fandarast
Forum Junior
Topics: 15
Posts: 53
|
A 23-year-old primigravida woman just delivered an infant weighing 4,350 g by spontaneous vaginal delivery. After 5 minutes of gentle traction on the umbilical cord, you deliver the placenta, which appears to be intact. You begin massaging the uterine fundus and ask the nurse to run 20 U of oxytocin in 1000 mL of LR solution as fast as possible. After careful inspection of the genital tract, you notice a second-degree laceration and a 2-cm left lateral vaginal wall laceration, which you attempt to repair. Suturing is difficult because of brisk bleeding from above the site of laceration. Physical examination reveals a soft, boggy uterine fundus. Her vitals are as follows: T = 98.9, BP = 164/92, P = 130, R = 18. Which of the following is the next best step in management?
A. Oxytocin 10 U direct IV infusion
B. Methylergonovine 0.2 mg IM
C. Prostaglandin F2a 0.25 mg IM
D. Manual exploration
E. Curettage
|
| Justice
Forum Fanatic
Topics: 101
Posts: 1,969
|
I am not sure if any of the drugs would cause contractions of the vagina or cervix... So,
D
___________________
Don't live in a town where there are no doctors
|
| fandarast
Forum Junior
Topics: 15
Posts: 53
|
You need to read the question carefully: the bleeding is from above the site of laceration and the uterus is boggy!!!
|
| nyimalay
Forum Elite
Topics: 9
Posts: 280
|
D
Patient still having atonic uterus despite the use of oxytocin.
Ergot is not recommended as she is having high BP.
PG F2a is given SC or directly into uterus.
Should rule out retained piece of placenta by manual exploration at first though it is said that placenta appears to be intact.
|
| fandarast
Forum Junior
Topics: 15
Posts: 53
|
The answer is C. So as you can see nyimalay, PGF2a can be used IM.
Uterine atony is the most common cause of postpartum hemorrhage. Because vigorous massage and dilute oxytocin have not been successful in ceasing her bleeding (i.e., uterus is soft and boggy), the next best step is to add another uterotonic agent. Methylergonovine is contraindicated because this patient is hypertensive despite brisk blood loss. The next best agent is prostaglandin F2a. Infusion of undiluted oxytocin 10 U intravenously would cause severe hypotension. Manual exploration would be appropriate if you suspect laceration as cause of bleeding. Here the diagnosis is most likely uterine atony. Curettage is appropriate for delayed postpartum bleeding when you suspect retained products of conception.
|
| fandarast
Forum Junior
Topics: 15
Posts: 53
|
Management of PP hemorrhage from NMS, ObGyn, 2005:
(1) Vigorous massage of the uterine fundus
(2) Use of uterine contracting agents
(a) Oxytocin 20 U in 1000 mL of lactated Ringer's solution intravenously
(b) Methylergonovine 0.2 mg intramuscularly or intravenously. Because methyler-
gonovine may cause hypertension, it should be avoided in patients with
preeclampsia.
(c) Prostaglandin F2a 0.25 mg intramuscularly up to eight doses at 20-minute
intervals
(3) Manual exploration of the uterine cavity for retained placental fragments or
uterine rupture
(4) Inspection of the cervix and vagina for lacerations
(5) Curettage of the uterine cavity
(6) Hypogastric artery ligation; embolization of the uterine vessels; and, rarely,
hysterectomy
|
| nyimalay
Forum Elite
Topics: 9
Posts: 280
|
Thanks fandarast.
|
| ricardoricardo
Forum Newbie
Topics: 0
Posts: 26
|
ergomtrine
|
| Markus2009
Forum Senior
Topics: 9
Posts: 189
|
Interesting, good to know
|
|
| |
| | | | | | | | | |
