What is the immediate management for a postpartum woman with hemorrhage, respiratory distress, seizures, and coagulopathy?

Immediate Management of Postpartum Hemorrhage with Respiratory Distress, Seizures, and Coagulopathy

This clinical presentation suggests amniotic fluid embolism (AFE) or severe hemorrhagic shock with multi-organ failure, requiring immediate resuscitation, airway management, correction of coagulopathy, and hemorrhage control in an intensive care setting.

Initial Resuscitation and Stabilization

Activate a massive transfusion protocol immediately for blood loss exceeding 1,500 mL, as rapid team-based response minimizes morbidity and mortality 1. The postpartum period represents a particularly vulnerable time with risks of cardio-respiratory decompensation, sepsis, and hemorrhage 2.

Airway and Respiratory Management

• Secure the airway immediately given respiratory distress and seizure activity to prevent aspiration and ensure adequate oxygenation 2.
• Consider assisted ventilation strategies with appropriate intensive care unit backup 2.
• Apply positive end-expiratory pressure if needed to maintain adequate oxygenation 2.
• Provide oxygen therapy to maintain normal saturations 2.

Seizure Management

• Administer magnesium sulfate as first-line therapy if eclampsia is suspected, though the constellation of symptoms suggests AFE as more likely 2.
• Protect the patient from injury during seizure activity.
• Consider benzodiazepines if seizures persist despite magnesium.

Hemorrhage Control

Medical Management

Administer oxytocin 5-10 IU slow IV or intramuscular immediately as the most important and effective component for uterine atony management 2, 1. Oxytocin is more effective than misoprostol and has fewer adverse effects 1.

• Avoid prostaglandin F2α and ergometrine in patients with respiratory distress, as prostaglandin F2α causes bronchoconstriction and ergometrine may cause bronchospasm, particularly with general anesthetics 2.
• Consider additional uterotonics if oxytocin alone is insufficient 1, 3.
• Apply uterine massage and consider uterine tamponade with balloon catheter if bleeding continues 2.

Coagulopathy Correction

Initiate early transfusion of plasma with high plasma-to-red blood cell ratios in massive postpartum hemorrhage complicated by coagulopathy 4. The "washout phenomenon" leading to coagulopathy must be corrected promptly 5.

• Administer tranexamic acid for hemorrhage complicated by coagulopathy, as it has been shown to reduce mortality in obstetric hemorrhage 4, 5.
• Consider fibrinogen concentrates if fibrinogen levels are critically low 4.
• Perform rapid laboratory assessment of coagulopathy including PT, PTT, fibrinogen, and platelet count 4.
• Replace clotting factors and platelets based on laboratory results and clinical bleeding 4, 5.

Diagnostic Evaluation

Perform rapid clinical assessment using the "Four T's" mnemonic to identify the cause: Tone (uterine atony), Trauma (lacerations, rupture), Tissue (retained placenta), and Thrombin (coagulopathy) 1.

• Examine for genital tract lacerations, hematomas, or uterine rupture 2, 1.
• Assess for retained placental tissue 2, 1.
• Consider imaging with ultrasound or CT angiography if the bleeding source is unclear or if vascular anomalies are suspected 2.

Surgical and Interventional Options

If conservative measures fail:

• Uterine artery embolization may be performed if the patient is hemodynamically stable enough for transfer to interventional radiology 2, 3.
• Surgical ligation of uterine or internal iliac arteries 2, 3.
• Peripartum hysterectomy should be performed without delay if other measures fail, as timely hysterectomy saves lives 3, 5.

Critical Care Considerations

Transfer to intensive care unit immediately given the multi-system involvement with respiratory failure, neurological compromise, and coagulopathy 2. The level of care must be determined in a multidisciplinary setting balancing obstetric and critical care needs 2.

Thromboprophylaxis

• Consider thromboprophylaxis with low-molecular-weight heparin once hemorrhage is controlled and coagulopathy corrected, as postpartum venous thromboembolic risk is increased with immobility 2, 6.
• Postpartum prophylaxis should typically continue for 6 weeks, particularly with additional risk factors such as emergency cesarean section, blood loss >1L, or BMI ≥30 kg/m² 6.

Common Pitfalls

• Underestimating blood loss is common; use objective measures like obstetric shock index rather than visual estimation 5.
• Delaying definitive surgical intervention (hysterectomy) when conservative measures fail increases mortality 5.
• Failing to activate massive transfusion protocols early enough 1, 4.
• Using respiratory-compromising uterotonics (prostaglandins, ergometrine) in patients with respiratory distress 2.