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Successful Resuscitation Following Massive Obstetric Hemorrhage in a Patient of the Jehovah’s Witness Faith: A Case Report

Hubbard, Richard M. MD*; Waters, Jonathan H. MD; Yazer, Mark H. MD

Erratum

The article, “Successful Resuscitation Following Massive Obstetric Hemorrhage in a Patient of the Jehovah’s Witness Faith: A Case Report,” 1 that appeared in the June 15th 2017 issue on pages 326–329, contained an error. The hemoglobin units “mg/dL” should read as “g/dL” throughout the article. Figure 3 should also include the unit “g/dL” for the Y-axis label. The author regrets this error.

A&A Practice. 10(7):188, April 1, 2018.

doi: 10.1213/XAA.0000000000000503
Case Reports: Case Report
Free
Erratum

Hemorrhage is a leading cause of maternal morbidity and mortality worldwide. It is especially difficult to treat in patients of the Jehovah’s Witness faith because they refuse certain blood products. This case report describes the resuscitation of a parturient Jehovah’s Witness whose postcesarean delivery course was complicated by massive hemorrhage from unrecognized arterial bleeding in the intensive care unit with significant hemodynamic instability that necessitated an emergency bedside laparotomy. Her hemoglobin nadir was 1.5 mg/dL. The case demonstrates the key place of preprocedure planning, blood conservation, and coagulation factor management in this specific patient population.

From the Departments of *Anesthesiology; Anesthesiology & McGowan Institute for Regenerative Medicine; and Pathology & Institute for Transfusion Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Accepted for publication December 14, 2016.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Richard Hubbard, MD, 3471 Fifth Ave, Suite 910, Pittsburgh, PA, 15213. Address e-mail to hubbardrm@upmc.edu.

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality worldwide, and its incidence has been increasing in recent decades.1–4 This condition is particularly difficult to treat when it occurs in members of the Jehovah’s Witness (JW) faith, a Christian denomination of >8 million people worldwide, whose teachings include a prohibition against the receipt of certain blood products.5 Retrospective studies of JW patients have demonstrated 6 to 65 times greater peripartum mortality than the general population.1,6,7 There is a common perception among health care workers that JW patients refuse all blood products, not just red blood cells (RBCs), platelets, and plasma. This misunderstanding may compromise care in acute hemorrhagic crises.1,5,6,8

A recent review emphasized an approach to parturient JW patients that includes careful predelivery care from a multidisciplinary team, including obstetricians, anesthesiologists, hematopathologists, and neonatologists, to anticipate and manage any peripartum complications.9 Careful discussions with these patients may reveal significant variations in acceptance of individual blood products, information which may become critical in cases of acute hemorrhage.5 Intraoperative and postoperative care should similarly be designed to minimize blood loss and optimize RBC production by utilizing all appropriate treatment modalities which do not violate the conscience of individual patients.9

A number of reports detailing hemorrhage as a cause of death in parturient JW patients, with documented nadir hemoglobin levels between 1.3 and 4.0 mg/dL.1,7,10,11 This report describes the successful resuscitation in a patient with a hemoglobin of 1.5 mg/dL and significant hemodynamic instability because of an arterial bleed in the intensive care unit (ICU) following an unanticipated cesarean hysterectomy.

Written consent was obtained from the patient for publication of this report. The host institution does not consider case reports to be human subject research, so no IRB approval was deemed necessary.

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CASE DESCRIPTION

A 24-year-old G2P1 JW patient was admitted for a planned repeat cesarean delivery at a regional maternal care hospital. Two weeks before the surgery, the patient completed a form through the Bloodless Medicine Service that detailed which blood products she considered acceptable (Figure 1). This service provides one-on-one phone consultation and referral to church elders to aid in decision making. Of note, this patient did not object to receiving albumin, clotting factor concentrates, or closed-circuit cell salvage, which was explained as a continuous circuit between the surgical field, the blood salvage machine, and the patient via intravenous (IV) line. Her outpatient medications included a prenatal vitamin and an oral iron supplement. On the day of admission, her hemoglobin was 10.6 mg/dL.

Figure 1.

Figure 1.

Neuraxial blockade was obtained through a single-shot spinal injection, and a vigorous female infant was delivered within 7 minutes of incision with Apgar scores of 9 at both 1 and 5 minutes of life. Uterine atony persisted despite the administration of oxytocin, carboprost, methylergonovine, and misoprostol. Active vaginal bleeding was noted at the time of misoprostol insertion. B-Lynch and O’Leary sutures were placed, and bilateral utero-ovarian ligament ligations were performed, without achieving hemostasis. An endotracheal tube was inserted after general anesthesia was induced, and a hysterectomy was performed.

An estimated 2500 mL of blood was lost during the procedure. A multimodal resuscitation strategy was utilized that included 1600 mL of lactated Ringer’s solution, 750 mL of 5% albumin, and 370 mL of salvaged RBCs. Systemic vascular resistance was supported with a phenylephrine infusion (0.33 μg/kg/mL), supplemented with multiple boluses of the same medication. The patient remained intubated but was hemodynamically stable without vasopressor support when she was transferred to the ICU 2 hours following the start of surgery. Her hemoglobin at the time of admission to the ICU was 7.4 mg/dL.

Approximately 90 minutes later, the patient was noted to be hypotensive and tachycardic (Figure 2). Initial resuscitation with both crystalloids (3 L) and colloids (1 L) was administered by the critical care team, along with a norepinephrine infusion. A transient normalization of hemodynamic status was achieved, but at postoperative hour 2 her hemoglobin was 3.7 mg/dL (Figure 3). Reexamination by the obstetric team at postoperative hour 4 was notable for worsening abdominal distension. Bedside ultrasound suggested a large amount of intraperitoneal blood that necessitated reexploration of the abdomen. However, in discussion with the critical care and anesthesia teams, she was deemed too unstable for transport to the operating room (OR).

Figure 2.

Figure 2.

Figure 3.

Figure 3.

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.

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DISCUSSION

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

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DISCLOSURES

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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REFERENCES

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