Review Question - QID 106951

This patient is presenting after delivery of twins with prolonged vaginal bleeding. This is likely due to uterine atony and initial treatment is a bimanual uterine massage.

The vast majority of postpartum hemorrhage is caused by uterine atony, which is characterized by a boggy uterus that is not able to effectively compress the spiral arteries. Risk factors for uterine atony include a history of fibroids, multiparity, and prolonged labor. Bimanual uterine massage is the most appropriate initial step in management that can directly compress the arteries and stop bleeding. Medical management can include oxytocin to stimulate uterine contraction and blood/fluid resuscitation if needed. Surgical treatment can be used if medical management fails and may involve embolization or hysterectomy in extreme cases.

Incorrect Answers:
Answer 2: Blood product transfusion is appropriate management of a hemodynamically unstable patient who is actively bleeding. Generally, the most appropriate initial step in management is to stop the bleeding (if possible) then start fluid/blood product transfusion.

Answer 3: Hysterectomy would be indicated for persistent and life-threatening bleeding that could not be managed with any other treatment.

Answer 4: Uterine tamponade should only be performed if uterine massage and medical therapy does not reverse the uterine atony.

Answer 5: Uterine artery embolization is the treatment of leiomyomas (firm and asymmetric uterus) and adenomyosis (soft, boggy, tender uterus). It may also be used for persistent vaginal bleeding secondary to uterine atony that is refractory to bimanual massage and medical management.

Bullet Summary:
Bimanual massage is the most appropriate initial step in management for uterine atony causing postpartum bleeding.