What is the management for a postpartum woman with fever, hypotension, and undelivered placenta?

Management of Postpartum Hemorrhage with Septic Shock and Retained Placenta

This patient requires immediate aggressive resuscitation with IV fluids and blood products, broad-spectrum antibiotics, and urgent surgical intervention for retained placenta—this is a life-threatening obstetric emergency combining septic shock with hemorrhagic shock. 1

Immediate Resuscitation (First 30 Minutes)

Activate massive transfusion protocol immediately and establish large-bore IV access for aggressive fluid resuscitation. 2, 1

• Transfuse blood products in a 1:1:1 ratio (packed red blood cells:fresh frozen plasma:platelets) rather than crystalloid alone to avoid dilutional coagulopathy. 2, 1
• Do not wait for laboratory results—treat based on clinical presentation of hypotension (BP 75/45) and fever (38°C), which indicates combined septic and hemorrhagic shock. 2, 1
• Keep the patient warm (temperature >36°C) as hypothermia impairs clotting factor function. 1
• Position with left uterine displacement to optimize venous return and cardiac output. 1

Antibiotic Therapy

Initiate broad-spectrum antibiotics immediately with specific activity against anaerobic bacteria, as postpartum endometritis with retained placenta is the most likely source of sepsis. 3

• The combination of fever, hypotension, and retained placenta strongly suggests endometritis progressing to septic shock. 3, 4
• Do not delay antibiotics while awaiting cultures—empiric coverage must be started within the first hour. 3

Uterotonic Management

Administer slow IV oxytocin (<2 U/min) to promote uterine contraction and control hemorrhage while avoiding systemic hypotension. 1

• Avoid methylergonovine due to its vasoconstrictive effects, which could worsen hypotension in this already hemodynamically unstable patient. 1
• Consider carbetocin if available, as it provides better hemodynamic stability than oxytocin with less significant blood pressure drops. 5

Surgical Intervention

Proceed urgently to manual removal of placenta or surgical evacuation once the patient is hemodynamically stabilized with fluids and blood products. 2, 6

• The lack of cervical dilation is not a contraindication—this is a life-threatening emergency requiring intervention regardless of cervical status. 1
• Have a low threshold for hysterectomy if bleeding is uncontrollable after placental removal. 2, 1
• Prepare for potential complications including disseminated intravascular coagulation (DIC), which occurs in >80% of severe hemorrhage cases. 1

Critical Pitfalls to Avoid

Do not use vasopressors like norepinephrine as first-line treatment—this patient is hypotensive from blood volume deficit and sepsis, requiring volume replacement first. 7

• Norepinephrine is contraindicated in hypovolemic shock except as a temporary bridge until blood volume replacement is completed. 7
• Continuous vasopressor administration without volume replacement causes severe peripheral vasoconstriction, decreased renal perfusion, tissue hypoxia, and lactate acidosis. 7

Do not delay intervention waiting for the cervix to dilate—retained placenta with septic shock requires urgent removal regardless of cervical status. 1

Post-Intervention Monitoring

Transfer to ICU for intensive hemodynamic monitoring for at least 24 hours postoperatively. 2, 1

• Monitor for ongoing coagulopathy, DIC, renal failure, liver failure, and unrecognized organ injury. 2, 1
• Have a low threshold for re-exploration if bleeding continues despite initial intervention. 2, 1
• Continue monitoring blood pressure every 4-6 hours and repeat laboratory studies (hemoglobin, platelets, creatinine, liver enzymes, coagulation panel) until stable. 8
• Watch for postpartum complications including wound infection, particularly given the septic presentation. 9, 3