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A near miss case of P.P.H.
Dr. Shobhana Mohandas MD.D.G.O
Dept. Of Infertility And Keyhole Surgery
Elite Mission Hospital, Thrissur, Kerala
Deepa, a 30 year old primigravida had undergone a normal
vaginal delivery at 3.56PM on 25.1.08. The labour was not
unduly prolonged (3-4 hours duration). She went into atonic
PPH and it did not respond to medical management. She was
given 3 pints of blood transfusion and her BP was 100/60mmHg
and she was referred to our institution.
She
reached there at about 8PM and by then she had no pulse or
BP.
On
admission, the 4th pint of blood was going on.
The patient was restless and uterus was relaxing in
between. Pulse and BP were un-recordable clinically. She
was not bleeding profusely from the uterus, probably due to
lack of pulse or BP.
Immediate measures taken were:
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Oxygen given
-
Inj.Hydrocortisone given IV.
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Inj Methyle amphetamine given IV.
-
Blood pushed in vigorously.
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Haemaccele started.
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Misoprostol 800umg kept intrarectally.
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Prostodine given IV.
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20 units oxytocin drip started.
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Patient sent into operation theatre immediately.
She
was immediately put on ventilator and electronic cardiac
monitor. Her heart rate was 156/minute. Pupils were fixed
and dilated. A hand was continuously kept on the uterine
fundus squeezing it as by now it was totally relaxed. She
was taken up for hysterectomy as even though she was not
bleeding very actively, this was attributed to the lack of
pressure in her vessels as her BP and pulse were
unrecordable.
Learning points from the case:
- When a woman comes in air hunger, she is going into
decompensatory phase of shock and these patients are best
put on a ventilator fast.
- Fixed and dilated pupils with absent pulse may mean
anoxic damage to the brain, but as long as heart beats are
there, intensive monitoring and resuscitation could save the
patient.
- Oxygen should be given in the rate of 8litres/min in a
case of shock.
- Lack of bleeding from the vagina does not mean the uterus
is not atonic. In this case, it was because there was not
enough pressure in the vessels to cause bleeding.
- Whenever steroids are being given in a patient in terminal
shock, it should be hydrocortisone, a short acting steroid,
instead of dexamethasone or Betamethasone, which take
slightly longer time to act.
- Every drop of blood loss is important and it is necessary
to continuously compress the uterus till definitive surgical
measures are taken.
- Fresh-frozen plasma is a secondary transfusion product
indicated mainly in states of coagulopathy or with massive
transfusion. It comes in 250-mL units and contains all the
coagulation factors, especially fibrinogen. One unit will raise the fibrinogen
level by 10 mg/% in a nonbleeding patient.. It is reasonable
to consider transfusing 1 unit of fresh-frozen
plasma to every 4 units of blood/Packed RBCs in an actively
bleeding patient.
There are reviews which suggest the use of Fresh frozen
plasma only in the face of demonstrable clotting disorders.
But in this patient, fresh frozen plasma was given only
because she was given 5 units of blood and clotting disorder
was anticipated. Inspite of giving fresh frozen plasma, she
subsequently went into coagulation failure as the reader
will shortly find out. So the author strongly would urge a
change in the average mindset that as long as fresh blood is
available and is given, there is no need to think of
clotting disorders. “fresh blood is best” , but when
massive transfusions are given, as a rule of thumb, it is
best to give 1 pint of fresh frozen plasma for every 4 pints
of blood transfused.
Operation findings:
Her tissues were pale . and there was no remarkable
oozing from any site. Total hysterectomy was done. While
closing, her BP came to 50 systolic and there was some
oozing from the rectus muscle and it was cauterized.
On being shifted to the post operative ward on a ventilator,
her BP was again unrecordable. Even the pulse oximetre was
not showing any reading as there were no capillary
pulsations. She was given one pint of blood during surgery
(Her 5th pint) and a central venous line inserted
in her subclavian vein.
Post-operatively her CVP was 20 cm of H2O showing that she
was no more hypovolemic. She also had adequate output, about
50ml urine/hour. As she still did not have any BP, a
vasopressor ,viz Dopamine and Dobutamine, mixed together in
a bottle of saline was started at 8 drops/minute.
