postpartum hemmorrhage - Nursing Case Study

Pathophysiology

• Primary mechanism: Uterine Atony - After childbirth, the uterus should contract to seal off blood vessels at the placental site. If the uterus does not contract adequately (atony), it leads to excessive bleeding. Factors contributing to uterine atony include prolonged labor, multiple pregnancies, and overdistension of the uterus.

• Secondary mechanism: Retained Placental Tissue - If parts of the placenta remain in the uterus after delivery, they can prevent uterine contraction, leading to postpartum hemorrhage. The retained tissue can also cause infection and inflammation, further exacerbating bleeding.

• Key complication: Coagulopathy - If bleeding is not controlled, it can lead to a coagulation disorder, where the body's ability to form blood clots is impaired. This is a serious complication that can increase blood loss and risk of shock.

Patient Profile

Demographics:

32 years old, Female, Works as a primary school teacher

History:

• Key past medical history - Gestational diabetes during pregnancy, Second-time mother, Previous C-section

• Current medications - Iron supplements, Multivitamins

• Allergies - No known allergies

Current Presentation:

• Chief complaint - Heavy vaginal bleeding post-delivery

• Key symptoms - Dizziness, Fatigue, Rapid heart rate

• Vital signs - Blood Pressure: 90/60 mmHg, Pulse: 110 bpm, Respiratory rate: 22 breaths per minute, Temperature: 98.6°F, Oxygen saturation: 95% on room air

Section 1

Change in Patient Status:

In the subsequent monitoring of the patient, there is a noticeable decrease in her blood pressure to 80/50 mmHg, and her pulse rate has increased to 120 bpm, suggesting a possible shock due to the ongoing blood loss. Her oxygen saturation has also dropped to 92% on room air, indicating potential hypoxia. The patient's dizziness has worsened, and she has started to complain of blurred vision. Her skin has turned pale and cool to touch, and her consciousness level has started to decrease, with a Glasgow Coma Scale (GCS) score of 13/15.

New Complications:

On further examination, her abdomen is found to be distended, tender, and firm on palpation, raising the suspicion of a Hematoma formation, possibly an uterine or vaginal hematoma which is a collection of blood within the uterine wall or vagina. This could be due to trauma during delivery or a ruptured blood vessel. Additionally, her hemoglobin level is found to be 7.2 g/dL, indicating a significant drop from her pre-delivery level of 12 g/dL, confirming the ongoing severe blood loss.

These new findings present a critical situation, requiring immediate intervention to prevent further deterioration of the patient's condition. The clinical team should consider re-evaluating the current management plan and possibly prepare for an emergency surgical intervention to control the bleeding and remove the possible hematoma. The patient's hemodynamic status should be stabilized with fluid resuscitation and possibly blood transfusion, and the patient should be closely monitored for further signs of deterioration.

Section 2

New Diagnostic Results:

Despite initial resuscitation efforts, the patient's condition continues to deteriorate. Her blood pressure remains low at 75/45 mmHg and her pulse rate has further increased to 130 bpm. Her oxygen saturation has dropped further to 89% on room air, necessitating the need for supplemental oxygen. Repeat blood tests show a further decrease in her hemoglobin level to 6.5 g/dL, indicating continued blood loss.

An urgent ultrasound of her abdomen reveals a large hematoma in the uterine fundus, confirming the initial suspicion. The hematoma is about 10 cm in diameter and appears to be exerting pressure on the surrounding structures, which could be the cause of the patient's abdominal distension and tenderness. The ultrasound also shows a slight enlargement of the uterus, suggestive of retained products of conception, which may be contributing to the ongoing bleeding. The clinical team needs to urgently address these findings, as the patient is at a high risk of developing disseminated intravascular coagulation (DIC) due to the severe blood loss. The team should consider immediate surgical intervention to remove the hematoma and any retained products of conception. Blood transfusion should be initiated to restore the patient's hemoglobin level, and her vital signs should be closely monitored.

Section 3

Change in Patient Status:

The patient's condition continues to worsen, with her blood pressure dropping further to 70/40 mmHg and her pulse rate now at 140 bpm. She is increasingly lethargic and disoriented, and her skin has become cold and clammy, indicating shock. Her oxygen saturation has slipped further to 85% despite the supplemental oxygen, suggesting that her body is struggling to get enough oxygen to her tissues. This is a critical situation, as shock can lead to organ damage and failure if not promptly reversed.

Response to Interventions:

Despite the team's rapid initiation of a blood transfusion, the patient's hemoglobin level has only marginally improved to 7.0 g/dL. She has been given 2 units of packed red blood cells, but her body seems unable to compensate for the ongoing blood loss. The team also tries to manually evacuate the retained products of conception, but this only results in a further increase in bleeding. A decision is made to take the patient to the operating room for an emergency hysterectomy to stop the hemorrhage. Meanwhile, the patient's low oxygen saturation and cold, clammy skin suggest that she may be developing hypovolemic shock, a life-threatening condition that requires immediate treatment. The team starts her on intravenous fluids and vasopressors to increase her blood volume and blood pressure. Her vital signs and other clinical data will need to be closely monitored throughout these interventions.

Section 4

New Complications:

Upon arrival in the operating room, the patient's condition deteriorates further. Her blood pressure continues to drop, now at 60/35 mmHg, and her pulse rate has escalated to 160 bpm. Her oxygen saturation has dipped to 80% despite the increased level of supplemental oxygen. The patient is now in a state of severe hypovolemic shock. The anesthesia team struggles to maintain her airway due to the profound hypotension and hypoxia, with a rapid sequence intubation (RSI) becoming necessary.

The surgical team moves swiftly to remove the uterus, but encounters unexpected difficulty due to the patient's severe adhesions from previous cesarean sections. The bleeding is copious, and the patient's hemoglobin level drops to 5.8 g/dL mid-procedure, necessitating massive transfusion protocol. Despite the complications, the surgeons successfully complete the hysterectomy and the bleeding is controlled. However, the patient remains critically ill and unstable, requiring transfer to the intensive care unit for further management. The team's next steps will need to center on stabilizing the patient's vital signs and managing her shock, with a particular focus on restoring her oxygenation and hemodynamic stability. The patient's clinical data will need to be closely monitored, as any further deterioration could be life-threatening.

Section 5

New Diagnostic Results:

In the ICU, the patient’s condition remains precarious. A central venous pressure (CVP) line is inserted to monitor her intravascular volume status. The initial CVP reading is 3 mmHg, reflecting the patient's profound hypovolemia. Blood gases show severe metabolic acidosis with a pH of 7.2, PaCO2 of 35mmHg, and HCO3 of 15 mEq/L, indicating a disturbed acid-base balance. Inflammatory markers are also elevated, with a C-reactive protein of 180 mg/L and a white blood cell count of 15,000 cells/mm3, suggesting the presence of an ongoing systemic inflammatory response.

The patient's serum lactate level has risen to 5 mmol/L, reflecting tissue hypoperfusion. Her coagulation profile shows prolonged prothrombin (PT) and partial thromboplastin time (PTT) at 16 seconds and 45 seconds respectively, indicating a coagulopathy. These findings suggest the development of Disseminated Intravascular Coagulation (DIC), a severe complication often associated with massive hemorrhage and sepsis. The patient's renal function is also affected, with creatinine levels of 2.5 mg/dL and blood urea nitrogen (BUN) at 50 mg/dL, indicating acute kidney injury. These new diagnostic results indicate a multi-system involvement that needs urgent and aggressive management. The ICU team must quickly interpret and apply this clinical data to institute appropriate therapeutic measures and prevent further deterioration of the patient's condition.