Case: Bleeding 1 week post-partum

[Jeff05]

30 f SVD 1 week ago presents to ED with ongoing vaginal bleeding. OB resident thinks - retained pacenta. Patient is hemodynamically stable, but is oozing continuously. hct is 30. OB resident says "there is a big clot in there, she may bleed once that comes out." you see that she is + for antibodies on a previous T&S.

Is there anything else you would like to know before going to OR?
Do you want blood available?

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[Planktonmd]

30 f SVD 1 week ago presents to ED with ongoing vaginal bleeding. OB resident thinks - retained pacenta. Patient is hemodynamically stable, but is oozing continuously. hct is 30. OB resident says "there is a big clot in there, she may bleed once that comes out." you see that she is + for antibodies on a previous T&S.

Is there anything else you would like to know before going to OR?
Do you want blood available?

Since you are obviously working at a university hospital and the procedure is going to be done by residents this means you have to be prepared for the worst Case scenario so:
Continue volume resuscitation and send blood to the blood bank to perform a cross match and find suitable blood.
Also get coagulation tests to make sure she is not in DIC.

 

[Jeff05]

coags WNL.
sample sent for T and Cross, + antibodies, blood bank "working on it..."

do you go to OR?

 

[Noyac]

I wait for blood in this case.

 

[jetproppilot]

30 f SVD 1 week ago presents to ED with ongoing vaginal bleeding. OB resident thinks - retained pacenta. Patient is hemodynamically stable, but is oozing continuously. hct is 30. OB resident says "there is a big clot in there, she may bleed once that comes out." you see that she is + for antibodies on a previous T&S.

Is there anything else you would like to know before going to OR?
Do you want blood available?

Can't wait too long as its hard to quantify how much blood she's losing....may be sequestered in the uterus/vaginal vault....HCT 30 but how long ago? Thirty minutes later it may be 25 and at some point the hemorrhage is gonna become a threat to her life.

Yes you need blood available.

I'd say call for O negative, have that ready to go, if her T&M blood shows up in the mean time even better. The bleedings gotta be addressed sooner than later.

 

[Substance]

I'm no anesthetist but I'll chime:

we know nothing about this patient except for the fact that she's bleeding post partum one week. One hematocrit doesn't say much about the acuity of a bleed, and if a bleed is bad enough the crit can be unchanged in the acute setting.

What I'd like to know about this patient:
1. Has she been taking NSAIDs post partum for pain?
2. What's her GPA? Any previous C-sections?
3. Why does the resident think its retained placenta? Was there an US done? Did he look?
4. History of previous bleeding difficulties(i'm thinking vWF; coags were normal but what about platelet function or vWF assay)
5. Birth and recent pregnancy history(severity of trauma, size of fetus, number of fetuses, post partum hematocrit etc)
6. Does she have any sequelae for connective tissue disorders like Ehler-danlos? A zebra, sure, but you never know...
7. Is she symptomatically anemic?

In the meanwhile I'd want O-negative blood stat while waiting for the cross-match, because we have no conclusive evidence that this is not a life-threatening situation. I'd also have her in the OR until we figure it out.

I'm not hugely knowledgeable of obs, but I would want to do some sort of imaging like US to see what's in the uterus. I would be concerned about doing a TVUS/spec exam because it could dislodge whatever clot may be maintaining her blood pressure. Nonetheless I'd take a non-invasive look to see if the bleeding isn't from a dehisced episiotomy or whatnot.

 

[jetproppilot]

I'm no anesthetist but I'll chime:

we know nothing about this patient except for the fact that she's bleeding post partum one week. One hematocrit doesn't say much about the acuity of a bleed, and if a bleed is bad enough the crit can be unchanged in the acute setting.