2 pints of fresh frozen plasma was given and Calcium
gluconate given IV. The time was 1.30AM on 26.1.08 by now.
She was put on Inj. Amikacin 750mg IV PD, Inj.Zocef 1gm IV
12 hourly and Inj. Ornida IV 12 hourly. INR was 2.14.
Learning points from the case:
Total vs Subtotal hysterectomy:
-Whenever hysterectomy is done in a patient with PPH, unless
there is placenta attached to the lower segment, a subtotal
hysterectomy should be the choice. Trauma to small vessels
will not be seen in a patient without pulse or BP and these
vessels will start bleeding when the pressure rises in these
vessels.
Importance of CVP line:
-A CVP through the subclavian vein is mandatory in all
patients in shock. Without a CVP it would have been
impossible in this patient to know that, the lack of BP and
Pulse was not entirely due to hypovolemia, but that it was
because she had gone into the decompensatory state of shock
where her vessels had become atonic, incapable of normal
pulsations.
Vasopressors:
- The initial choice of vasopressors in this patient was not
appropriate. In a patient with absent pulse and BP,
Dopamine and Dobutamine will not act. It will act only in a
patient with some systolic BP, however low. Dobutamine is
chosen in patients with very high heart rates, as it does
not affect heart rate while improving Blood pressure with
it’s vasopressor effect.
Use of Calcium Gluconate:
To quote from Miller’s anaesthesia, “Even in patients
with low-output states, I believe that emphasis should be
placed on correcting the underlying disorder (i.e.,
hypovolemia) and that calcium administration is rarely
necessary. The reason that serum ionized calcium levels
rapidly return to normal immediately after cessation of the
blood transfusion, probably is rapid citrate metabolism by
the liver and rapid calcium mobilization from available
endogenous stores. Hypothermia, and hyperventilation
increase the possibility of citrate intoxication. Infusion
of more than 1 unit of blood every 10 minutes is necessary
for ionized calcium levels to begin to decrease. Even at
these rates of infusion, ionized calcium levels do not
decrease enough to cause bleeding”.
Although current opinion does not support use of Calcium
Gluconate, in this patient, calcium levels were low the next
day in spite of calcium administration and its
administration was repeated after the report came. On the
basis of this case at least, the author would believe the
good old school of thought which thought that calcium
gluconate administration should be done after massive blood
transfusion as the preservatives of transfused blood would
deplete calcium in the body.
Use of antibiotics:
All patients with haemorrhagic shock of this magnitude
invariably go into systemic inflammatory response
syndrome(SIRS). Adequate antibiotic coverage with
antibiotics which cover aerobes, anaerobes and gram negative
organisms should be given with no regard for cost. The
infection is generally gastro-intestinal in laparotomy
patients and antibiotics which have higher GI concentration
should be chosen and care should be taken to see that these
antibiotics are not the ones routinely used in the hospital,
as the organisms are invariably hospital-aquired and
resistant to routinely used antibiotics. Early use of
antibiotics will prevent the organisms from throwing toxins
into the blood. Once the organisms start throwing toxins
into the blood, toxemia follows and once toxemia occurs,
killing the bacteria alone with antibiotics will not help.
Even if the bacteria are dead, the toxins produced by them
will take the patient into systemic inflammatory response
syndrome, which is difficult to treat.
Continuation of case report:
At 9 AM on 26.1.08, noradrenaline drip and dopamine drip
were started simultaneously through separate IV lines. The
line with one drip which had both Dopamine and Dobutamine
together was stopped. Dose of Noradrenaline: 1mg of
Noradrenalin in 250 ml of 5% Dextrose can be given at
3microdrops / minute upto 45 microdrops / minute. In this
patient, about 10 microdrops/ minute was the starting dose.
Dopamine 1 amp added to 1 pint dextrose was given through
another IV line at a rated of 12 drops/ minute. The pulse
rate was in the range of 150-160/minute. BP could be
recorded by about 11 AM.
Inj. Vitamin K was given IM. Her calcium level was low and
a repeat calcium administration was done. Hb was 7.6 gm and
futher 3 pints of blood was ordered. At 3PM, CVP was 20,
BP,110/70 and Pulse about 160/minute. Inj. Levofloxacin was
started IV.
