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Postpartum DIC with an epidural in situ and bleeding at the site
Abstract Number: S-59
Abstract Type: Case Report/Case Series
Introduction: Epidural hematoma is a common fear but uncommon occurrence in obstetric anesthesia. Disseminated intravascular coagulation (DIC) and epidural-site bleeding present a high-stakes dilemma for diagnosis and management.
Case: A 31 year old G1P0 presented for induction of labor at 40+ weeks. Approximately 5 hours after an uneventful epidural placement, emergency cesarean was done due to non-reassuring fetal heart tones. The block was inadequate, and general anesthesia was induced. Delivery of the fetus was uncomplicated, but severe hypotension developed after placenta removal, requiring epinephrine to resolve. The working diagnosis was amniotic fluid embolism (AFE), so a DIC panel was drawn. The remainder of the cesarean was uneventful. Estimated blood loss (EBL) was 600cc.
When the drapes were removed, significant vaginal bleeding and a pool of blood under the patient were noted. Bleeding could not be controlled with a Bakri balloon and vaginal packing, so the abdomen was re-opened. 500cc of blood without clot, and bleeding from the hysterotomy site and peritoneal edges were found. The DIC panel resulted, showing D-dimer>34, fibrinogen<35, INR>10, PTT>200, and 126,000 platelets. With AFE the likely etiology, supportive care was considered the best approach. O’Leary sutures and Floseal were used for hemostasis. The abdomen was packed and fascia closed. 8 units PRBCs, 9 units FFP, 3 units cryoprecipitate, 2 platelet six-packs, 500cc albumin, and 5 L crystalloid were given. EBL was 6 L.
On transfer of the patient to her bed, significant oozing from the epidural site was noted. Due to sedation, neurologic assessment could not be done. Neurosurgery was consulted and recommended a CT scan to determine the need for urgent surgical intervention for epidural hematoma. A suspicious area was noted on the non-contrast CT, and confirmatory MRI was recommended by radiology. The risk of heat-induced tissue injury with an in-situ lumbar catheter and a 1.5-Tesla MRI were insufficiently known to recommend the MRI with the catheter-in situ. The patient’s most recent platelet count was 19,000.
Epidural hematoma is a known risk of catheter removal in coagulopathic patients, so the care team weighed the risks of waiting for normalized coagulation v. proceeding with imaging. The potential tissue injury of MRI with the catheter in situ, and the delay for serial lab tests and transfusions were considered unacceptable. 2 six-packs of platelets were transfused and the catheter removed. MRI showed a hematoma at L3-L4, and the patient was managed expectantly. She was discharged to home on postpartum day 10 neurologically intact.
Discussion: The MRI compatibility of epidural catheters in vivo is essentially unknown. There is a paucity of data regarding them quantity of heat generation with MRI coils other than the transmit/receive RF head coil.
Reg Anesth & Pain Med 2014; 39