What I'd like to know about this patient:
1. Has she been taking NSAIDs post partum for pain?
2. What's her GPA? Any previous C-sections?
3. Why does the resident think its retained placenta? Was there an US done? Did he look?
4. History of previous bleeding difficulties(i'm thinking vWF; coags were normal but what about platelet function or vWF assay)
5. Birth and recent pregnancy history(severity of trauma, size of fetus, number of fetuses, post partum hematocrit etc)
6. Does she have any sequelae for connective tissue disorders like Ehler-danlos? A zebra, sure, but you never know...
7. Is she symptomatically anemic?

In the meanwhile I'd want O-negative blood stat while waiting for the cross-match, because we have no conclusive evidence that this is not a life-threatening situation. I'd also have her in the OR until we figure it out.

I'm not hugely knowledgeable of obs, but I would want to do some sort of imaging like US to see what's in the uterus. I would be concerned about doing a TVUS/spec exam because it could dislodge whatever clot may be maintaining her blood pressure. Nonetheless I'd take a non-invasive look to see if the bleeding isn't from a dehisced episiotomy or whatnot.

Thats a nice post.

 

[Planktonmd]

I'd say call for O negative, have that ready to go, if her T&M blood shows up in the mean time even better. The bleedings gotta be addressed sooner than later.

Is O negative blood safe to give a patient with atypical antibodies (which appears to be the case here)?
If we are going to do that then why not just give type specific blood?

 

[jetproppilot]

Is O negative blood safe to give a patient with atypical antibodies (which appears to be the case here)?
If we are going to do that then why not just give type specific blood?

I hear you and thats a good point.....all has to do with risk verses benefit of the transfusion.

At some point her risk of sequelae from hypovolemic shock (she's still actively bleeding) is gonna outweigh the risk of a possible transfusion reaction from the administration of O negative blood in a lady with alloantibodies.

Of course the best case scenerio is the blood shows up.

What if she goes down the tubes before the typed blood shows up?

I posted a case a while back with a similar scenerio....parturient post D&C for fetal demise with continued bleeding who was in hypovolemic shock...oh....and she was combative (from blood loss) and uhhhhhhhh.....she was obese (hard IV stick) and pulled out her only IV.

(you can read about that case in the cold case clinical files section, post #8 at the bottom)

What if the OP's lady gets to this point before her blood is ready?

Even if her hemorrhage did not progress to the extent in my posted case, it certainly could've.

Then what?

 

[Planktonmd]

I hear you and thats a good point.....all has to do with risk verses benefit of the transfusion.

At some point her risk of sequelae from hypovolemic shock (she's still actively bleeding) is gonna outweigh the risk of a possible transfusion reaction from the administration of O negative blood in a lady with alloantibodies.

Of course the best case scenerio is the blood shows up.

What if she goes down the tubes before the typed blood shows up?

I posted a case a while back with a similar scenerio....parturient post D&C for fetal demise with continued bleeding who was in hypovolemic shock...oh....and she was combative (from blood loss) and uhhhhhhhh.....she was obese (hard IV stick) and pulled out her only IV.

(you can read about that case in the cold case clinical files section, post #8 at the bottom)

What if the OP's lady gets to this point before her blood is ready?

Even if her hemorrhage did not progress to the extent in my posted case, it certainly could've.

Then what?

Agree with the risk versus benefit idea and certainly you might find yourself in a position where you have to proceed regardless of the availability of blood products.
You don't necessarily have to give O negative in this case you can give whatever the patient's blood type is since we already know that from the existing type and screen.

 

[urge]

I would wait for the blood. My only trigger to do the case before that would be if CPR is being given. In that scenario any blood is good.

2. What's her GPA?

Why are you concerned about her academic performance?

 

[jetproppilot]

My only trigger to do the case before that would be if CPR is being given.

 

[Noyac]

My thinking here is that she has been bleeding for a week and her crit is still good. There is a clot there that the resident saw and it is holding everything together now. Wait for blood then go tugging at that clot. If someone tells me she is tachy and clamped down then we go now with Type O neg.

