A bedside exploratory laparotomy was performed by the obstetric team. Approximately, 3000 mL of blood was drained from the peritoneum and collected in the cell salvage device for reinfusion. Surgical hemostasis of an active right adnexal arterial bleed was eventually achieved. Surgicel and thrombin spray were applied to lacerated areas of adnexa and peritoneum, and her abdomen was packed.
During the case, hemodynamic instability was treated with a vasopressin infusion (3 units/h) in addition to the preexisting norepinephrine infusion (0.4 μg/kg/min). In the setting of severe anemia, further hemodilution was avoided by administering 550 mL of salvaged blood. Her hemoglobin concentration rose from a nadir of 1.5 mg/dL at the beginning of the bedside laparotomy to 3.5 mg/dL at the end of surgery, with a concurrent improvement in hemodynamic status. By the end of the 90-minute procedure, she was weaned from all vasopressor medications.
During the case, continued oozing was evaluated by thromboelastography. A low R time (3.2 min), low maximum amplitude (41.7 mm), and elevated LY30 (11.1%) were measured. Because the patient refused platelet transfusion, clot formation was promoted with recombinant factor VIIa (total dose 110 µg/kg IV), calcium chloride 1 g IV, tranexamic acid 1 g IV, and sodium bicarbonate 100 mEq IV despite an arterial pH 7.47.
In the acute postsurgical period, attention was focused on enhancement of endogenous RBC and clotting factor production. In consultation with the anesthesiology and hematology services, the patient received erythropoietin (40,000 units IV), vitamin K (two 10-mg doses IV), iron IV, and folate.
Her midline incision was closed later that day after several hours of hemodynamic stability and no new signs of bleeding. She was extubated on postoperative day 2, and transferred to a regular ward bed on postoperative day 3. Her hemoglobin concentration before discharge on postoperative day 11 was 5.1 mg/dL. The patient’s postdischarge course was notable for a brief hospital admission to manage a postoperative wound seroma and wound breakdown but otherwise was uncomplicated.
Numerous treatment modalities are available to prevent and treat postpartum hemorrhage without the need for allogenic blood products. These treatments can include prenatal medications to enhance the production of endogenous RBCs, primarily iron supplementation and exogenous erythropoietin administration.9,12 Intraoperatively, cell salvage is considered acceptable to many JW, as are some blood component products and coagulation factors.5,8 Although initial concerns of amniotic fluid and air embolism existed in the use of cell salvage, numerous studies have demonstrated the safety of this modality in the obstetric population, and its use is endorsed by the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists.2–4
Retrospective analysis of this case reveals a number of informative points of discussion. Preoperatively, her utilization of the bloodless medicine consult service would prove invaluable later in her care, especially in regard to her acceptance of salvaged blood. However, more aggressive treatment of the patient’s baseline anemia with iron supplementation and erythropoietin in the weeks before delivery was indicated.
A number of points are also worthy of consideration when considering the patient’s intraoperative and postoperative course. First, the use of cell salvage in this patient during cesarean delivery in the OR and her secondary bleed in the ICU proved critical. The safety and life-saving benefits of this modality in the obstetric population must be emphasized. At the time of initial hemorrhage, tranexamic acid or procoagulant medications could have been administered to help promote coagulation, rather than waiting until the second bleed episode. Third, because the patient refused transfusion of fresh frozen plasma, and 4 factor prothrombin concentrate was not in common use at the time of this event, factor VII concentrates were administered. Had this event occurred today, a multifactor concentrate such as prothrombin concentrate would likely have been the first choice. Finally, some patients may benefit from induced coma to decrease their cerebral metabolism in the setting of low oxygen supply. Fortunately, this patient’s rapid recovery meant this step was unnecessary.
At the same time, these interventions must be considered in the light of the primary etiology of the patient’s hemodynamic instability, namely an arterial bleed. The decision to perform a bedside exploratory procedure stemmed from the realization that stabilization could only occur through immediate surgical hemostasis. No pharmacologic attempts at hemostasis could have achieved an adequate outcome. Had time been wasted in transport to the OR, the patient’s outcome may have been much worse. Overall, the patient made a remarkable recovery from a situation of true extremis, in large part to the cooperation of her interdisciplinary care team.
In summary, a sound strategy for management of obstetric patients refusing blood involves all phases of care. In the antepartum period, detailed discussions of the use of specific blood products should be documented. Risk factors for peripartum hemorrhage should be identified, and anemia should be treated with iron supplementation, with the addition of erythropoietin as indicated. In the peripartum period, blood conservation modalities (most notably RBC salvage) must be strongly considered, and resuscitation strategies should aim to ensure tissue perfusion while avoiding dangerously low hemoglobin concentrations. Finally, careful monitoring for postpartum hemorrhage must be ensured. An excellent tool for the management of such patients is provided through the Safe Motherhood Initiative, and online resource that provides simple instructions for managing parturients who refuse blood products.13
Name: Richard M. Hubbard, MD.
Contributions: This author helped review the literature and write the manuscript.
Name: Jonathan H. Waters, MD.
Contributions: This author helped provide guidance and revise the manuscript.
Name: Mark H. Yazer, MD.
Contributions: This author helped provide guidance and revise the manuscript.
This manuscript was handled by: Raymond C. Roy, MD.
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