Secondary Postpartum Hemorrhage

Ruby¹, Farzana²

¹Senior Deputy Nursing superintendent, Maa Kauvery, Trichy, Tamil Nadu

²Nursing supervisor, Maa Kauvery, Trichy, Tamil Nadu

Case Presentation

A 33-year-old female admitted with the following history:

LMP:26.04.2024, EDD:09.02.2025

Booked Primi/IVF conception / 9 months’ amenorrhea / ANA positive/ ; she was admitted for safe confinement, She was able to perceive fetal movements well

No c/o lower abdominal pain / bleeding PV

Menstrual history: Regular cycle 3/30 days

Marital history: Married since 5 years / NCM

Obstetric history: Primi/IVF conception (1. Tried Twice for IVF at 2022 – not successful Undergone Laparoscopic myomectomy on 2023- Post operatively patient had pulmonary embolism

? DIC – Re-laparotomy done for pelvic hemorrhage.

Intra op: Frozen pelvis, Fundal scar given way

H/o Left lower limb LFT thrombosis (+), Diagnosed as ANA positive after that, on (from May 2023) Tab. Apgot 10mg 1-0-0

In 2024 – One IVF failure, In May 2024 – conceived via IVF, on Inj.Clexane since – conception)

Past history: S/P Laparoscopic myomectomy – 2023 (Post-operative patient had pulmonary embolism)

On Examination

Patient conscious, oriented, afebrile, No pallor / no pedal edema ,PR :86 /min
BP:120/70mmHg,CVS:S1S2(+)RS:NVBS(+)

P/A: Uterus term / Not acting, FH good

P/V: Cervix uneffaced/OS closed.

Delivery type

Indication

Primi/IVF conception/Term gestation/Transverse lie / S/P DVT. Patient posted for Elective LSCS done under Spinal anaesthesia on 13.01.2025. Patient in supine position, Parts painted & draped, Abdomen opened through Pfannenstiel incision.

Intra op Findings

Uterus rotated laterally with right round ligament seen anteriorly

Left round ligament seen posteriorly, bilateral tubes & ovaries normal

Dense bowel adhesion noted to the posterior surface of uterus & POD

Lower uterine regiment normal, Liquor – Clear, Placenta complete,

Cord Normal, Transverse lie. An alive male baby delivered at 10:02 am, weight:2.600 kg

Baby cried immediately after birth. Cord clamped & cut

Baby handed over to Pediatrician. Placenta & membranes delivered in toto

Uterus closed in 2 layers. Hemostasis secured. Mops & instruments count verified. Abdomen closed in layers. Clear urine drained.

Post Natal Period: Day 0 and 1 was uneventful

Followed Bundle care

Morning, evening & Night nursing bundle care.

Nursing Documentation done on BUBBLE HE

BUBBLE-HE: is an acronym used in postpartum maternal assessment, standing for: Breasts, Uterus, Bladder, Bowels, Lochia, Episiotomy/Perineum, Homan’s, Emotional status. It’s a comprehensive way to assess a woman’s recovery after childbirth.

Cauti &SSI bundle care.

PLABSI Bundle.

Breast milk manual expression done and given to NICU for feeding.

POD 2 on 15.1.2025: Patient complaint of pain over the surgical site. Bleeding PV ++. Abdominal distension +, Vital sign BP 100/70 mmhg, Pulse 130 /mts. Atonic PPH with Hypovolumic shock.

Emergency abdomen scan taken and Reported – 15.01.2025

Large heteroechoic area in uterine cavity and fundal region – Likely intrauterine hematoma-suggested CT abdomen / Angio for further management
Right mild hydroureteronephrosis
Mild ascites
Gall bladder calculus with sludge.

Posted for Emergency Obstetric Hysterectomy done on 15.01.2025, under GA

Intra op Findings

Atonic PPH, Uterus enlarged upto 32 weeks, no evidence of hemoperitoneum

Bilateral fallopian tubes & ovaries normal

Incision made over uterus & 1 liter of clots evacuated

Proceeded to obstetric hysterectomy in view of atonic PPH & hemodynamic

Obstetric hysterectomy done in usual way

Specimen sent for HPE

Hemostasis secured. Mops & instruments count verified

Abdomen closed in layers.

