Case Study: Interpreting Patient Deterioration

This case study discusses the medical history of a patient with postpartum hemorrhage caused by retained placenta. It explores the pathophysiology, anatomy, and treatment options for this condition. Find study material and solved assignments on Desklib.

Assessment 1:
Case study: Interpreting Patient
Deterioration
Student’s Name:
University:
The present case study will explain about a 23 year old women Miss Kate who was presented to
the emergency department diagnosed with post postpartum hemorrhage after 10 days of her
normal delivery. This study essay will discuss about the medical history of Miss Kate as well as
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a detailed description of the postpartum hemorrhage caused due to retained placenta. The
pathophysiology, anatomy and physiological mechanisms of the problem will be discussed.
On her arrival to emergency department she was observed to have tachycardia, with low blood
pressure and had a pale look on her face. She was soon examined for other signs and symptoms
which depicted she has a saturated vaginal pad and has to change around 2-3 pads after every
half an hour. Further investigations were carried out in emergency department such as ultrasound
as well as a blood test. The reports stated her hemoglobin to be at 99 after first blood gas was
carried out on her. The ultrasound results depicted the presence of retained placenta. The
observations led to close monitoring of Miss Kate in the emergency department till the obstetric
surgeon arrived. Another blood gas was carried out in another span of half an hour depicting a
drop in hemoglobin as compared to the previous one i.e., 70 which led to the conclusion of
carrying out a surgery on her to remove the retained placenta, hence, was transferred to OT.
Miss Kate also shows signs of bad dizziness and weakness. Before she was transferred to
emergency department she was on 18G IV cannula and 1L of CSL. After she was transferred to
OT she was given 1 unit of blood. The vital signs observed in OT is blood pressure 70/52 and
provided with 2 units blood induction and she was further put on arterial line by the anesthetic
doctor. The doctor further tried to take off the retained products for stopping blood loss. She was
kept on oxytocin, ergometrine medicines for stopping blood loss while the surgeons have
struggled to stop the blood loss hence, bakri balloon was used to stop bleeding.
The postpartum period is related to the extraordinary change in physiology changes for the
mother. After the child's birth, the contraction in uterus takes place for detaching the placenta out
of the uterine wall and carry out the delivery of placenta and membranes. The myometrium is
made out of a system of muscle filaments and the veins providing travel of the placental bed
inside this system. The contraction in muscles which is caused post-delivery is essential for
avoiding excessive blood loss which is life-threatening through the placental bed through the
constriction of open vessels of blood. These type of change in physiology proceed all through the
postpartum period of around two months and the uterus experiences a considerable process of
involution. Directly after birth, the uterus has an expected load of around a thousand gram and
can be effectively palpated at the dimension of the umbilicus. A month and a half later the uterus
has returned to its state of non-pregnancy and has been found to weighs below 100 g
(Abedzadeh-Kalahroudi, 2015).
Lots of blood loss happening post-delivery is alluded to as postpartum hemorrhage (i.e., PPH).
The postpartum hemorrhage is additionally connected with the maternal mortality rate and
records for around 50 percent of the deaths of maternal brought about by PPH. The purpose
behind the optional PPH is an insufficient contraction of the uterus brought about by the
intrauterine disease or the retained placenta. Besides, interventions of surgery can be convoluted
by disease or puncturing and, in extreme cases, may result in Asherman's disorder, which is
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related to intrauterine grips. Such type of potential dangers upgrade the significance of the
precise diagnosis of retained placenta (Aibar et al., 2012).
In postpartum hemorrhage excessive amount of blood loss occurs post delivery. PH usually
occurs after the delivery of the placenta characterized by the average blood loss of about 500 ml
in normal delivery of the newborn. However, it is found to be around 1-quart in a cesarean birth.
Most of the PH usually occurs soon after the delivery, yet it can happen later also. When an
infant is born, the uterus regularly keeps on contracting (fixing of uterine muscles) and removes
the placenta. After the delivery of the placenta, such type of constrictions helps in compressing
the blood vessels in the region where there is an attachment of placenta. On the off chance that
the uterus does not contract unequivocally enough, the condition which is also referred to as
uterine atony, such type of vessels containing blood drain uninhibitedly causing hemorrhage.
This is the most widely recognized reason for postpartum hemorrhage. In any case, even a small
part of placenta remained retained inside the body it results in excessive bleeding (Bohlmann and
Rath, 2013).
