Obstetrics and Gynecology

Mock Simulation Output

Dejelo, Carlo Jay Maniago, Kathleen Grace

Garcia, John Eric Oh, Seyoung
Januto, Freomel
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UTERINE ATONY
This is the most common cause of excessive post-partum bleeding
Pathophysiology: Normally, the uterine corpus contracts immediately after the delivery
of the placenta, constricting the spiral arteries and preventing excessive bleeding from
the placental implantation site. In uterine atony, there is failure of the uterus to contract
efficiently after delivery to arrest bleeding vessels at the placental implantation site.

RISK FACTORS
Chorioamnionitis
Medications such as magnesium sulfate
Extraordinary enlargement of the uterus such as in multiple gestations, macrosomic
fetus, or polyhydramnios
Abnormal labor such as prolonged labor, precipitous labor, or labor augmented by
oxytocin
History of atony with any prior pregnancies
Grand multipara (more than five deliveries).
Conditions that interfere with uterine contractions such as Leiomyomas

DIAGNOSIS
The clinical diagnosis of atony is based largely on the tone of the uterine muscle on
palpation. Instead of the normally firm, contracted uterine corpus, a softer, more
pliable often called boggyuterus is found. The cervix is usually open. Frequently,
the uterus contracts briefly when massaged, only to become relaxed again when the
manipulation ceases.

MANAGEMENT
A. Assess the hemodynamic status of the patient
Monitor vital signs, give supplemental oxygen.
If hemodynamically unstable, place 2 large bore IV and begin fluid resuscitation
with rapid intravenous infusion of crystalloids.
Reassess for adequacy of resuscitation
B. Perform bimanual uterine massage
Uterine massage is performed by rubbing or
stimulating the fundus of the uterus. It is
hypothesized that massage releases local
prostaglandins that promote uterine contractility
hence reduces bleeding.
Bimanual compression is performed by inserting
the right hand into vagina at anterior surface of the
uterus and the left hand is on abdomen at the
fundus towards the posterior surface of uterus.
The uterus is compressed between the two hands
to minimize bleeding.

C. Administer uterotonic agents

PHARMACOLOGIC MANAGEMENT OF UTERINE ATONY
Oxytocin Acts by stimulating rhythmic uterine contraction particularly in the upper
segment.
It is administered intramuscularly or intravenously; however the onset of
action is delayed if given intramuscularly (3-7minutes) as compared to
immediate onset if given by intravenous route.
Furthermore, due to its short plasma half-life of 3minutes, continuous
intravenous infusion is preferred.
IV oxytocin is given 10-40 units by infusion in 1000 mL of IV fluid at a rate
sufficient to control uterine atony, maximum of 40units/1000ml ml.
Long acting Administered via intramuscular or intravenous route. The recommended
synthetic dose is 100 g.
Oxytocin Carbetocin has the advantage of rapid onset of action, within 2 minutes,
analogue similar to oxytocin with additional benefit of longer duration of action.
(Carbetocin) These actions do not differ by the route of administration. However,
intramuscular Carbetocin (120 minutes) had been reported to give a longer
uterine contraction as compared to intravenous route (60 minutes)
Ergot Results in sustained myometrial contraction.
derivatives It is given as 0.25 mg intramuscularly or intravenously with rapid clinical
(Ergometrin) effect within 2 to 5 minutes that can persist up to 3 hours.
Ergometrine is metabolized in the liver and has a plasma half-life of 30
minutes. A repeat dose of ergometrine can be given after 5 minutes if the
uterus is still not well contracted.
Nausea, vomiting and dizziness are commonly reported side-effects. If ergot
agents are intravenously administered, they may cause dangerous
hypertension, especially in women with preeclampsia
Prostaglandin The initial recommended dose is 250 g (0.25 mg) given intramuscularly.
analogs This is repeated if necessary at 15- to 90-minute intervals up to a maximum
(Carboprost of eight doses. Side effects are diarrhea, hypertension, vomiting, fever,
Tromethamine) flushing, and tachycardia.
Misoprostol It has also been evaluated for prophylaxis of postpartum hemorrhage. At
600-g oral dose postpartum hemorrhage was signifcantly reduced from 12
to 6 percent, and severe hemorrhage from 1.2 to 0.2 percent with
misoprostol use
D. Uterine Packing or Balloon Tamponade
Intrauterine balloon exerts hydrostatic pressure on the uterine arteries resulting in reduced
blood loss.

E. Surgical procedures
B lynch Uterus will be exteriorized from the patient with frog legged position. Uterine
compression cavity will be checked and explored after transverse lower segment incision is
suture made. Then, Vicryl 1.0 will be applied with even tension. After complete drainage
of blood debris and inflammatory materials, check if bleeding is successfully
controlled. Close abdomen if bleeding is well controlled.

Uterine It is used when the uterus is not previously

compression opened. Multiple simplified suture like square
suture sutures are used to cease bleeding. However, it is
a time consuming procedure and may cause
uterine cavity drainage restriction.
Hayman suture Another simplified suture technique which does not
require to open the lower uterine segment. It is time
saving method compared to square suture but
unequal tension may cause a segmented ischemia
secondary to slippage of suture.

Vascular Uterine artery ligation: it is considered when simple compression suture is

Ligation or failed. Since blood supply of uterus is 90% from uterine arteries, it ligates
occlusion the artery at the cervical isthmus above the bladder flap. First of all, a
suture will be made on broad ligament including 2-3cm of myometrium.
This is approximately 2cm above the point where incision of lower
segment CS would be. Carefully ligate ascending branch of the uterine
artery by avoiding inclusion of ureter. Because uterus still get the blood
supply from other vessels like ovarian arteries, the patient is mostly free
from infertility problem.

Ovarian Artery ligation: Ovarian artery is directly from aorta which is

anastomosed with the uterine artery in the utero-ovarian ligament, thus
this procedure is ligation of the utero ovarian anastomosis

Internal iliac artery ligation: Before the procedure, the common, internal,
and external iliac arteries must be identified clearly because it will only
entertain internal iliac artery. The artery is double ligated with an
absorbable suture as well as its contralateral side. It must be carefully
since hypogastric vein which lies deep lateral to the artery may be injured
that resulting in massive fatal bleeding. It may reduce as much as 85% of
pulse pressure and 50% of blood flow. This procedure is indicated for
refractory atonic uterus, ruptured uterus in which uterine artery may be
torn out, abruptio placenta with uterine atony. Continuous bleeding or
diffuse bleeding with unidentifiable vascular bed also requires internal iliac
artery ligation.

Hysterectomy Peripartum hysterectomy must be carried out if conservative surgical

procedures are ineffective or patient is already showing signs of
cardiovascular decompensation. Subtotal hysterectomy that only removes
the uterus is usually good enough for the patient because of less
transfusion, faster operative time, decreased intraoperative and
postoperative complications.