Interesting Clinical Cases - A near miss case of P.P.H. by Dr. Shobhana Mohandas

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:

  • Oxygen given

  • Inj.Hydrocortisone given IV.

  • Inj Methyle amphetamine given IV.

  • Blood pushed in vigorously.

  • Haemaccele started.

  • Misoprostol 800umg kept intrarectally.

  • Prostodine given IV.

  • 20 units oxytocin drip started.

  • 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. 


- 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. 


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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