- Email: [email protected]
Management of an unusual major obstetric haemorrhage in a resource-poor setting
Correspondence
4. 5.
6. 7. 8.
previous caesarean delivery. J Matern Fetal Neonatal Med 2011;7:900–3. Crawford JS. The epidural sieve and MBC (Minimal Blocking Concentration); a hypothesis. Anaesthesia 1976;31:1277–80. Murphy JD, Henderson K, Bowden MI, Lewis M, Cooper GM. Bupivacaine vs bupivacaine plus fentanyl for epidural analgesia: effect on maternal satisfaction. BMJ 1991;302:564–7. Tehan B. Abolition of the extradural sieve by addition of fentanyl to extradural bupivacaine. Br J Anaesth 1993;71:920. Rashiq S, Hustol LJ. Fentanyl and the extradural sieve. Br J Anaesth 1993;71:920. Rowbottom SJ, Critchley IAH, Gin T. Uterine rupture and epidural analgesia during trial of labour. Anaesthesia 1997;52:483–8.
0959-289X/$-see front matter
c 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2012.01.009
Management of an unusual major obstetric haemorrhage in a resource-poor setting A 35-year-old ASA 1, G7P6 woman was referred to Queen Elizabeth Central Hospital, Malawi, with right upper quadrant pain and ultrasound report suggesting a 23 week, 600 g live extrauterine fetus with hepatic placental implantation. She was scheduled for urgent caesarean delivery. The anaesthetists were informed of the case on the morning of surgery. The patient had a clear chest and no heart murmurs. Her blood pressure (BP) was 120/70 mmHg and heart rate 90 beats/min. Preoperative bloods included haemoglobin (Hb) 8.7 g/dL and platelets 357 · 109/L. Neither clotting studies nor urea and electrolytes were available. With a high risk of bleeding, surgery proceeded once blood products consisting of whole blood 1500 mL and two units of fresh frozen plasma (FFP) were confirmed. Senior surgeons and anaesthetists were present and a postoperative intensive care unit (ICU) bed was available. General anaesthesia was chosen because of the midline incision and likely haemorrhage. Two large-bore peripheral cannulae and a urinary catheter were inserted preoperatively. A modified rapid-sequence induction of ketamine and suxamethonium was performed and anaesthesia was maintained with halothane and ketamine. Ranitidine, metoclopramide and sodium citrate were not available. Arterial and central lines were inserted after induction. As the fetus was not considered to be viable, exposure to anaesthetic agents was not a consideration in the anaesthetic technique. At surgery a hepatic mass was identified and an infant was delivered. Some limb movements were present before cord clamping but with poor respiratory effort, early gestation and no facilities to ventilate neonates <1500 g, a decision to not resuscitate was made. The removal of the placenta resulted in massive haemorrhage with an estimated blood loss of 4800 mL. Having used
201 the allocated blood products, and without an efficient telephone network, anaesthetists visited the transfusion laboratory to negotiate a further three units of whole blood, exhausting the hospital’s supply of cross-matched and O-negative blood. The Malawi Blood Transfusion Service was contacted for further products. The patient was resuscitated with Gelofusine 3000 mL, Hartmann’s solution 2000 mL, whole blood 3000 mL and FFP 550 mL. The systolic blood pressure at its lowest was 45 mmHg, necessitating adrenaline and calcium boluses and an adrenaline infusion. Haemostasis was difficult to achieve so the liver was packed. The patient was transferred to ICU with observations including BP 90/50 mmHg without inotropic support, a heart rate of 110 beats/min, oxygen saturations of 100% (FiO2 1.0) and a temperature of 33.7C. No patient or fluid warming equipment was available. Blood results the following day included Hb 9.0 g/dL and platelets 186 · 109/L. The patient was sedated with morphine and ketamine, and ventilated with an HT50 ventilator on SIMV mode. She received two further units of FFP overnight. The patient