 

[Jeff05]

OB attending calls - this is about 3 hours later, says she is in house and wants to go NOW. patient is still stable, still oozing, but attending thinks risk of waiting more than risk of giving 0- (nicely documented in chart).

i call the blood bank to personally make sure that the OB resident requested PRBCs like i asked - 3 hours earlier. they have no idea. OB resident blows up in self defense after i mention this fact - "i called and called an no one picked up..." anyhoo, so now, we're rolling back to OR, no crossed blood available.

induction is smooth. a line. hct 21. 0- called for. they pull off clot and she opens up. uterus floppy. pit, methergen, hemabate, miso PR. i am holding off giving until absolutely necessary (another discussion).

bleeding finally under control. EBL difficult to quantify, but my guess more than 500mL. hct 16. due to +ab blood bank having trouble finding compat. units.

get her to pacu, units arrive. transfused. goes to floor stable in 4 hours.


OB attending gives me sh2t that we didn't go to OR earlier. i explain that i requested blood hours ago and that her resident didn't follow through. that the patient was completely hemodynamically stable, had a slow ooze, and, as presented to me had a large clot that if removed would (and did) lead to a period of brisk bleeding. OB resident super defensive - she did nothing wrong.
OB attending thanks me at the end...

 

[aphistis]

OB attending calls - this is about 3 hours later, says she is in house and wants to go NOW. patient is still stable, still oozing, but attending thinks risk of waiting more than risk of giving 0- (nicely documented in chart).

i call the blood bank to personally make sure that the OB resident requested PRBCs like i asked - 3 hours earlier. they have no idea. OB resident blows up in self defense after i mention this fact - "i called and called an no one picked up..." anyhoo, so now, we're rolling back to OR, no crossed blood available.

induction is smooth. a line. hct 21. 0- called for. they pull off clot and she opens up. uterus floppy. pit, methergen, hemabate, miso PR. i am holding off giving until absolutely necessary (another discussion).

bleeding finally under control. EBL difficult to quantify, but my guess more than 500mL. hct 16. due to +ab blood bank having trouble finding compat. units.

get her to pacu, units arrive. transfused. goes to floor stable in 4 hours.


OB attending gives me sh2t that we didn't go to OR earlier. i explain that i requested blood hours ago and that her resident didn't follow through. that the patient was completely hemodynamically stable, had a slow ooze, and, as presented to me had a large clot that if removed would (and did) lead to a period of brisk bleeding. OB resident super defensive - she did nothing wrong.
OB attending thanks me at the end...

Anesthesia resident owns OB resident on her own turf, and is given key to city.

 

[proman]

I'd make sure to do the case in our main OR where the blood bank is located not 5 flights down where OB is.

And the only harm to giving blood to someone with antibodies to minor antigens is shortened life span of the transfused blood.

 

[Planktonmd]

And the only harm to giving blood to someone with antibodies to minor antigens is shortened life span of the transfused blood.

Antibodies to secondary (minor) RBC antigens (other than ABO and RH) can produce reactions that range from mild to severe and you could actually have a hemolytic reaction although less severe and less common than ABO incompatibility.
Giving O negative is not helpful in preventing these reactions although the OP seems to think so because he mentioned risk of bleeding versus risk of giving O negative.
If you decide to ignore the atypical antibodies which are not (ABO or RH antibodies) you can just give type specific blood not O negative.

 

[dfk]

Can't wait too long as its hard to quantify how much blood she's losing....may be sequestered in the uterus/vaginal vault....HCT 30 but how long ago? Thirty minutes later it may be 25 and at some point the hemorrhage is gonna become a threat to her life.

Yes you need blood available.

I'd say call for O negative, have that ready to go, if her T&M blood shows up in the mean time even better. The bleedings gotta be addressed sooner than later.

what is THIS?