Intra op 1 unit LDPC, 2 units Platelets, 2 units FFP, 2 unit PRBC transfused

POD 2 To POD 6^th

Patient was shifted to ICU with Ventilator support.

Her GCS was E4 VT M6, Bilateral pupil RTL, HR – 130/min, BP – 110/80 mmHg with Inj. Nor adrenaline 5ml/hour with DT inside. Bedside Echo done showed good LV, mild PAH, IVC, partially collapse lungs, right sided mild collapse and mild free fluid abdomen.

Preliminary labs showed Hb – 7.1 low with coagulopathy for which 3 LDPC, 7 platelets, 6 FFP, transfused totally till now. Fluid resuscitation done as ABG showed mild metabolic acidosis along with potassium correction for hypokalemia. CBC showed TC elevation and urine routine evaluation showed features of UTI for which empirical antibiotics were given. OBG team was involved and abdominal girth was monitored periodically and drain tube amount was monitored. Hematologist opinion obtained and orders were carried out. Patient slowly tapered from inotrope support and anticoagulation were initiated. She was further extubated and switched to NIV, O2 support and weaned from O2 support. DT tube was removed by OG team. Hb and INR were on improving trend

Drugs Used

Drugs	Dose	Route	Frequency
Inj. Taximax	1.5gm	IV	1-0-1
Inj. Pantop	40mg	IV	1-0-1
Inj. Emeset	4mg	IV	1-0-1
Inj. Tramadol	50mg	IV	1-0-1
Inj. Trapic	1gm	IV	stat
Inj. Noradrenaline	8ml+12ml	IV	Infusion
Inj. Fentanyl	100mcg	IV	Infusion
Inj. Piptaz	4.5gm	IV	1-1-1-1
Tab. Ecosprin	75mg		0-1-0
Tab. Calpol	500mg		1-1-1
Tab. Pan	40mg		1-0-1
Tab. Taxim O	200mg		1-0-1
Neb. Budecort	0.5ml		1-0-1
Neb. Duolin	0.5ml		1-1-1
Tab. Wysolone	10mg		1-0-1
Tab. Trapic	1gm		1-1-1
Inj. Clexane	60mcg		1-0-1

Patient was treated with IV fluids, IV antibiotics, nebulization, anticoagulant and other supportive measures. CVC line removed. Patient was symptomatically improved, hence discharged with following advice.

Condition at Discharge

Patient stable, afebrile, hydration adequate, Urine output adequate, Vitals stable, Systems normal. No undue bleeding PV. Breasting feeding the baby well. Mother and baby discharged in a satisfactory condition.

Birth Intimation: Given

Advice Medication on Discharge

S. No	Drug Name	Strength	Frequency			Route of Admin	Relationship with Meal	Days
			M	A	N
1	Tab. Livogen	–	1	0	0	Oral	After food	3 Months
2	Tab. Shelcal	500MG	0	1	0	Oral	After food	3 Months
3	Tab. Limcee	–	1/2	0	1/2	Oral	Chewable	15 days
4	Tab. Taxim O	200MG	1	0	1	Oral	After food	5 days
5	Tab. Pan	40MG	1	0	0	Oral	Before food	5 days
6	Tab. Dolo	650MG	–	–	–	Oral	After food	10 tablets – (sos)
7	Tab. Apixaban	5MG	1	0	1	Oral	After food	To continue

Advice On Discharge

Report immediately in case of headache, blurring of vision, epigastric pain, altered sensorium, Bleeding PV, abdominal pain, breathlessness, Palpitation & Giddiness.To check BP alternative days in local hospital

Other Instructions

Postnatal exercise (Hand book given)
Regular diet (Hand book given)
Daily bathing and wound care advice given.
Abstinence for 6 weeks
Not to lift heavy weight for 3 months

Secondary Postpartum Hemorrhage

Secondary Postpartum Hemorrhage

Ruby1, Farzana2

Nightingale Journals

Ruby¹, Farzana²