Disease and retained placenta at the time of delivery are the main sources of postpartum
hemorrhage. Pelvic ultrasound might be carried out to recognize retained fragments of the
placenta. Clinicians might speculate retained parts in a patient with postponed lactogenesis. The
retained placenta can prompt uterine atony— which is the loss of contraction in the uterine wall
post delivery. Hazard factors incorporate an excessively expanded uterus brought about by
polyhydramnios, different incubation, or macrosomia. The depletion in the muscle of the uterine
wall is brought about by labor, delayed work, or high equality. Intraamniotic disease brought
about by fever or delayed labor, anatomic variations as well as the limitations in the uterine
atony or influence on the entire musculature has been recognized as other risk factors of retained
placenta (Kaya and Sezer, 2017).
Beginning assessment of the patient ought to incorporate a fast appraisal of the patient's status
and hazard factors. In postpartum females, signs or side effects of excessive bleeding, for
example, tachycardia and hypotension might be veiled, so if these signs are available, there
ought to be a worry for significant loss of blood from the body i.e., around 25 percent of the
absolute blood volume. Persistent evaluation of indispensable signs and on-going estimation of
total loss in the blood is a significant factor in guaranteeing safe consideration of the patient with
PPH. A test of the patient in the situation of hemorrhage can distinguish the reasonable
justification of blood loss concentrated on particularly vulnerable factors the patient may have. A
fast evaluation of the whole genital tract for cuts, hematomas, or indications of uterine burst
ought to be performed. Conceivable manual test and extraction for any retained placenta
fragments or appraisal by bedside ultrasound might be a piece of the assessment. A delicate, or
non-contracted uterus is the normal finding with uterine atony. Uterine reversal displays as a
round lump or mass with palpation of the lining of the fundal present in the cervix or lower
uterine section and is frequently connected with extreme traction in the umbilical string or
unusually attached placenta. Excessive bleeding, for example, from venipuncture places, is an
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indication of dispersed intravascular coagulation (DIC). Lab studies can be requested in a PPH to
help assess and deal with the patient, in spite of the fact that mediations, for example,
prescription or blood item organization ought not be retained pending the aftereffects of such
examinations. Type and screen or crossmatch might be requested to get ready for conceivable
blood transfusion. Complete blood check to survey hemoglobin, hematocrit, and platelets can be
assessed at interims despite the fact that lab esteems frequently linger behind the clinical
introduction. Coagulation studies and fibrinogen will be helpful in the patient where DIC is
suspected (Lockhart, 2015).
The treatment and assessment of postpartum hemorrhage are centered around the revival of the
patient while recognizing and treating the particular reason. Keeping up hemodynamic steadiness
of the patient is imperative to guarantee proceeded with perfusion to crucial organs. Abundant
intravenous (IV) access ought to be gotten. Cautious direct evaluation of aggregate blood loss is
significant, and an emphasis ought to be on early commencement of conventions for the arrival
of blood items and huge transfusion conventions. Fast distinguishing proof of the reason for
postpartum hemorrhage and excessive blood loss and starting treatment ought to be done at the
same time. Exchange to a working suite with anesthesia help might be shown for help with a
troublesome cut fix, to address uterine reversal, to help give absence of pain if necessary to the
evacuation of held items, or if a careful investigation is demonstrated. In the event that the
postpartum hemorrhage is because of uterine atony, treatment modalities incorporate restorative
administration with uterotonic specialists tamponade, embolization, and careful administration
(Lalonde, 2013).
Medicinal administration with agents of pharmacology and uterotonic is normally the initial step
if uterine atony is recognized. While oxytocin is given routinely by most foundations at the
season of conveyance (see counteractive action), extra uterotonic drugs might be given with
bimanual back rub in an underlying reaction to blood loss. Uterotonic specialists incorporate
oxytocin, ergot alkaloids, and prostaglandins (Marcova et al., 2012). Regularly utilized
uterotonic include:
● Oxytocin: A hormone normally delivered by the back pituitary act quickly to cause
uterine constriction without any contraindications and negligible reactions.
● Methylergonovine: Semi-engineered ergot alkaloid. Act quickly for continued uterine
withdrawal. Contraindicated in patients with hypertension.
● Carboprost: Synthetic prostaglandin simple of PGF Contraindicated in extreme hepatic,
renal, and cardiovascular sickness, may cause bronchospasm in asthmatics.
● Misoprostol: Prostaglandin E1 simple. More deferred beginning than above meds.
On the off chance that bimanual back rub and uterotonic meds are not adequate to control drain,
uterine tamponade might be considered. An intrauterine inflatable tamponade framework can be
utilized, commonly by filling an intrauterine inflatable with 500 mL of typical saline. On the off
chance that there isn't an intrauterine inflatable promptly accessible, the uterus might be stuffed
with bandage, or numerous huge Foley catheters might be set simultaneously. It is essential to
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keep an exact include of anything put in the uterus to anticipate held remote body. Uterine
corridor embolization might be considered in the steady patient with determined dying.
