OB Hemorrhage Complicated by DIC… Are You Ready?
Title: OB Hemorrhage Complicated by DIC… Are You Ready?
- Discuss the management of a Labor & Delivery (L&D) patient experiencing hemorrhage with resulting disseminated intravascular coagulopathy (DIC).
- Identify and implement quality improvement initiatives that improve the readiness, response and recognition of obstetric hemorrhages.
- Implement scenarios and in-situ drills in a realistic environment to identify improvement processes in which no harm can be done to the patient.
This presentation discusses the management of a patient admitted to Baylor University Medical Center’s Labor and Delivery (L&D) sustaining massive hemorrhage with resulting DIC and peripartum hysterectomy after an induction of labor and forceps assisted vaginal delivery. Prompt recognition, timely intervention and a collaborative multidisciplinary team approach were required to save this patient’s life.
Case:
This case involves a 35 year old healthy female, primigravida at 40 1/7 weeks gestation admitted for oxytocin induction of labor. The patient required a low forceps assisted vaginal delivery for persistent occiput posterior (OP) position, and delivered a healthy male, weighing 8lb 7oz. Following the repair of a third-degree midline episiotomy and bilateral sidewall lacerations, the patient had an initial EBL of 800mL, with a firm fundus and vaginal packing left in place for a noted friable posterior wall.
Over the next hour, after the vaginal packing was placed, the patient’s mean arterial pressure (MAP) showed a significant drop from 89 on admission to 52. Fluid resuscitation was initiated utilizing LR and Hespan , additionally 2.5mg of Methergine was administered. Continued bleeding was noted and the patient was taken to the operating room (OR) for further evaluation. A stat hematocrit was resulted at 16.6, the patient’s starting hematocrit was 32.3.
In the operating room, the patient was noted to have further deteriorating vital signs and oozing was noted from previous puncture sites. The patient was intubated by anesthesia. Lab work from a hemostasis profile revealed DIC. For the next two hours extensive resuscitation with cryoprecipitate, fresh frozen plasma, blood, and platelets were administered in an attempt to correct the DIC, and preserve the patient’s uterus, as well as return her to a hemostatic state. Continued bleeding was noted and the decision was made by the physician to proceed with a hysterectomy. Following hysterectomy, the patient was transferred to the ICU in stable condition.
Conclusion:
Massive hemorrhage is a leading cause of maternal death. Prompt recognition, timely, effective communication and rapid response are crucial for positive outcomes. Case review and debriefing led to quality action items being identified. Simulation training has played a key role in quality improvement initiatives. The ability to activate a massive transfusion protocol was crucial in the above case. Simulation scenarios and in-situ drills have been developed such as OB hemorrhage through which multidisciplinary collaboration allows identification and improvement in processes without harm to patients.
Keywords:
obstetric hemorrhage, maternal mortality, safety