returned to theatre the following day for re-exploration and pack removal. She was anaesthetised with ketamine and halothane and paralysed with vecuronium. Hepatic haemostasis was achieved with Floseal. During surgery the patient received Gelofusine 2000 mL, Hartmann’s solution 1000 mL, whole blood 460 mL, platelets 150 mL and FFP 500 mL. Intraoperatively, a right pneumothorax of probable surgical cause was detected and a chest drain inserted. The patient was discharged from ICU three days later and discharged home on day 13. Extrauterine pregnancies have an incidence of 1 in 10 000 pregnancies,1 although the liver is a rare site of placental implantation.2 With 30% maternal mortality secondary to haemorrhage, the literature supports urgent operative intervention in extrauterine pregnancies where the fetus is not viable.3,4 In our case, delaying surgery would not have increased blood product availability. Additionally, due to limited imaging, the full extent of hepatic involvement was not appreciated. It may be argued that the placenta should have been left in-situ but complications of conservative management include secondary bleeding, peritonitis, ileus and abscess formation.5 Ramphal et al considered that conservative management of the placenta is safe, ‘‘as long as [the patient is] hospitalized in a centre with immediate recourse to emergency interventions’’.6 Other management options such as embolisation techniques7 and postoperative methotrexate8 are not currently feasible in Malawi. The anaesthetic difficulties incurred included limited preoperative imaging and planning, a lack of laboratory and near-patient testing, no advanced massive transfusion equipment, and limited blood product availability. While ideally we would have given the patient more
202
Correspondence
blood products intra- and postoperatively, in reality we gave all products that were available. The case highlights the importance of a multidisciplinary approach, clinical judgment in assessing and managing major haemorrhage and the impressive physiological reserve of young obstetric patients. This is a rare example of an advanced hepatic pregnancy managed with limited resources, with a good maternal outcome. L. Peltola, G. Pollach Department of Anaesthesia, Queen Elizabeth Hospital, Blantyre, Malawi E-mail address: [email protected] E. Borgstein Department of Surgery, College of Medicine, Blantyre, Malawi
References 1. Jazayeri A, Davis TA, Contreras DN. Diagnosis and management of abdominal pregnancy. A case report. J Reprod Med 2002;47:1047–9. 2. Shippey SH, Bhoola SM, Royek AB, Long ME. Diagnosis and management of hepatic ectopic pregnancy. Obstet Gynecol 2007;109:544–6. 3. Paternoster DM, Santarossa C. Primary abdominal pregnancy. A case report. Minerva Ginecol 1999;51:251–3. 4. Ramachandran K, Kirk P. Massive hemorrhage in a previously undiagnosed abdominal pregnancy presenting for elective Cesarean delivery. Can J Anesth 2004;51:57–61. 5. Barbosa Ju´nior Ade A, de Freitas LA, Mota MA. Primary pregnancy in the liver. A case report. Pathol Res Pract 1991;187:329–31. 6. Ramphal SR, Moodley J, Rajaruthnam D. Hepatic pregnancy managed conservatively. Trop Doct 2010;40:121–2. 7. Cardosi RJ, Nackley AC, Londono J, Hoffman MS. Embolization for advanced abdominal pregnancy with a retained placenta. A case report. J Reprod Med 2002;47:861–3. ´ , Joo´ 8. Demendi C, Langma´r Z, Ba´nhidy F, Bo¨rzso¨nyi B, Csatlo´s E JG. Successful operative management of an intact second trimester abdominal pregnancy with additional preoperative selective catheter embolization and postoperative methotrexate therapy. Med Sci Monitor 2011;17:CS53–5. 0959-289X/$-see front matter
c 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2012.01.009
