Interesting OB case

[bluewater]

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I am the senior resident covering trauma with 2 junior residents and 1 covering OB.

I get called by the OB resident for a hypotensive pt. She is a G6P5 (now P6), no prior C/S, that has just delivered with the help of outlet forceps. Pt has a working epidural. She is complaining of pain below the level of the epidural block. There is limited vaginal bleeding. The pt appears somnolent and BP syst of 80. Ephedrine and fluids given with only minimal improvement in BP. Over the next 5 mins, BP declines into the 70s with fluid running wide open in 2 PIV with boluses of neo and ephedrine.

OB wants to do a D&C for what they suspect is retained placenta causing bleeding leading to hypotension.

What do you do?

 

[Jeff05]

patient is bleeding out. DIC is comin.
before you do anything call for BLOOD - 10 units asap.
also call for FFP and platelets.

1. get to OR
2. large bore access
3. a line
4. tube

stay on top of the products. very easy to fall behind.

I am the senior resident covering trauma with 2 junior residents and 1 covering OB.

I get called by the OB resident for a hypotensive pt. She is a G6P5 (now P6), no prior C/S, that has just delivered with the help of outlet forceps. Pt has a working epidural. She is complaining of pain below the level of the epidural block. There is limited vaginal bleeding. The pt appears somnolent and BP syst of 80. Ephedrine and fluids given with only minimal improvement in BP. Over the next 5 mins, BP declines into the 70s with fluid running wide open in 2 PIV with boluses of neo and ephedrine.

OB wants to do a D&C for what they suspect is retained placenta causing bleeding leading to hypotension.

What do you do?

 

[MTGas2B]

I am the senior resident covering trauma with 2 junior residents and 1 covering OB.

I get called by the OB resident for a hypotensive pt. She is a G6P5 (now P6), no prior C/S, that has just delivered with the help of outlet forceps. Pt has a working epidural. She is complaining of pain below the level of the epidural block. There is limited vaginal bleeding. The pt appears somnolent and BP syst of 80. Ephedrine and fluids given with only minimal improvement in BP. Over the next 5 mins, BP declines into the 70s with fluid running wide open in 2 PIV with boluses of neo and ephedrine.

OB wants to do a D&C for what they suspect is retained placenta causing bleeding leading to hypotension.

What do you do?

Uterine rupture, she needs a hyst not a d&c.
-Get your uncrossmatched emergency blood supply
-Politely tell the obstetricians to pull their heads out of their *****es

 

[Planktonmd]

I am the senior resident covering trauma with 2 junior residents and 1 covering OB.

I get called by the OB resident for a hypotensive pt. She is a G6P5 (now P6), no prior C/S, that has just delivered with the help of outlet forceps. Pt has a working epidural. She is complaining of pain below the level of the epidural block. There is limited vaginal bleeding. The pt appears somnolent and BP syst of 80. Ephedrine and fluids given with only minimal improvement in BP. Over the next 5 mins, BP declines into the 70s with fluid running wide open in 2 PIV with boluses of neo and ephedrine.

OB wants to do a D&C for what they suspect is retained placenta causing bleeding leading to hypotension.

What do you do?

Multiparous patient who became hypotensive in the early post partum period with sudden pelvic pain ---> something bad is going on, could be uterine atony or uterine rupture secondary to the instrumentation.
Stick with the basics: make sure you have good IV access like 2 large bore peripherals or a central line.
Take her to the OR.
Have blood ready to transfuse ASAP.
continue aggressive volume resuscitation in the mean time because this is hypovolemia until proven otherwise.
RSI, secure the airway and let them do their D&C if that does not work she needs a laparotomy so you might want to remind your OB to consider that.
Keep giving volume.

 

[pgg]

Hypotension, coagulopathy, uterine atony, and bleeding are also signs of AFE. (Although the pain & lack of dyspnea/hypoxia don't fit so much.) Wouldn't really change management much but it's something to have on the differential.

 

[Noyac]

I'd take her to the OR for D&C. She gets a GETA.

This seems too soon for DIC for me. But if you hesitate, DIC may be on its way.

Start with D&C and move on to hyst if necessary. Remember, OBGYN surgeons are not usually very good and rapid surgical techniques which require quick thinking and quicker action. They are always trying to save the all mighty uterus. Sometimes that poor bastard needs to be removed. And really, this is baby #6. Does she really need that worn out organ any longer?

Word of advice, don't say this to the OB. They can't see the reality.

 

[aphistis]

And really, this is baby #6. Does she really need that worn out organ any longer?

Truer words were ne'er spoken.

 

[bluewater]

Several of you have hit the nail on the head.

