///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

MANAGEMENT OF A JEHOVAS WITNESS WITH AN ACUTE OBSTETRIC HAEMORRHAGE AND EXTREMELY LOW LEVELS OF HEMOGLOBIN.

Abstract Number: 244
Abstract Type: Case Report/Case Series

GERMAN MONSALVE ANESTHESIOLOGIST1 ; AGUSTIN OSORIO ANESTHESIOLOGIST2; TATIANA GALLO ANESTHESIOLOGIST3; GONZALO ARANGO ANESTHESIOLOGIST4; ERICA HOLGUIN ANESTHESIOLOGIST5; MARIA VIRGINIA GONZALEZ ANESTHESIOLOGIST6

Jehovahs Witness pregnant patient are a growing group with a 44-fold increase of death when obstetric hemorrhage is present.

CASE REPORT: A 29 year old primigravid with 39 weeks, Jehovas Witness, with a normal prenatal care, who had a forceps delivery and a major bleeding secondary to uterine atony managed with misoprostol, oxytocin and Methylergonovine with no response. She was taken to a birth canal and uterine cavity revision under general anesthesia without lacerations found; a subtotal hysterectomy was performed. At the end of surgery she was severely anemic (hemoglobin value 3.5 gr/dl), hipovolemic and acidotic, requiring high doses of vasopressors, colloids and crystalloids. She was transferred to the High Dependency Unit were mechanical ventilation under profound sedation, analgesia and muscular relaxation was started; D dimer was 5920 ng/ml and fibrinogen 249 mg/dl with no alteration of other coagulation tests; tranexamic acid was initiated.12 hours later, the hemoglobin value was 2,7 gr/dl, intravenous iron (2 gr per day), human recombinant erythropoietin (EPO) 10000 per day IV, folic acid and B12 vitamin were initiated and so enoxaparine and intermittent pneumatic compression. Extubation was achived at day 3, but vasopressor support remained until day 5 when she began to complain of oppressive chest pain and dyspnea; anterolateral T wave inversion and ST-segment elevation were evident. Pulmonary edema was managed with morphine and furosemide, and nitroglycerine. Evolution was satisfactory. Table1.

DISCUSSION:. The patient management begins at prenatal care keeping a hematocrit level over 40%. Uterine atony prophylaxis must be aggressive, including prophylactic haemostatic sutures and hypogastric arteries ligations. Management of hypovolemia and coagulopathy are the basis. Antifibrinolytic agents and recombinant factor VII have been described also high doses of EPO although the optimal dose in the critical obstetric patient has not been standardized. Taking laboratory samples must be avoided with the aim of not making the anaemia worse, as well as removing invasive monitoring as soon as possible to control all sources of infection. During mechanical ventilation reducing oxygen consumption with profound sedation, analgesia and muscular relaxation is recommended. Besides, these patients must always have thromboembolic prophylaxis.

References:

1. Pharmacotherapy 2008; 28 (11):1383-1390

2. Chest 2004; 125:1151-1154.



SOAP 2009