CME Module 8: Management of Post Partum Hemorrhage Next >

 

Sample Case

A previously healthy 34 year old P2G3 at 36 weeks gestation was admitted to hospital for the management of mild pregnancy induced hypertension.

Initial history, physical examination and laboratory investigations were all within normal limits except for trace proteinuria and an elevated BP of 150/90. Specifically, she had no complaints of headache, epigastric pain or visual disturbances. Her Hgb, electrolytes, liver function tests and coagulation screen were all normal, as were the BUN, creatinine and uric acid.

Following admission, she was started on oral labetolol with good effect. Four days later she had spontaneous rupture of membranes. At this point she was transferred to the labor and delivery unit. Repeat blood work was again within normal limits. Vaginal examination found the patient to be 3 cm dilated. An epidural was sited at the patient’s request without incident. Five hours later, at 7cm dilatation, she developed a profound fetal bradycardia with poor recovery and variability. At this point the obstetrician elected to do an urgent cesarean section which was preformed under epidural anesthetic without complications. During the surgery the obstetrician mentioned the possibility of an abruption and noted generalized ooziness. Consequently a hemovac drain was inserted and all NSAIDS were withheld. The blood loss was estimated to be 1000ml with a total of 3000ml of crystalloid administered during the surgery.

On admission to the recovery room the patient was hemodynamically stable. Vital signs included a BP of 130/80, HR 65 and RR of 16. She was noted to somewhat drowsy but easily aroused. Three hours later the hemovac had only 50ml of blood while the urine output was diminished with a total of 40ml for the entire 3 hour period. At this point the patient complained of feeling dizzy and the systolic BP was noted to be 75 with a HR of 95. Oxygen saturation was 96% on room air. Anesthesia and the obstetrical service were urgently summoned. A large bore IV was started following which the patient was given a 2 liter bolus of crystalloid and 500ml of pentaspan with good hemodynamic response (BP 125/80, HR 75). Oxygen was administered by face mask, an arterial line was started and stat blood work was sent. On examination the abdomen was noted to be slightly distended, the uterine fundus was firm and there was no evidence of vaginal bleeding. A bedside abdominal ultrasound was preformed by the obstetrician which did not show any obvious intra-abdominal bleeding.

The results of the stat blood gases revealed a hemoglobin of 48. A decision was therefore made to send the patient for an urgent abdominal CT scan. While arrangements were being made, 4 units of PRBC’s were administered which increased the patient’s blood pressure to 160/100 with a heart rate of 80. However, shortly thereafter, the patient rapidly deteriorated and suffered a cardiac arrest. She was immediately intubated, CPR was initiated and 2 amps of epinephrine were given for PEA. Volume resuscitation was continued with a total of 8 units PRBC’s, 4 units of FFP and 5 units of platelets. Ten minutes post arrest, spontaneous circulation was restored. Another bedside ultrasound was preformed by the radiologist on call which once again failed to reveal any obvious intra-abdominal bleeding. Therefore a decision was made to transfer the patient to the ICU at which point she was hemodynamically stable.

Admission blood work in the ICU revealed Hgb 86, platelets 77, PTT 195, INR>8, D-Dimers 35, fibrinogen 0 and elevated LFT’s. Chest xray was consistent with ARDS. Due to ongoing difficulties with oxygenation, the patient was switched from conventional ventilation to the high frequency oscillator. The following day a repeat bedside ultrasound now revealed a large intraperitoneal bleed which was initially managed conservatively with ongoing correction of the coagulopathy and anemia. However, despite hemodynamic stability and correction of the coagulopathy, she continued to have a “slow ooze”. This was corrected with one dose of recombinant factor VIIa. The remainder of hospital course was one of gradual improvement. She was weaned off the high frequency oscillator and in turn conventional ventilation. Her LFT’s remained elevated for several days and the creatinine was slightly increased at 150. Eighteen days later she was discharged from hospital without further sequela. All blood work was now normal.

 

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