicine and surgery. One of the consultants emphasized that there should be an
appropriate or proper timing when to refer our patients. In this case, the surgery department was
immediately asked to co-manage as the right mid-ureter was torn. During the hospital stay, patient has
developed Ventilator Associated Pneumonia (causing the shift in the antibiotics to Piperacillin
tazobctam); management of acute respiratory failure Type 4; correction of hypokalemia; and correction
of anemia of the patient was co-managed with the IM department.

It is also important as Doctors, that we should always remember to stabilize the patient first
before anything else as it increases our patient’s chances to survive It is important that we also. Thus, IV
insertion was done, and Airway, breathing and circulation of the patient was assessed. It is also
important that Doctors should remember the 4T’s of Postpartum Hemorrhage for us to be trained to
think quickly when faced with patients presenting with profuse bleeding.

Therefore, this case presented to us has emphasized to us on how to be systematic in managing

patients and should weigh the pros and cons of all the options to be used in managing a patient with
Uterine Atony.