This presentation addresses the management of a patient admitted to Baylor University Medical Center's labor and delivery sustaining massive hemorrhage with resulting disseminated intravascular coagulation (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.
A 35-year-old healthy female, primigravida at 40 1/7 weeks gestation was admitted for oxytocin induction of labor. The patient required a low forceps assisted vaginal delivery for persistent occiput posterior 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 estimated blood loss of 800 ml, 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 showed a significant drop from 89 on admission to 52. Fluid resuscitation was initiated utilizing Lactated Ringer's solution and Hespan, and 2.5 mg 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 16.6; the patient's starting hematocrit was 32.3.
In the OR, 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 2 hours extensive resuscitation with cryoprecipitate, fresh frozen plasma, blood, and platelets were administered in an attempt to correct the DIC, preserve the patient's uterus, and 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 intensive care unit in stable condition.
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 through which multidisciplinary collaboration allows identification and improvement in processes without harm to patients.