What is the cause of profuse vaginal bleeding in a 37-year-old woman, gravida 4, para 0, aborta 3, with a history of dilation and curettage (D&C), who delivered a 4.5-kg male infant and had a manual placental extraction with avulsion of the umbilical cord from the placenta, unresponsive to uterine massage and uterotonic medications?

From the Guidelines

The patient is experiencing a life-threatening postpartum hemorrhage (PPH) and should be taken immediately to the operating room for exploratory laparotomy, with possible hysterectomy, as the clinical presentation suggests placenta accreta or other severe complications. The clinical presentation strongly suggests a severe complication, such as placenta accreta, based on several risk factors: history of multiple uterine procedures (three prior D&Cs), lack of prenatal care, avulsion of the umbilical cord, fragmented placental extraction, and persistent hemorrhage despite a firm uterus and uterotonic medications 1. The most common cause of early PPH is related to uterine atony or lack of effective uterine contraction after delivery, which is typically a clinical diagnosis in >75% of patients, and is initially treated by uterine massage and uterotonic drugs such as oxytocin 1. However, in this case, the patient's bleeding is unresponsive to uterine massage and uterotonic medications, suggesting a more severe complication. While preparing for surgery, aggressive resuscitation with crystalloid fluids and blood products (packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate in a 1:1:1:1 ratio) should be initiated, and a massive transfusion protocol should be activated 1. Additionally, tranexamic acid should be given at an initial dose of 1 g, as it reduces total blood loss in severe postpartum hemorrhage 1. Anesthesia support for general anesthesia is necessary, and interventional radiology for uterine artery embolization could be considered if available and the patient is stable enough. The patient's history of multiple D&Cs created a predisposition for this life-threatening complication, and prompt surgical intervention is necessary to prevent further morbidity and mortality. Key considerations in the management of this patient include:

• Aggressive resuscitation with crystalloid fluids and blood products
• Activation of a massive transfusion protocol
• Administration of tranexamic acid
• Surgical intervention with possible hysterectomy
• Anesthesia support for general anesthesia
• Consideration of interventional radiology for uterine artery embolization if available and the patient is stable enough.

From the FDA Drug Label

OVERDOSAGE Overdosage with oxytocin injection (synthetic) depends essentially on uterine hyperactivity whether or not due to hypersensitivity to this agent Hyperstimulation with strong (hypertonic) or prolonged (tetanic) contractions, or a resting tone of 15 to 20 mm H2O or more between contractions can lead to tumultuous labor, uterine rupture, cervical and vaginal lacerations, postpartum hemorrhage, uteroplacental hypoperfusion and variable deceleration of fetal heart, fetal hypoxia, hypercapnia or death The patient's postpartum hemorrhage is unresponsive to uterine massage and uterotonic medications, but the provided text from the oxytocin label does not directly address the management of postpartum hemorrhage in this specific scenario.

• The label mentions postpartum hemorrhage as a potential complication of oxytocin overdosage, but it does not provide guidance on how to manage it when it occurs.
• The management of oxytocin overdosage is mentioned, which consists of immediate discontinuation of oxytocin, and symptomatic and supportive therapy 2. However, this information does not directly answer the question of how to manage the patient's postpartum hemorrhage.

From the Research

Patient Presentation and Symptoms

• The patient is a 37-year-old woman, gravida 4 para 0 aborta 3, presenting with painful contractions at 37 weeks gestation.
• She has had no prenatal care and has a history of 3 elective pregnancy terminations with dilation and curettage.
• On physical examination, the cervix is 6 cm dilated and 90% effaced with the fetal head at +1 station.

Postpartum Hemorrhage Management

• The patient develops profuse vaginal bleeding after delivery, which is unresponsive to uterine massage and uterotonic medications 3.
• Studies suggest that combined therapy, rather than oxytocin alone, is effective in preventing postpartum hemorrhage 3.
• Tranexamic acid has been found to be effective and safe in decreasing maternal mortality in women with postpartum hemorrhage 3, 4, 5.

Causes and Management of Vaginal Bleeding

• Vaginal bleeding can be a sign of life-threatening medical disorders, such as carcinoma, bleeding disorders, and trophoblastic disease 6.
• In nonpregnant patients, abnormal uterine bleeding is a common reason for seeking gynecologic care, and emergency clinicians should have a thorough understanding of the underlying physiology of the menstrual cycle to manage these patients 7.
• The approach to managing vaginal bleeding in the emergency department involves identifying the underlying cause and initiating treatment to temporize the bleeding episode until timely follow-up with a gynecologist can be obtained 6, 7.

Placenta Accreta Spectrum Disorders

• Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality 4.
• Hemorrhage and transfusion of blood products represent 90% of placenta accreta spectrum morbidity, and both tranexamic acid and uterine artery embolization have been shown to decrease obstetrical hemorrhage 4.
• A protocol combining uterine artery embolization and tranexamic acid has been found to be effective in reducing maternal morbidity in patients with placenta accreta spectrum disorders 4.