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Management of Post-partum Hemorrhage in a Jehova's Witness Patient
Abstract Number: F2C-4
Abstract Type: Case Report/Case Series
We present the anesthetic management of a Jehovah’s Witness patient whose peripartum course was complicated by massive PPH.
A 30 years old Jehovah’s Witness parturient (G2P0) with gestational diabetes was admitted for induction of labor secondary to late term. The patient refused all allogenic blood products, but consented to the use of cell salvage and was appropriately counseled about her decisions with written consent obtained. An early combined spinal epidural was placed uneventfully for provision of labor analgesia. After a 34 hours labor complicated by likely chorioamnionitis, she had a spontaneous vaginal delivery of a 3935g healthy infant. The third stage of labor was delayed causing uterine atony and active bleeding which was treated with fluid resuscitation and multiple uterotonics (methylergonovine, carboprost, oxytocin and misoprostil) however surgical intervention was needed. The patient was transferred to the OR for manual removal of placenta and the existing epidural was carefully dosed to obtain surgical anesthesia. Hematology, gynecology oncology surgery and cell salvage teams were all contacted. Multiple attempts to remove the placenta were unsuccessful and decision to perform emergency hysterectomy to treat atony and hemorrhage was made. Invasive monitoring (arterial line and central venous catheter) was established and the case was converted to general anesthesia. A total of 5000ml of blood loss occurred postpartum requiring resuscitation with 6000ml crystalloid, 1500ml colloid and low dose norepinephrine infusion to maintain hemodynamic stability. Despite being contacted, cell salvage were unable to attend immediately and therefore the technology was not utilized in this case. Serial laboratory results revealed a rapid decline in hemoglobin (11.3g/dL->6.6g/dL->3.6g/dL) and coagulopathy that was treated with calcium chloride, tranxemic acid, vitamin K and recombinant factor VIIa as per hematology advice. Post operatively the patient was transferred to the ICU where she was mechanically ventilated for 20 hours and weaned off norepinephrine infusion. The epidural catheter was removed four days after insertion without any complications. Severe anemia was treated with erythropoetin, iron, folate and B12. The patient was discharged from hospital post-operative day 10 with a hemoglobin of 7.5g/dL.
This case highlights how PPH in an obstetric patient refusing allogenic blood transfusion remains a clinical challenge for obstetric anesthesiologists. Early intervention and multidisciplinary team involvement are vital for optimal care. Intraoperative cell salvage has been shown to reduce allogenic blood transfusion and utilizing it in this case may have been invaluable. Developing a protocol to manage PPH in this specific group of parturients may prove beneficial and warrants further research.
1. Silva, LL. et al. (2013) Rev Bras Cir Cardiovasc. 28(2):183-9