Fluoroscopy is utilized to distinguish and impede draining vessels. While the flimsy patient isn't
a contender for this methodology, it has the advantage of uterine protection and conceivable
future richness (Matsubara and Takahashi, 2016).
Exploratory laparotomy is regularly demonstrated in the setting where less obtrusive measures
for baby blues discharge have fizzled or if the speculated explanation behind baby blues drain,
for example, drearily follower placenta, requests it. A midline vertical stomach cut ought to be
considered to boost presentation; nonetheless, if the patient had a cesarean conveyance, the
current entry point might be used. Vascular ligation sutures might be endeavored to diminish
beat weight at the uterus. Respective uterine supply route ligation sutures might be put just as
reciprocal utero-ovarian tendon ligation sutures. Ligation of the interior iliac veins may likewise
be performed anyway as this involves a retroperitoneal approach, it is seldom utilized. Uterine
pressure sutures may likewise be utilized as a treatment for atony. The B-Lynch suture strategy,
the most usually performed of the pressure sutures, physically packs the uterus circling from the
cervix to the fundus. The complete treatment for postpartum hemorrhage is a hysterectomy
(Prata, Bell and Weidert, 2013).
Miss Kate is presented with postpartum hemorrhage due to retained placental fragments. In this
case, even a small part of placenta remained retained inside the body it results in excessive
bleeding. The fragment of placenta leads to loss of blood in the present case. The purpose behind
the optional PH is an insufficient contraction of the uterus brought about by the intrauterine
disease or the retained placenta. Pelvic ultrasound was be carried out to recognize retained
fragments of the placenta with postponed lactogenesis in emergency department. The blood test
was carried out assess blood loss organization ought not be retained pending the aftereffects of
such examinations. So that type and screen or crossmatch might be requested to get ready for
conceivable blood transfusion. Furthermore, total blood test to survey hemoglobin, hematocrit,
and platelets was be assessed. Miss Kate was given medicinal administration with agents of
pharmacology and uterotonic such as oxytocin and ergometrine medicines routinely in an
underlying reaction to blood loss. An intrauterine inflatable tamponade framework can be
utilized, commonly by filling an intrauterine inflatable with 500 mL of typical saline to keep up
with the hemodynamic steadiness of her, which is imperative to guarantee proceeded with
perfusion to crucial organs. Abundant intravenous (IV) access ought to be gotten before she was
transferred to emergency department she was on 18G IV cannula and 1L of CSL (Tunçalp,
Souza and Gülmezoglu, 2014).
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References
Abedzadeh-Kalahroudi, M. (2015). Prevention of Postpartum Hemorrhage: Our Options.
Nursing and Midwifery Studies, 4(3).
Aibar, L., Aguilar, M., Puertas, A. And Valverde, M. (2012). Bakri balloon for the
management of postpartum hemorrhage. Acta Obstetricia et Gynecologica
Scandinavica, 92(4), pp.465-467.
Bohlmann, M. and Rath, W. (2013). Medical prevention and treatment of postpartum
hemorrhage: a comparison of different guidelines. Archives of Gynecology and
Obstetrics, 289(3), pp.555-567.
Kaya, B. and Sezer, S. (2017). The prevention and management of postpartum
hemorrhage. İstanbul Kanuni Sultan Süleyman Tıp Dergisi.
Lalonde, A. (2013). Prevention and Treatment of Postpartum Hemorrhage in Low-
Resource Settings. Obstetric Anesthesia Digest, 33(3), pp.136-137.
Lockhart, E. (2015). Postpartum hemorrhage: a continuing challenge. Hematology,
2015(1), pp.132-137.
Markova, V., Sørensen, J., Holm, C., Nørgaard, A. And Langhoff-roos, J. (2012).
Evaluation of multi-professional obstetric skills training for postpartum hemorrhage.
Acta Obstetricia et Gynecologica Scandinavica, 91(3), pp.346-352.
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Matsubara, S. and Takahashi, H. (2016). Pseudoaneurysm Hidden Behind Secondary
Postpartum Hemorrhage. Birth, 43(2), pp.184-185.
Prata, N., Bell, S. and Weidert, K. (2013). Prevention of postpartum hemorrhage in low-
resource settings: current perspectives. International Journal of Women's Health,
p.737.
Tunçalp, O., Souza, J. and Gülmezoglu, M. (2014). New WHO Recommendations on
Prevention and Treatment of Postpartum Hemorrhage. Obstetric Anesthesia Digest,
34(4), pp.195-196.
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