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Handheld Ultrasound Guiding Postpartum Hemorrhage Resuscitation
Abstract Number: F-57
Abstract Type: Case Report/Case Series
The patient was a 25-year-old female whose baseline values were: blood pressure (BP) 134/83, pulse 74, temperature 98.3 F, weight 71 kg, hematocrit (HCT) 33. The patient had an uncomplicated pregnancy and after induction of labor, delivered a healthy infant at 13:57. Estimated blood loss (EBL) was 600 mL plus a returned clot of 150 mL. Soon after delivery, the patient became pale, confused, and then somnolent with BP 84/50, pulse 97, and temp 101.4 F. The time-of-day notes that follow correspond to the attached TTE images.
When anesthesiologists arrived, resuscitation had not begun. Initial TTE images at 14:10 revealed “kissing papillary muscles,” suggesting an empty ventricle at end systole and severe hypovolemia. End diastolic diameter was 3.3 cm suggesting a left ventricular end diastolic volume of 44 mL as estimated by the Teichholz method. Anesthesiologists rapidly gave 2 L of Lactated Ringer’s (LR) fluid. They also gave divided doses of ephedrine and phenylephrine, totalling 15 mg and 100 mcg, respectively, over a period of 10 minutes. The patient showed signs of endometritis so antibiotics were started. BP responded well to the fluids and vasopressors and within 10 minutes, systolic BP was 120. By 14:33, the patient’s LVESV by TTE was 16 mL and LVEDV was 70 mL. BP continued to be within normal limits (wnl).
Despite a BP and pulse wnl, subsequent TTE at 14:59 again showed “kissing papillary muscles,” and a LVEDV of 54 mL. Based on these findings, a 3rd liter of LR was given, and both blood and fresh frozen plasma transfusions were started. It was thought that the fluids given during the initial resuscitation had left the intravascular space. Labs showed a HCT of 28.2 and white blood cell count of 27.
Over the next several hours, the patient received a total of 2 units of packed red blood cells (pRBCs) and 2 units of fresh frozen plasma (FFP). TTE images throughout this time, for example as seen at 16:09, consistently showed a LVESV of 38 mL and a LVEDV of 92 mL with BP wnl.
Later that evening, the patient was taken to the operating room for suspected retained products of conception. Uterine curettage under monitored anesthesia care was performed. BP and pulse remained wnl. TTE images continued to show LVESV of about 40 mL and LVEDV of about 90 mL throughout the surgery. EBL was 1,500 mL and HCT after surgery was 21. Post-operatively, the primary team gave 2 additional units of pRBCs and 2 additional units of FFP.
The following day, the patient was feeling well, ambulating, and eating. The HCT remained stable at 24 in the morning and evening. TTE in the evening showed a LVESV of 22 mL and LVEDV of 88 mL.
By showing the effect of fluids and blood products on cardiac filling in real time, TTE can give the team increased confidence in administering adequate resuscitation. A handheld TTE is not meant to replace a formal TTE study, but rather helps quickly evaluate volume status, contractility, and gross structural anatomy of the heart.