Successful resuscitation following amniotic fluid embolism in a patient undergoing induction of labour for late miscarriage Amniotic fluid embolism (AFE) is a rare but poorly understood condition that contributes significantly to maternal morbidity and mortality.1 Classical presentation occurs during labour or shortly postpartum with cardiovascular, respiratory or neurological collapse, or disseminated intravascular coagulopathy (DIC). The
clinical course is rapidly progressive and life-threatening. Mortality rates have improved significantly and were recently quoted as 20%, but analysis of the US registry revealed neurological impairment in 85% of survivors.2,3 We report successful cardiopulmonary resuscitation (CPR) following induction of labour for late miscarriage. A 36-year-old Ghanaian woman was admitted for induction of labour following miscarriage at 20 weeks of gestation. Her past medical history included well-controlled type II diabetes mellitus, two live births, an intrauterine death of unknown aetiology at 39 weeks of gestation, and a termination of pregnancy for fetal anomaly at 15 weeks. Routine blood tests (biochemistry, C-reactive protein, full blood count and clotting profile) were within normal limits. A gemeprost (prostaglandin) vaginal pessary was inserted. Half an hour later the patient collapsed with irregular breathing, reduced consciousness and rapid progression to loss of cardiac output. CPR was started immediately combined with left lateral uterine tilt and early tracheal intubation. Pulseless electrical activity was noted. Vaginal examination and pelvic ultrasound were unremarkable. The pessary had dissolved and was unretrievable. Return of spontaneous circulation occurred after 30 min following CPR, and adrenaline 6 mg and intravenous colloid 1 L. The patient was transferred to the operating room sedated, paralysed and ventilated for further stabilisation. There was evidence of pulmonary oedema and hypoxaemia. Noradrenaline was commenced for cardiovascular support. An electrocardiogram showed sinus rhythm with an S1Q3T3 pattern; a normal variant in pregnancy. Echocardiogram, chest radiograph and CT pulmonary angiogram, performed once the patient was stable, were all unremarkable. During the angiogram bleeding was noted from the nose. Further blood tests showed DIC (International Normalised Ratio >10). Possible intrauterine sepsis prompted uterotomy after haematological advice and administration of blood products. A retroperitoneal haematoma was identified. A macerated fetus in an intact sac was delivered, following which uncontrolled uterine bleeding necessitated hysterectomy, abdominal packing and extensive transfusion of blood and clotting products. The patient remained sedated and ventilated on the intensive care unit (ICU) for 48 h. Mast cell tryptase concentrations were within normal limits immediately post-arrest, several hours later on ICU, and at 24 and 48 h. After sedation was stopped, initial signs of hypoxic encephalopathy slowly improved. Several weeks later the patient was transferred to a specialist neurorehabilitation centre, and 10 weeks following initial collapse was cognitively intact and independently mobile, with some residual weakness in her right hand. This case is of particular interest for several reasons. Other diagnoses, including pulmonary embolism, anaphylaxis to gemeprost and intrauterine sepsis, were excluded. The clinical presentation was typical of AFE,
4. 5.
6. 7. 8.
previous caesarean delivery. J Matern Fetal Neonatal Med 2011;7:900–3. Crawford JS. The epidural sieve and MBC (Minimal Blocking Concentration); a hypothesis. Anaesthesia 1976;31:1277–80. Murphy JD, Henderson K, Bowden MI, Lewis M, Cooper GM. Bupivacaine vs bupivacaine plus fentanyl for epidural analgesia: effect on maternal satisfaction. BMJ 1991;302:564–7. Tehan B. Abolition of the extradural sieve by addition of fentanyl to extradural bupivacaine. Br J Anaesth 1993;71:920. Rashiq S, Hustol LJ. Fentanyl and the extradural sieve. Br J Anaesth 1993;71:920. Rowbottom SJ, Critchley IAH, Gin T. Uterine rupture and epidural analgesia during trial of labour. Anaesthesia 1997;52:483–8.
