///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Castor Oil as an Instigator of Peripartum DIC?

Abstract Number: RF6BI-167
Abstract Type: Case Report Case Series

Simon A Martin MD1 ; Laura L Sorabella MD2; Anna J Hartzog MD3

Peripartum hemorrhage is an all too common and deadly event. The timely and accurate diagnosis of peripartum hemorrhage is paramount for initiation of life-saving treatment and limitation of sequala. We describe the case of a 33 y/o G3P0 female at 41 weeks and 6 days who presented from a birthing center. Prior to transfer, the patient received a Foley bulb cervical catheter and oral castor oil for labor induction. Upon arrival a lumbar epidural was placed. Following epidural placement, uterine contraction pattern appeared irritable raising concern for abruption. Vital signs remained stable with no vaginal bleeding. Pre-delivery coagulation labs showed: Fibrinogen <60, INR 2.9, PTT 66.5, PT 30.1, and platelets 187. PRBCs, FFP, tranexamic acid, and cryoprecipitate were obtained. Patient did not have excessive bleeding from large bore IV placement, but minor bleeding from her gums was noted. Pre-eclampsia labs were negative and blood pressure was mildly elevated at 141/76.

Within an hour a healthy infant and intact placenta were delivered. Tone was adequate in the fundus, but hemorrhage ensued from lack of lower uterine segment tone and a small vaginal laceration. Methergine, carboprost, FFP, and cryoprecipitate were rapidly administered. Patient then had one liter of coffee ground emesis and an increase in vaginal bleeding. General anesthesia was induced and after initial cryoprecipitate, plasma, pRBCs, and TXA failed to rectify the patient’s disseminated intravascular coagulopathy (DIC), fibrinogen concentrate was administered. OB team performed a hysterectomy as blood loss was too severe for Bakri placement and vaginal packing.

The patient received a total of 13 units FFP, 12 units pRBCs, 6 packs of cryoprecipitate, and 3 packs of platelets. Blood pressure increased intraoperatively with SBPs reaching 160s-180s while PPVs 8-10. Magnesium was eventually initiated. Postoperative labs were: Fibrinogen 421, INR 1.2, PTT 29.5, PT 14.9, platelets 187, HCT 22. Patient was extubated, and epidural was removed on POD1 after coagulation labs remained normal. Preeclampsia with severe features was ultimately diagnosed as SBPs remained in 160s-170s post-operatively, but HELLP labs remained normal throughout. She was discharged home on POD 7 with oral nifedipine.

Castor oil is a commonly used home remedy to hasten birth by causing uterine contractions. A case has been described in the literature of DIC after amniotic fluid embolus (AFE) in association with castor oil. Castor oil is known to increase systemic concentration of prostaglandin E, a uterotonic, and it has been hypothesized that the strong contraction elicited by this substance could cause irregular, strong uterine contractions potentially leading to an AFE. Although pre-eclampsia/HELLP is the most likely cause of this patient’s DIC, the recommended dose of oral castor oil is 1-2 tbsp, and this patient consumed several hundred times this dose.

SOAP 2019