Can We Save Her Without Giving Blood? An Incredible Case of Obstetric Hemorrhage

Background:

This case presentation involves a patient with an incredible hospital course. Mary Smith a 22 year old, G3 P0 at 39 0/7 weeks gestation well known to clinic was admitted for a scheduled Primary Cesarean for breech presentation. External cephalic version was offered and declined. History significant for molar pregnancy treated in 2010. The patient was Jehovah's Witness by religion. Based on religious beliefs, she refused any treatment that involved donor blood transfusion but autologous cell saver and albumin were authorized. Admission hemoglobin was 10.4 and Hematocrit 31.9.

Case:

A primary low transverse cesarean was performed and the actual birth was uncomplicated. The placenta was difficult to extract, found to be embedded into the myometrium, and suspicious for fundal placenta accreta. Uterine curettage was performed, however, hemostasis couldn’t be achieved and bleeding continued. She became hypotensive, lost consciousness, and required endotracheal intubation. The patient’s body mass index was 54 and intubation was difficult. After 2 failed attempts at endotracheal intubation, a fiberoptic bronchoscope was used and successful intubation was achieved. The surgeons placed a B Lynch Suture around the uterus, administered uterotonics: Oxytocin, Methylergonovine Maleate, Carboprost, and Misoprostol. Vasopressor infusions were required to maintain vital signs. 500 mLs of cell saver blood was administered intraoperatively. The estimated blood loss (EBL) was 3 liters. She was transferred to ICU intubated,her vital signs continued to deteriorate,and she required increased pressor support. She was transferred to Interventional Radiology for bilateral uterine artery embolization. Lab values were significant for: Hg of 5 and HCT of 15. She remained unconscious, in critical condition with unstable vital signs. Her father consented for a total abdominal hysterectomy. Per the patient's request, she did not receive any blood products other than albumin which she had consented. Total EBL was 3.65L, Nadir Hg 4.3, and Nadir Hematocrit 13.6. She survived and was ultimately discharged home.

Conclusion:

This case study highlights numerous implications for nursing practice. A high reliable perinatal department should plan and prepare for alternative management for patients with critical anemia who hemorrhage and refuse blood transfusion. Utilization of cell saver for blood salvage and other alternative management strategies may mean the difference of life or death. Respect and honor of religious or cultural beliefs for all woman during childbirth is essential, but may come with a heavy burden for the provider.

Keywords:

Jehovah's Witness, missed placental accreta, critical anemia, intra/postoperative management, debrief