Postpartum hemorrhage remains the single most significant cause of maternal death worldwide. It occurs in 2% to 6% of women who deliver vaginally. It can occur early (<24 hours after birth) or late (>24 hours and <6 weeks after birth). The primary cause of early postpartum hemorrhage is uterine atony, and it is typically defined as >500 ml blood loss following vaginal delivery, >1,000 ml following cesarean, or a 10% decrease in hematocrit (HCT). Interventions for postpartum hemorrhage include treating the underlying cause and managing the symptoms with medications, surgical interventions, placement of uterine tamponade devices, and blood volume replacement. Improved outcomes are seen with coordinated team efforts and established hospital processes.
A 45-year-old, G4P1 presented to labor and delivery in early labor at term. On admission her HCT was 39.9. Her labor was augmented, and she progressed quickly and delivered vaginally. Following delivery of her placenta, she began to hemorrhage. The patient was treated in the delivery room with fundal massage, Misoprostol, Hemabate, placement of Foley catheter, and Bakri balloon. Anesthesia and a second obstetrician were consulted and a disseminated intravascular coagulation (DIC) panel and two units of packed red blood cells were ordered. The patient became symptomatic and was transferred to the operating room (OR). A Code White was called and an interdisciplinary team of obstetricians, laboratory, intensive care unit (ICU), and spiritual care personnel responded.
After intubation in the OR, the patient continued to hemorrhage. The decision was made to proceed with a hysterectomy. A massive transfusion protocol was initiated with the blood bank to facilitate preparation and thawing of blood products. During the surgical procedure, the patient developed ventricular tachycardia, and a Code Blue was activated. Additional interdisciplinary team members from the emergency department, pharmacy, and ICU responded. At this time, the patient's HCT dropped to 21.9, fibrinogen <60, PT = 40, INR = 4.15, and arterial blood gas pH 6.97. During the surgical case, the patient received 11,440 ml fluid and 11 units PBRC, 7 units fresh frozen plasma, 3 units of platelets, 4 units cryoprecipitate. Her DIC stabilized and her heart rhythm returned to sinus tachycardia. She remained intubated and was transferred to ICU. The following day she was extubated and transferred to postpartum and she was discharged home on postoperative day 4. The patient is now a spokesperson for the community blood bank.
To efficiently manage massive postpartum hemorrhage, early treatment must be initiated, interdisciplinary teams should be utilized, and in this case our massive transfusion protocol was activated. Coordination of care with the blood bank was critical to receive the necessary blood products in a timely manner.