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Obstetrics & Gynaecology·intermediate
Full Case Report
Demographics
Demographics
35yr/F · Emergency Department, Mulago Hospital presenting with Excessive vaginal bleeding following delivery
History
History of Present Illness
A 35-year-old gravida 4, para 3, who delivered a healthy baby boy via spontaneous vaginal delivery at a local health centre 6 hours prior to presentation. She reports that the delivery was complicated by a prolonged second stage of labour and that she experienced severe perineal pain during the delivery. Following delivery, she began experiencing excessive vaginal bleeding that soaked through multiple pads. She was referred to the hospital by the midwife on a boda-boda because ambulance was not available.
Past Medical History
Hypertension in pregnancy during her previous pregnancy, treated with methyldopa
Past Surgical History
None
Medications
Iron supplements and folic acid during pregnancy
Allergies
NKDA
Family History
Mother had a history of postpartum haemorrhage
Social History
Subsistence farmer from Kamuli district, lives with her husband and four children
Review of Systems
No other symptoms apart from the vaginal bleeding and perineal pain
Examination
Vital Signs
Weight
65
kg
Physical Examination
Patient is pale, anxious, and experiencing severe perineal pain. Abdominal examination reveals a soft, non-tender uterus. Perineal examination shows a 2cm cervical tear with active bleeding.
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Investigations
Laboratory Results
| Test | Result | Notes |
|---|---|---|
| Full Blood CountABNORMAL | Hb 8g/dL | Indicates significant blood loss |
| Coagulation profileABNORMAL | INR 1.2 | Mild coagulopathy |
Summary of Abnormal Findings
The patient presents with signs of hypovolemic shock and a low haemoglobin level, indicating significant blood loss. The physical examination reveals a cervical tear as the likely cause of the bleeding.
Updated Diagnosis
Now that you've seen the investigations — what's your leading diagnosis?
Assessment
Assessment
Summary Statement
A 35-year-old mother with postpartum haemorrhage due to a cervical tear following a complicated vaginal delivery
Diagnostic Reasoning
The patient's history of a prolonged second stage of labour, severe perineal pain, and excessive vaginal bleeding following delivery, coupled with the physical examination finding of a cervical tear, led to the diagnosis of postpartum haemorrhage due to a cervical tear.
Evolving Diagnosis / Clinical Course
The diagnosis evolved as the patient's condition worsened, with the bleeding becoming more severe and the patient showing signs of hypovolemic shock.
Final Diagnosis
Postpartum haemorrhage due to cervical tear (O72.1)
Management
Learning purposes only. Cases on Osler Market are handpicked from real clinical encounters. The management described does not represent the full standard of care as per current guidelines and should not be taken as the ideal. Always refer to up-to-date guidelines and your institutional protocols.
Outcomes
Clinical Timeline
Day 1 on ward
Patient presented to the emergency department with excessive vaginal bleeding
Day 1 on ward
Patient was resuscitated with IV fluids and blood transfusions
Day 1 on ward
Cervical tear was repaired, and uterotonic agents were started
Hospital Course
The patient was resuscitated with IV fluids and blood transfusions. The cervical tear was repaired, and the patient was started on uterotonic agents to control the bleeding. The patient's condition improved, and the bleeding was controlled.
Complications
The patient experienced hypovolemic shock and required blood transfusions, but no other complications were noted.
Outcome
recovered
Follow-up Recommendations
The patient was advised to follow up with her healthcare provider in one week for a postpartum check-up and to monitor for any signs of infection or further bleeding.
Discharge Summary
The patient was discharged in stable condition, with the bleeding controlled and no further complications noted.
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