Post Partum Hemorrhage – An Unusual Cause
Kelly Durrett, M.D.
Department of Anesthesiology, University of Florida, Gainesville, Florida
ABSTRACT
A 34-year-old woman, 32 weeks pregnant, presented with preeclampsia. She
suffered from a blood pressure of 160/80 mmHg, 2+ proteinuria, and a fetus
in breech position. The patient was taken to the operating room for urgent
cesarean section. She was given a spinal anesthetic using bupivacaine.
Intraoperative vital signs were stable. The obstetrician was unable to
extract the fetal head and, therefore, performed a classic (vertical)
incision to facilitate delivery. The baby was delivered and the mother
continued to have stable vital signs. Following delivery, the mother was
given cefazoline (1 g) and oxytocin (40 units). The patient’s vital signs
remained stable until the case ended. At this time her systolic blood
pressure had decreased to the lower 90s mm Hg. Intravenous (IV) fluids, 2000
ml, were administered for an estimated blood loss of approximately 1000 ml.
The abdomen was closed and the patient transported to the postanesthesia
care unit (PACU). At that time, the surgeons noticed 500 ml of hemorrhage
from the vagina. The uterus felt boggy and uterine atony was diagnosed.
Additional oxytocin (40 units) was given IV and carboprost tromethamine (250
mg) was injected intramuscularly..
About one hour after arrival in the PACU, her systolic blood pressure
decreased to 40-50 mmHg. The obstetrical service administered additional
crystalloid IV fluids and two units packed red blood cells (PRBCs). Her
hematocrit was 24%. Her systolic blood pressure continued to be low with
signs of shock (cold and clammy skin), crying, and constant pain. The repeat
hematocrit was 22% and she was given an additional two units of PRBCs. At
this time the anesthesia service was called to place an arterial catheter,
but the patient was vasoconstricted, which precluded successful placement. A
blood sample was taken to measure arterial blood gas values and demonstrated
a hematocrit of 18%. Another two units of PRBCs were administered. In
addition, urinary output was substantially decreased. In view of these
facts, a central venous catheter was inserted to monitor fluid status and to
provide fluid. The patient was then transferred to the SICU.
In the SICU the patient continued to be unstable with low blood pressure, a
hematocrit of 24 %, and an INR of 1.7. She was given 1.5 L of 5% albumin,
two units PRBCs, and four units of fresh frozen plasma. Abdominal ultrasound
was performed and demonstrated a fluid collection at the uterine fundus.
Upon paracentesis, the hemoglobin of this fluid was 5 g/dl. No decision was
made to return the patient to the operating room. However, the patient
remained unstable with systolic blood pressure in the 60s, decreased urinary
output, increased shortness of breath, and increased abdominal girth. The
patient was returned to the operating room the following afternoon for an
exploratory laparotomy, which showed laceration and bleeding of the left
ascending uterine artery. The artery was ligated and the patient transported
back to the SICU intubated. She was extubated the following day and made a
good recovery.
Discussion: This case report illustrates an unusual cause of post partum
hemorrhage (PPH), an event that is a potentially life-threatening
complication of both vaginal and cesarean delivery. Traditionally, PPH is
defined as blood loss greater than 500 ml during vaginal delivery and
greater than 1,000 ml during a cesarean delivery. The exact incidence of PPH
is difficult to determine, but a reasonable consensus is that 2-4 % of
pregnancies are complicated by PPH. More common causes include uterine atony
(70%), retained placenta, trauma (uterine rupture, obstetric lacerations),
and clotting disorders. Nevertheless, anesthesiologists and obstetricians
should maintain vigilance for undiagnosed intra-abdominal trauma such as a
lacerated artery when postpartum hemorrhage continues and is recalcitrant to
the administration of intravenous fluids and smooth muscle constrictors
(i.e., oxytocin, carboprost) of the uterus.