We persuaded the OB/GYN team to take the pt to the OR for ex lap. By the time we were in the OR- the cuff was continously cycling. Pt was induced (with minimal drugs due to hypotension) and tubed. Neo was pushed and an A line was started- first reading on the montior syst 45. 14 g IV to L arm and 9Fr in RIJ. Lotsa products going in via rapid infuser.

Once in the Abdomen- there was a huge uterine rupture. It extended from just above the cervix on the pts right to the top of the fundus and had basically torn the uterine artery on that side. Lotsa blood in the belly.

Full on trauma style rescusitation ensued. First set of Coags clearly showed DIC. Over the next hour we were able to correct the DIC and get her Hgb to 7-8 (initial 3.)Hyst performed. Then the OB team consulted the trauma service for ligation of branches from the R iliac artery.

Ultimately, the pt lived, remained intubated and went to the ICU.

In retrospect, I believe the rupture may have occurred before forceps placement because her previously well controlled pain became excruciating prior to instrumentation. I think she was unable to push the baby out because of the rupture and that is why forceps were applied.

The blood loss associated with the deilvery was only about 300-400 ml, but the hypotension and pain (even with the epidural) keyed us into badness. All of the blood was pouring into the abdomen and retroperitoneal space rather than out of the vagina.

 

[ProRealDoc]

Like the pros have said, you gotta step up to the mike on this one. All excellent advice. Way to practice medicine folks!

 

[pushthesux]

So, when do you take the epidural out?

 

[Planktonmd]

So, when do you take the epidural out?

When the patient is not coagulopathic??

 

[Noyac]

How did you correct the DIC?
Blood and products or pharmacology, ie Factor 7?

 

[bluewater]

DIC was corrected with products- however, we did have the Factor 7 available.

Epidural was pulled several days later (coags normal.)

 

[proman]

What kind of blood was transfused?

 

[bluewater]

As best I can remember
10 u PRBCs
4 FFP
2 Cryo
2 plts

I think crystalloid was about 6 L.

 

[SleepIsGood]

2 questions:

1)Would anyone do this case using the epidural? yes, I know the pt is hypovolemic here so it is a contraindication.

2)Blue water what did you do with the epidural? Just keep it in place for those few days and not run anything through it?

Awesome management by the way!👍

 

[bluewater]

1. We felt that the case was a rescusitation and immediately went the GETA route. Never comtemplated using the epidural for the ex lap

2. In the ICU, when the hemodynamics were stable (the next day), we actually used the epidural for pain control.

 

[New2Midwest]

This points out the adage that the pain of uterine rupture is enough to break through the analgesic effects of a functioning epidural-likely due to referred visceral pain pathways as well

 

[nutmegs]

Agh, OB scares me.

 

[wilner2]

I had nearly the same case 3 weeks ago. We were back doing a C-section when we got called about another patient that was continuing to bleed vaginal birth, uterine atony however this time. When we arrived she obtuned (already vomitted on herself), hypotensive (systolic in the 80's) and hypoxic (sats in the 70's). She got a tube immediately, R SC cordis, left ax. a-line (no palpable radial pulses) and brought to OR. After the 4L crystalloid, 1L colloid, 12 U PRBC, 8 U FFP, 4 platlets, and cryo her INR > 7, PTT > 200, plts= 39. Her DIC bought her a round of factor 7, which post-op corrected her INR= 1.1 . She left the OR with an open abdomen (after consultation placed by us in the OR for Trauma team to come in and explain to the OB's what they needed to do), intubated/sedated. Went back to OR 2 days later and closed by general surgery, to the floor 3 days later, epidural pulled POD# 4 (when plts normalized), home POD#6.

Most interesting part to me though, was that we weren't called until 45 minutes into her bleeding and waxing of consciousness. The OB team and OB nurses didn't realize that we actually do things other than epidurals/spinals!

 

[jetproppilot]

Multiparous patient who became hypotensive in the early post partum period with sudden pelvic pain ---> something bad is going on, could be uterine atony or uterine rupture secondary to the instrumentation.
Stick with the basics: make sure you have good IV access like 2 large bore peripherals or a central line.
Take her to the OR.
Have blood ready to transfuse ASAP.
continue aggressive volume resuscitation in the mean time because this is hypovolemia until proven otherwise.
RSI, secure the airway and let them do their D&C if that does not work she needs a laparotomy so you might want to remind your OB to consider that.
Keep giving volume.

I've, uhhhh, HIGHLIGHTED the above because its....uhhhh

PROPHETIC.

Put Plank's response in your MEMORY BANKS,

resident colleagues.

It'll serve you well one day when you're out on your own.

Nice post, Planky.