 

[2ndyear]

So her Hct is 16 in PACU. What did she look like clinically? I'll play devils advocate and ask if we NEED to transfuse at this point. Ongoing bleeding has been stopped. 16 is very very low. Nobody will blame you for transfusing, but does she need it?

 

[proman]

Antibodies to secondary (minor) RBC antigens (other than ABO and RH) can produce reactions that range from mild to severe and you could actually have a hemolytic reaction although less severe and less common than ABO incompatibility.
Giving O negative is not helpful in preventing these reactions although the OP seems to think so because he mentioned risk of bleeding versus risk of giving O negative.
If you decide to ignore the atypical antibodies which are not (ABO or RH antibodies) you can just give type specific blood not O negative.

We're saying the same thing. Transfusion reactions involving minor antigens, by definition, are delayed hemolytic reactions. ABO, Rh, and a few rare others cause INTRAvascular acute hemolytic reactions and end-organ consequences we all know. Minor antigens cause EXTRAvascular delayed hemolytic reactions that involve the reticuloendothelial system and reduces the life span of the RBC to arond 10 days. The use type specific un-cross matched is one thing we can insist on using if we absolutely need blood and we know the ABO and Rh status. O blood should only be used if the patient's ABO type is not known.

 

[Planktonmd]

We're saying the same thing. Transfusion reactions involving minor antigens, by definition, are delayed hemolytic reactions. ABO, Rh, and a few rare others cause INTRAvascular acute hemolytic reactions and end-organ consequences we all know. Minor antigens cause EXTRAvascular delayed hemolytic reactions that involve the reticuloendothelial system and reduces the life span of the RBC to arond 10 days. The use type specific un-cross matched is one thing we can insist on using if we absolutely need blood and we know the ABO and Rh status. O blood should only be used if the patient's ABO type is not known.

Agree.

 

[9french]

We're saying the same thing. Transfusion reactions involving minor antigens, by definition, are delayed hemolytic reactions. ABO, Rh, and a few rare others cause INTRAvascular acute hemolytic reactions and end-organ consequences we all know. Minor antigens cause EXTRAvascular delayed hemolytic reactions that involve the reticuloendothelial system and reduces the life span of the RBC to arond 10 days. The use type specific un-cross matched is one thing we can insist on using if we absolutely need blood and we know the ABO and Rh status. O blood should only be used if the patient's ABO type is not known.

Normally the "minor antigens" do lead to a delayed transfusion reaction. A, B, Duffy, Kell, and some others I have forgotten often lead to acute intravascular hemolysis, which is bad. Rh antibodies more often than not cause a delayed reaction, not acute intravascular hemolysis. This is why some older attendings say you can give a male trauma patient O positive if you run out of O neg. Nonetheless, nothing is set in stone. If someone has a large number of circulating pre-formed antibodies to a minor antigen, intravascular hemolysis may occur. Anytime you give a patient blood which they have an invitro reaction to, you are taking chances.

 

[MTGas2B]

i call the blood bank to personally make sure that the OB resident requested PRBCs like i asked - 3 hours earlier. they have no idea. OB resident blows up in self defense after i mention this fact - "i called and called an no one picked up..." anyhoo, so now, we're rolling back to OR, no crossed blood available.

I've gotten in a habit of always confirming blood availability personally. At the U our blood bank posts a list of the days patients and what products they have in house. Easy check. At the county hospital I have the blood bank's number memorized. I've been misled to sooo many times. ICU nurse says we have this many units in house, we don't. Surgeon has ordered this many (but failed to have patient come in for blood draw for t&c), so we really have none.

How long do your hospital blood banks take to get stat matched blood delivered? We have a weird system in Seattle. There is actually only one blood bank for the city. Couriers shuttle blood back and forth to the hospitals. Despite the potential problems stat orders are generally taken care of in under an hour. Each hospital keeps a stash of emergency uncrossmatched products around as well. In fact for OB if we declare a "bleeding emergency" we get uncrossed products and the blood center hematologist on the phone asking what we need.