Obstetrics and gynaecology · Moderate
This case is fictional and exists for study. It describes no real patient.
29 years · female
A 29-year-old primigravida female at 39 weeks gestation undergoes a spontaneous vaginal delivery of a healthy infant weighing 4.1 kg. The third stage of labour was managed actively with intramuscular oxytocin, and the placenta was delivered complete within 15 minutes. Thirty minutes post-delivery, the midwife notes heavy vaginal bleeding with large blood clots. The estimated blood loss currently exceeds 900 mL. On abdominal examination, the uterine fundus is palpated 3 cm above the umbilicus and feels soft and relaxed. Speculum examination reveals no ongoing bleeding from vaginal or cervical lacerations, and active dark red blood with clots is seen issuing from the cervical os.
Vital signs
- HR
- 118 bpm
- BP
- 88/54 mmHg
- RR
- 22/min
- Temp
- 36.8 °C
- SpO₂
- 96%
Examination findings
- Uterine fundus soft, boggy, and palpated 3 cm above the umbilicus
- Active vaginal bleeding with large blood clots (>900 mL loss)
- Intact vaginal wall and cervix with no structural tears
Investigations
| Haemoglobin | 9.4 g/dL | reference: 11.5-16.0 |
| Platelets | 210 10^9/L | reference: 150-400 |
| Prothrombin time (PT) | 11.5 seconds | reference: 10.0-13.0 |
| Activated partial thromboplastin time (aPTT) | 31 seconds | reference: 25-35 |
Question 1 of 3
Which of the following is the most likely cause of postpartum haemorrhage in this patient?
Uterine atony is the single most common cause of primary postpartum haemorrhage, accounting for approximately 70-80% of cases. The clinical finding of a soft, boggy uterus palpated high above the umbilicus, alongside complete placenta delivery, strongly confirms atony. Retained tissue typically presents with an incomplete placenta or a partially contracted uterus. Cervical lacerations present with a firmly contracted uterus and persistent bright red bleeding. Uterine inversion presents with severe shock disproportionate to blood loss and a uterine fundus that is absent on abdominal palpation.
Teaching point: Uterine atony is the primary cause of early postpartum haemorrhage and is characterized by a soft, poorly contracted uterus high in the abdomen.
Question 2 of 3
Which of the following is the most appropriate initial bedside intervention to manage this patient's bleeding?
First-line management of uterine atony after initiating resuscitation involves physical measures to stimulate contraction (bimanual uterine massage/compression) combined with first-line uterotonic drugs (intravenous oxytocin). Laparotomy and balloon tamponade are second- and third-line interventions utilized when first-line medical therapy and physical compression fail to achieve haemostasis. Misoprostol alone without physical uterine stimulation or first-line oxytocin is insufficient in an acute primary PPH scenario where IV access is available.
Teaching point: Initial management of uterine atony requires prompt mechanical uterine massage/compression combined with first-line intravenous oxytocin.
Question 3 of 3
Despite uterine massage and intravenous oxytocin, bleeding continues. The patient has a background of pre-existing hypertension but no history of asthma. Which pharmacological agent should be administered next?
Carboprost (prostaglandin F2-alpha) is an effective second-line IM uterotonic agent indicated when oxytocin fails to control uterine atony. Ergometrine is strictly contraindicated in patients with pre-existing hypertension or pre-eclampsia because it induces widespread vasoconstriction and severe blood pressure spikes. Carboprost is contraindicated in severe asthma, which is absent in this patient. Misoprostol can be used as an adjunct, but IM carboprost is preferred in acute hospital settings. Recombinant factor VIIa is reserved for catastrophic life-threatening coagulopathic bleeding.
Teaching point: Carboprost is preferred over ergometrine for refractory uterine atony in patients with pre-existing hypertension.
Key learning points
- Uterine atony is the most frequent cause of primary postpartum haemorrhage and presents with a boggy fundus.
- First-line management of atonic PPH involves resuscitation, bimanual uterine massage, and intravenous oxytocin.
- Ergometrine should be avoided in patients with hypertension, whereas carboprost should be avoided in patients with severe asthma.
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