0959-289X/$-see front matter
c 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2012.01.009
Management of an unusual major obstetric haemorrhage in a resource-poor setting A 35-year-old ASA 1, G7P6 woman was referred to Queen Elizabeth Central Hospital, Malawi, with right upper quadrant pain and ultrasound report suggesting a 23 week, 600 g live extrauterine fetus with hepatic placental implantation. She was scheduled for urgent caesarean delivery. The anaesthetists were informed of the case on the morning of surgery. The patient had a clear chest and no heart murmurs. Her blood pressure (BP) was 120/70 mmHg and heart rate 90 beats/min. Preoperative bloods included haemoglobin (Hb) 8.7 g/dL and platelets 357 · 109/L. Neither clotting studies nor urea and electrolytes were available. With a high risk of bleeding, surgery proceeded once blood products consisting of whole blood 1500 mL and two units of fresh frozen plasma (FFP) were confirmed. Senior surgeons and anaesthetists were present and a postoperative intensive care unit (ICU) bed was available. General anaesthesia was chosen because of the midline incision and likely haemorrhage. Two large-bore peripheral cannulae and a urinary catheter were inserted preoperatively. A modified rapid-sequence induction of ketamine and suxamethonium was performed and anaesthesia was maintained with halothane and ketamine. Ranitidine, metoclopramide and sodium citrate were not available. Arterial and central lines were inserted after induction. As the fetus was not considered to be viable, exposure to anaesthetic agents was not a consideration in the anaesthetic technique. At surgery a hepatic mass was identified and an infant was delivered. Some limb movements were present before cord clamping but with poor respiratory effort, early gestation and no facilities to ventilate neonates <1500 g, a decision to not resuscitate was made. The removal of the placenta resulted in massive haemorrhage with an estimated blood loss of 4800 mL. Having used
201 the allocated blood products, and without an efficient telephone network, anaesthetists visited the transfusion laboratory to negotiate a further three units of whole blood, exhausting the hospital’s supply of cross-matched and O-negative blood. The Malawi Blood Transfusion Service was contacted for further products. The patient was resuscitated with Gelofusine 3000 mL, Hartmann’s solution 2000 mL, whole blood 3000 mL and FFP 550 mL. The systolic blood pressure at its lowest was 45 mmHg, necessitating adrenaline and calcium boluses and an adrenaline infusion. Haemostasis was difficult to achieve so the liver was packed. The patient was transferred to ICU with observations including BP 90/50 mmHg without inotropic support, a heart rate of 110 beats/min, oxygen saturations of 100% (FiO2 1.0) and a temperature of 33.7C. No patient or fluid warming equipment was available. Blood results the following day included Hb 9.0 g/dL and platelets 186 · 109/L. The patient was sedated with morphine and ketamine, and ventilated with an HT50 ventilator on SIMV mode. She received two further units of FFP overnight. The patient returned to theatre the following day for re-exploration and pack removal. She was anaesthetised with ketamine and halothane and paralysed with vecuronium. Hepatic haemostasis was achieved with Floseal. During surgery the patient received Gelofusine 2000 mL, Hartmann’s solution 1000 mL, whole blood 460 mL, platelets 150 mL and FFP 500 mL. Intraoperatively, a right pneumothorax of probable surgical cause was detected and a chest drain inserted. The patient was discharged from ICU three days later and discharged home on day 13. Extrauterine pregnancies have an incidence of 1 in 10 000 pregnancies,1 although the liver is a rare site of placental implantation.2 With 30% maternal mortality secondary to haemorrhage, the literature supports urgent operative intervention in extrauterine pregnancies where the fetus is not viable.3,4 In our case, delaying surgery would not have increased blood product availability. Additionally, due to limited imaging, the full extent of hepatic involvement was not appreciated. It may be argued that the placenta should have been left in-situ but complications of conservative management include secondary bleeding, peritonitis, ileus and abscess formation.5 Ramphal et al considered that conservative management of the placenta is safe, ‘‘as long as [the patient is] hospitalized in a centre with immediate recourse to emergency interventions’’.6 Other management options such as embolisation techniques7 and postoperative methotrexate8 are not currently feasible in Malawi. The anaesthetic difficulties incurred included limited preoperative imaging and planning, a lack of laboratory and near-patient testing, no advanced massive transfusion equipment, and limited blood product availability. While ideally we would have given the patient more
202
Correspondence