Learning points:
In a patient with a systolic BP<70, after hypovelemia has
been corrected, the pressor of choice should be
Norepinephrine. All hospitals dealing with difficult cases
should make it a point to stock it in the hospital, even if
it is not used frequently. Dosage: 0.5-30umg/min IV. When
BP is 70-100mmhg, Dopamine could be started at 5 to
15umg/min IV. In this patient, use of norepinephrine was the
key factor in bringing back the BP .
The use of norepinephrine is associated with improved mean
arterial pressure, sustained aortic and mesenteric blood
flow, and better tissue oxygenation when compared with fluid
resuscitation alone, irrespective of time of administration.
The early use of
norepinephrine plus volume expansion is associated with a
higher proportion of blood flow redistributed to the
mesenteric area, lower lactate levels, and less infused
volume.
Thus, the early use of norepinephrine is safe and may
decrease the need for volume resuscitation.
This drug should be stocked in all tertiary care hospitals,
however infrequent it’s use is, as it is not easily
available outside.
Vitamin K used in a dose of 10mg Im once daily for three
days is useful in patients with raised prothrombin time(as
in this patient), since prothrombin is a product of the
liver and raised PT may be a part of deteriorating liver
function. Therefore vitamin K helps in increasing the
productionof prothrombin. However, use of vitamin K for
more than 3 days is of no use.
On 27.1.08 morning, her Hb had further dropped to 6 gm% and
creatinine was 2.8, though her out put was well maintained.
INR ratio was 1.97, better than the day before, but she was
bleeding from all puncture sites. 2 pints of cryoprecipitate
was given and further 2 pints of fresh frozen plasma given.
2 packed cells were given as her Hb was low, but she could
not be overloaded due to kidney failure. Her fluids would
also have to be curtailed from now on. By evening she had a
distended abdomen and due to falling
Hb , internal bleeding was thought of. An ultrasonogram
showed moderate “ascities” , but a tap with a 16 NO needle
did not reveal any blood .
Learning points:
-Cryoprecipitate is a tertiary transfusion product that
contains as much fibrinogen as a unit of fresh-frozen plasma
but in a volume of only about 15 mL. It also contains factor
VIII, factor XIII, and von Willebrand's factor. It also will
raise the fibrinogen level about 10 mg/% per unit. Its main
indication for transfusion is in a hemorrhaging patient who
is volume replete but has low fibrinogen levels(<1g/dl). A
large amount of fibrinogen can be administered in a small
volume using cryoprecipitate.
-In a patient with falling Hb levels in spite of multiple
blood transfusions, internal bleeding should be thought of.
In this patient, there was no bleeding at the time of
surgery, as she had no BP. But once her BP picked up she
started bleeding from many open vessels which may have been
missed at the time of initial surgery. The blind tap into
the abdomen did not reveal blood, as a massive clot was
sitting lower down, where the tap was done blindly. Fluid
blood was displaced much higher up.
28.1.08 : Next day the ultrasonogram directed aspiration
revealed frank blood and about 1000ml of blood was drained.
Repeat Hb on two occasions 2 hours apart showed falling
values and it was decided to reexplore her. At
re-exploration, the main pedicles were not bleeding. There
were minor oozing points from some peritoneal edges,
fimbriae, surface of bladder, and from the minor vessels on
the rectus muscle. These oozing points were rendered
non-haemorrhagic with cautery and ligatures and the abdomen
washed thoroughly.
Following surgery, noradrenalin drip was gradually tapered
off. Her BP and CVP continued to be stable , but she had a
pulse rate of 150/minute and she was in respiratory
failure. She continued to be on ventilator and her out put
reduced to about 25ml/ hour.
Learning points:
Reopening is never an easy proposition in a bleeding
patient as there will never be any frank area of spurting.
The ooze is always generalized. In this case,
procastrination was not rewarding as her Hb continued to
fall and ultimately she had to be opened up. These patients
invariably go into systemic inflammatory response syndrome
with multi-organ failure. At this point of time, the
patient was in respiratory failure and Kidney failure,
besides going through hypovolemic shock.
