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Management of postpartum hemorrhage (PPH) and disseminated intravascular coagulation (DIC) in a parturient with DTGA – another factor to consider
Abstract Number: SUN-73
Abstract Type: Case Report/Case Series
Patients with congenital heart disease are at increased risk of obstetric complications, including PPH.1 Safety bundles provide recommendations for blood management in obstetric hemorrhage.2 We report the use of prothrombin complex concentrates (PCC) in the treatment of refractory DIC.
A 32-year-old G2P1 with DTGA was s/p elective CS (breech) 2 years prior without complication. She had a neonatal atrial switch procedure and insertion of a pacemaker 16 years prior to this pregnancy. Her systemic right ventricle had borderline depressed function. She was admitted for TOLAC of an intrauterine fetal demise at 38 weeks. Hours into labor with epidural analgesia, she became hypotensive and was treated with fluids and phenylephrine. Hypotension recurred as labor progressed. With suspicion of chorioamnionitis and early sepsis, delivery was assisted with forceps. Immediately post Stage 3, she had hemorrhage with progressive hypotension and tachycardia. The hemorrhage protocol was activated. She was transferred to the OR for laceration repair (eventual laparotomy) and resuscitation. This included crystalloid, over 20 liters of banked blood products (PRBC, FFP, cryoprecipitate, platelets) and fibrinogen concentrate. Despite ongoing resuscitation, she continued to massively exsanguinate. PCC was administered at a dose of 50U/Kg. Almost immediately, her ability to form clot dramatically improved. Exposure revealed uterine rupture from the previous hysterotomy extending to the uterine artery. A hysterectomy was performed. Estimated blood loss was 12-15 liters. She was brought to the ICU intubated and in stable condition with good hemostasis.
The presence of a hemorrhage protocol with adequate blood bank personnel was vital in resuscitation. There is no recommendation on the use of PCC in obstetric hemorrhage. PCC is a combination of factors II, VII, IX, X (increasing the generation of thrombin), protein C and protein S (preventing excessive clot). Arterial thrombosis, however, is a potential risk.3 The utility of PCC for PPH and DIC has not been reported. In weighing the risk benefit in this case, it proved to be an important factor to consider. This case demonstrates the importance of obstetric hemorrhage protocols, the need for effective communication between a number of teams (Fig), and consideration of PCC in refractory DIC.
1Intl J Cardiol 2010 Oct 8;144(2):195-9
3Anesthesiology 4 2015,122:923-931