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An Emergent Cesarean Delivery in a Jehovah’s Witness with a 30 x 16 x 25 cm Uterine Fibroid and Massive Hemorrhage
Abstract Number: T 76
Abstract Type: Case Report/Case Series
Intro: In 2008, 1,914,000 Americans described themselves as Jehovah’s Witnesses. Since most JW’s refuse blood products, it is important to have frank discussions about possible blood loss and be appropriately prepared for massive hemorrhage when a JW undergoes a surgical procedure.
Report: A 36-year-old G1P0 JW at 37 weeks presented emergently with regular painful contractions. On exam, the patient was 3 cm dilated, 90% effaced and breech presentation. The patient had a known 30x16x25 cm uterine fibroid. She was consulted about the risk of massive hemorrhage with her fibroid and likely need for blood transfusions however the patient refused any blood products other than albumin and Cell Saver. A 14g IV and lumbar epidural were placed. Within 1 hour, the patient was 5 cm dilated with late decelerations. The patient was then taken to the OR for an emergent cesarean delivery. Standard ASA monitors were placed and an arterial line and rapid infusion catheter were secured. A triple lumen central line, Cell Saver, and rapid infuser were made available for emergent use in the OR. The patient was again consulted about possible massive hemorrhage but continued to refuse any blood products. The patient’s lumbar epidural was slowly dosed with fentanyl, 2% lidocaine and sodium bicarbonate. The patient’s blood pressure and fetal heart tones decreased immediately after lying supine with left uterine displacement. Hypotension was only responsive to epinephrine boluses. The OB team made a vertical midline incision to avoid the fibroid and delivered the baby 1 minute after incision. The patient lost 4000cc of blood during this period and became unconscious. Conversion to a general anesthetic using RSI and video laryngoscopy was performed. A central line was placed and an epinephrine infusion initiated. Cell saver was started and albumin boluses given to maintain perfusion. The patient was given pitocin, hemabate and methergine to control bleeding but to no avail. Due to numerous adhesions and continuous bleeding, hysterectomy was not feasible and bilateral uterine artery embolization was required. The patient was transported under anesthesia to IR and successfully embolized. She was then transported to the ICU with a Hgb of 3.3. Despite the patient’s pre-op wishes, her husband requested a blood transfusion for her on post-op day 1. She was extubated on POD 2. By POD 3 she was fully conversant and expressed appreciation of all resuscitative measures including the transfusion. She explained that, despite all of our counseling, she did not truly understand her life was in danger. She was discharged on POD 12.
Discussion: Since the public typically considers cesarean deliveries to be a low risk procedure, it is important to clearly express the risks associated with massive hemorrhage to JW patients so they can make informed decisions about their own care. It is also imperative to make appropriate preparations for JW patients in the OR in case of massive hemorrhage.