blood products intra- and postoperatively, in reality we gave all products that were available. The case highlights the importance of a multidisciplinary approach, clinical judgment in assessing and managing major haemorrhage and the impressive physiological reserve of young obstetric patients. This is a rare example of an advanced hepatic pregnancy managed with limited resources, with a good maternal outcome. L. Peltola, G. Pollach Department of Anaesthesia, Queen Elizabeth Hospital, Blantyre, Malawi E-mail address: [email protected] E. Borgstein Department of Surgery, College of Medicine, Blantyre, Malawi
References 1. Jazayeri A, Davis TA, Contreras DN. Diagnosis and management of abdominal pregnancy. A case report. J Reprod Med 2002;47:1047–9. 2. Shippey SH, Bhoola SM, Royek AB, Long ME. Diagnosis and management of hepatic ectopic pregnancy. Obstet Gynecol 2007;109:544–6. 3. Paternoster DM, Santarossa C. Primary abdominal pregnancy. A case report. Minerva Ginecol 1999;51:251–3. 4. Ramachandran K, Kirk P. Massive hemorrhage in a previously undiagnosed abdominal pregnancy presenting for elective Cesarean delivery. Can J Anesth 2004;51:57–61. 5. Barbosa Ju´nior Ade A, de Freitas LA, Mota MA. Primary pregnancy in the liver. A case report. Pathol Res Pract 1991;187:329–31. 6. Ramphal SR, Moodley J, Rajaruthnam D. Hepatic pregnancy managed conservatively. Trop Doct 2010;40:121–2. 7. Cardosi RJ, Nackley AC, Londono J, Hoffman MS. Embolization for advanced abdominal pregnancy with a retained placenta. A case report. J Reprod Med 2002;47:861–3. ´ , Joo´ 8. Demendi C, Langma´r Z, Ba´nhidy F, Bo¨rzso¨nyi B, Csatlo´s E JG. Successful operative management of an intact second trimester abdominal pregnancy with additional preoperative selective catheter embolization and postoperative methotrexate therapy. Med Sci Monitor 2011;17:CS53–5. 0959-289X/$-see front matter
c 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2012.01.009
Successful resuscitation following amniotic fluid embolism in a patient undergoing induction of labour for late miscarriage Amniotic fluid embolism (AFE) is a rare but poorly understood condition that contributes significantly to maternal morbidity and mortality.1 Classical presentation occurs during labour or shortly postpartum with cardiovascular, respiratory or neurological collapse, or disseminated intravascular coagulopathy (DIC). The
clinical course is rapidly progressive and life-threatening. Mortality rates have improved significantly and were recently quoted as 20%, but analysis of the US registry revealed neurological impairment in 85% of survivors.2,3 We report successful cardiopulmonary resuscitation (CPR) following induction of labour for late miscarriage. A 36-year-old Ghanaian woman was admitted for induction of labour following miscarriage at 20 weeks of gestation. Her past medical history included well-controlled type II diabetes mellitus, two live births, an intrauterine death of unknown aetiology at 39 weeks of gestation, and a termination of pregnancy for fetal anomaly at 15 weeks. Routine blood tests (biochemistry, C-reactive protein, full blood count and clotting profile) were within normal limits. A gemeprost (prostaglandin) vaginal pessary was inserted. Half an hour later the patient collapsed with irregular breathing, reduced consciousness and rapid progression to loss of cardiac output. CPR was started immediately combined with left lateral uterine tilt and early tracheal intubation. Pulseless electrical activity was noted. Vaginal examination and pelvic ultrasound were unremarkable. The pessary had dissolved and was unretrievable. Return of spontaneous circulation occurred after 30 min following CPR, and adrenaline 6 mg and intravenous colloid 1 L. The patient was transferred to the operating room sedated, paralysed and ventilated for further stabilisation. There was evidence of pulmonary oedema and hypoxaemia. Noradrenaline was commenced for cardiovascular support. An electrocardiogram showed sinus rhythm with an S1Q3T3 pattern; a normal variant in pregnancy. Echocardiogram, chest radiograph and CT pulmonary angiogram, performed once the patient was stable, were all unremarkable. During the angiogram bleeding was noted from the nose. Further blood tests showed DIC (International Normalised Ratio >10). Possible intrauterine sepsis prompted uterotomy after haematological advice and administration of blood products. A retroperitoneal haematoma was identified. A macerated fetus in an intact sac was delivered, following which uncontrolled uterine bleeding necessitated hysterectomy, abdominal packing and extensive transfusion of blood and clotting products. The patient remained sedated and ventilated on the intensive care unit (ICU) for 48 h. Mast cell tryptase concentrations were within normal limits immediately post-arrest, several hours later on ICU, and at 24 and 48 h. After sedation was stopped, initial signs of hypoxic encephalopathy slowly improved. Several weeks later the patient was transferred to a specialist neurorehabilitation centre, and 10 weeks following initial collapse was cognitively intact and independently mobile, with some residual weakness in her right hand. This case is of particular interest for several reasons. Other diagnoses, including pulmonary embolism, anaphylaxis to gemeprost and intrauterine sepsis, were excluded. The clinical presentation was typical of AFE,