P072: THE CLOT THICKENS, OR NOT: A CASE OF UNSUSPECTED, UNCONTROLLABLE HEMORRHAGE IN A "HEALTHY" PARTURIENT FOLLOWING SCHEDULED CAESAREAN DELIVERY
Reena S John, DO; Kalina Nedeff, MD; Jorge Sanchez-Medio, MD; Isabelle Jean-Pierre, MD; Sophia Fischer, MD; Kendall Regional Medical Center
Introduction: 27 yo F G1P0 with IUP at 40 weeks admitted for elective induction of labor. Obstetrician called to bedside for prolonged fetal decelerations, Pitocin discontinued, however, the obstetrician felt there was no immediate need for cesarean delivery at the time of evaluation. He discussed that cesarean delivery was an alternative to labor, and pt consented to c/s. Pt was taken to OB OR, spinal anesthesia provided in the setting of normal CBC and coags (Hbg 10.3, Hct 32, Plt 248,000, PT 10.6, INR 0.9, PTT 26.1). The course of c/s was uneventful up until closure when obstetrician noticed excessive bleeding and oozing, however at that time hemodynamically stable.
Management: Pt started vomiting blood, and was immediately intubated in RSI fashion. Code trauma alert was called and anesthesia help was called STAT. PRBCs were given and MTP was initiated. RIJ introducer and R radial arterial line were placed immediately. Repeat CBC, coags, fibrinogen, d-dimer, plt function, and TEG were sent off immediately. POC testing showed undetectable Hgb and pt was reopened for hemoperitoneum and supercervical hysterectomy was performed Pt was transfused 23u PRBCs, 13 FFP, 11 cryo, 4 plts, given CaCl, NaHCO3, and TXA. Pt was adequately resuscitated and taken intubated to the ICU for close observation and critical care. Fibrinogen 670, d-dimer 5250, and plt function/ADP & epi > 300. Pt developed pulmonary edema in the operating room, postop ECHO showed RVSP of 59. It was later brought to our attention by the pt’s spouse that she had been coughing up clots throughout her pregnancy which they thought nothing of. The obstetrician suspects that the postpartum hemorrhage is 2/2 to uterine atony and DIC. In the ICU her plts have dropped significantly (37,000) and her LFTs are elevated, consistent with HELLP syndrome.
Discussion: Disseminated intravascular coagulation (DIC) life-threatening condition is a complication of obstetrical and non-obstetrical causes including: (1) acute peripartum hemorrhage (uterine atony, cervical and vaginal lacerations, and uterine rupture); (2) placental abruption; (3) Pre-eclampsia/HELLP syndrome; (4) retained stillbirth; (5) sepsis; (6) amniotic fluid embolism; and (7) acute fatty liver of pregnancy.
Acute obstetrical hemorrhage is one of the leading causes for DIC in pregnancy and is one of the most avoidable etiologies of maternal death.
Disseminated intravascular coagulation (DIC) in obstetrical disorders can arise from the spillover of heightened placental coagulation activation into the systemic circulation.
Intrauterine fetal demise (IUD) has been classically described as frequently associated with DIC.
The key to management is in early recognition to facilitate timely intervention.
In pregnancy-associated DIC, the primary approach is to address the obstetric abnormality. Once this is corrected, the DIC will usually subside.
The aim of resuscitation is to establish normotensive, normothermic patients with adequate coagulation factors.
The treatment is urgent. It requires first to the cause and the shock by massive transfusions of packed red blood cells, fresh frozen plasma, and platelets, associated with antifibrinolytic drugs, if necessary.