Virginia I: After Birth

Female Reproductive System & Breast


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G8_F2.jpg"}},{"insert":"\n\n\u0022Doctor! Doctor!\u0022 You blearily open your eyes. Your nurse is gently shaking your shoulder. Glancing at the clock, you see that it\u0027s 1:30 AM.\n\n\u0022Doctor, Virginia has vaginal bleeding. You\u0027d better take a look,\u0022 the nurse says, after making sure you\u0027re fully awake.\n"}]}


{"ops":[{"insert":"You recall that Virginia, a 32-year-old stay-at-home mom, delivered her fifth child vaginally around four hours ago. At the time of onset of labor, she was at 40 weeks of gestation.\n\nVirginia\u0027s pregnancy was uncomplicated. She wanted a delivery \u0022without any drugs\u0022\u2014which you respected. Labor was spontaneous in onset. However, the second stage was prolonged. Episiotomy was not performed. The baby weighed 2.9 kg and had perfect Apgar scores. The placenta and products of conception were fully expelled. There was no vaginal bleeding afterwards. \n\nAll of Virginia\u0027s preceding pregnancies were without complications. Her medical, surgical, and family histories were all unremarkable. Her blood group is A+.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G8_F3.jpg"}},{"insert":"\n\nArriving at Virginia\u0027s room, you note that she is conscious, rational and fully oriented. Her pulse is 100 bpm and her blood pressure is 100\/70 mmHg. A quick review of her charts show that just one hour ago, her pulse was 80 bpm and blood pressure 120\/80 mmHg.\n\nOn examination, the uterus feels boggy and poorly contracted. There is active vaginal bleeding. Based on the number of blood soaked swabs, you roughly estimate that she must have lost around 500 mL of blood so far. Via careful inspection of the vulva, vagina, and cervix, you exclude local trauma as the cause of the bleeding.\n\nYour capable team has already started oxygen via face mask. They have also inserted a wide-bore cannula and started a normal saline drip. Once you complete your examination, they elevate Virginia\u0027s legs as well. You ask them to call the blood bank and reserve two units of matched packed red cells. You also order an urgent full blood count and coagulation profile.\n"}]}


{"ops":[{"insert":"Which of the following conditions do you suspect?\n"}]}
1. Disseminated intravascular coagulation
2. Cervical tears
3. Uterine atony