Her creatinine on 29.1.08 was 4.9 and continued to rise to
5.9 on 30.1.08. Her INR however gradually came down to
1.05. Now she was in systemic inflammatory reaction
syndrome , with multi organ failure. Her temperature was
105 0 f, she had circulatory failure with a pulse rate
hovering between 150/minute and 160/minute. She was in
respiratory failure and in renal failure. Her creatinine
further rose to 6.4 on 31.1.08 and her serum potassium level
rose to 5.3. She underwent haemodialysis. Her temperature
continued to be 105 0 f and pulse 150/minute. She was
started on Meropenam, Combitaz was put in place of inj
Zocef. Amikacin had already been stopped. One dose of
vancomycin was given. Metrogyl was started in place of
Ornidazole. Oral Moxifloxacin was given in place of
Levofloxacin.
She was covered with wet blankets all the time
Learning points:
Rising creatinine levels, and potassium levels is an
indication for haemodialysis. The author prefers to change
antibiotics to rare ones, if one course of antibiotics does
not work. Meropenam, though costly, saves the day in many a
case of septic shock. Moxifloxacin is the latest
fluroquinolone. She was put on Ryles tube feeding and care
was taken to provide adequate carbohydrates, fat and
proteins.
On 1.2.08, Immunoglobulins were started. Dose:
0.5mg/Kg/day.
Learning point:To
quote an article on immunoglobulins,
“ There is ongoing debate about the efficacy of polyvalent
immunoglobulins as adjunctive therapy for sepsis or septic
shock. Two meta-analyses by the Cochrane collaboration
calculated a significant reduction in mortality. However,
data of the largest study were missing in one, and a subset
of four high-quality studies failed to show an effect in the
other. To broaden the database, we performed a meta-analysis
of all randomized controlled studies published so
far.Polyvalent immunoglobulins exert a significant effect on
mortality in sepsis and septic shock, with a trend in
favor of IgGAM”. In this patient, use of
immunoglobulins saved the day and temperature came down from
105degree to 102 degree farenheit. Immunoglobulins ,
in experimental studies, have been postulated to improve
opsonization , prevent nonspecific complement activation ,
protect against the antibiotic-induced liberation of
endotoxin , neutralize endotoxin as well as a wide variety
of superantigens .
By next day, on 2.2.08, her temperature came down to
102degree f. IV immunoglobulin was continued for another 3
days, during which time her temperature came down steadily
and pulse rate started dropping to 130/minute. On 4.2.08, a
trachostomy was done and the ventilator connected through
the tracheostomy.
Learning point:
Ventillation cannot be continued through endotracheal tube
for more than a week and a tracheostomy tube has to be put
in.
She had developed a pneumonic consolidation in her lung on
5.2.08 and pulse rate again rose to 158/minute. Injectable
azithromycin and amoxicillin clavulinic acid combination was
started.
Learning point:
One cannot be complacent even if there is improvement.
Examination by specialists from various branches is useful.
Pneumonic consolidation should be looked for in all
ventilator patients and a chest X-ray proved the diagnosis.
Antibiotics with greater concentration in the respiratory
tract had to be started at this point.
By 7.2.08, her respiratory failure settled and she could be
weaned off the ventilator at times. It was seen that she
was fully conscious and she had no power in her lower limbs,
but all her other faculties seemed intact. A repeat
haemodialysis was given. Urine culture showed plenty of
yeast cells and forcanazole was started in the dose of 150mg
stat followed by 50mg/day. She was weaned off the
ventilator on 11.2.08. Active physiotherapy was started for
mobilizing her lower limbs. Ryles tube was removed and
oral food started. The trachostomy tube was removed on
19.2.08. She started walking on her own and was discharged
on 25.2.08.
Learning point:
Early physiotherapy should be started even if the patient is
sick as it helps prevent wastage of muscels. In this
patient, both lower limbs were weak as a result of cerebral
anoxia, probably in the level of anterior cerebral artery.
Conclusion:
A case of intractable PPH needs a multidisciplinary approach
and opinion should be sought from all specialists.
Adequate ventillatory care timely dialysis is important
Nursing care using wet blankets is important.
Daily monitoring and charting of Hb, S.electrolytes,
Prothrombin time , BT, CT,S creatinine is important
Use of antibiotics which cover all organisms is important
Use of immunoglobulins is highlighted.
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