DOI: 10.18410/jebmh/2015/632
CASE REPORT
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 30/July 27, 2015 Page 4484
ANESTHETIC MANAGEMENT OF ATONIC POST-PARTUM
HEMORRHAGE WITH HEMORRHAGIC SHOCK AND IMPENDING
CARDIAC ARREST FOR EMERGENCY PERIPARTUM HYSTERECTOMY
Ravishankar R. B1, Praveen P. V2, Shruti Hiremath3, Keerthana D. S4HOW TO CITE THIS ARTICLE:
Ravishankar R. B, Praveen P. V, Shruti Hiremath, Keerthana D. S. ”Anesthetic Management of Atonic Post-Partum Hemorrhage with Hemorrhagic Shock and Impending Cardiac Arrest for Emergency Peripartum Hysterectomy”. Journal of Evidence based Medicine and Healthcare; Volume 2, Issue 30, July 27, 2015; Page: 4484-4486, DOI: 10.18410/jebmh/2015/632
ABSTRACT: Post-partum hemorrhagic complication is a critical situation for an anesthesiologist,
which requires timely and skillful anesthetic management. A massive post-partum bleeding leading to severe hypovolemic shock may result in life threatening cardio-pulmonary arrest. Here is a case report of 25 year old with atonic post-partum hemorrhage resulting in hypovolemic shock & impending cardiac arrest and successful anesthetic management for emergency peripartum hysterectomy to save the life of the patient.
KEYWORDS: PPH, Hypovolemic shock, Cardiac Arrest, RSI, Hysterectomy.
INTRODUCTION: PPH is defined as blood loss of more than 500 ml following vaginal delivery or
more than 1000 ml following cesarean delivery. A loss of these amounts within 24 hours of delivery is termed early or primary PPH, whereas such losses are termed late or secondary PPH if they occur 24 hours after delivery.(1) The usual presentation of PPH is one of heavy vaginal bleeding that can quickly lead to signs and symptoms of hypovolemic shock. This rapid blood loss reflects the combination of high uterine blood flow and the most common cause of PPH, i.e., uterine atony.(2) Hypovolemia may lead to the scenario of cardiac arrest, which is a feared one in the labor and delivery suite; yet, the incidence is 1 in 30,000 pregnancies.(3) Circulatory arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively.(4) Resuscitation and management of obstetric hemorrhage and, possibly, hypovolemic shock and identification and management of the underlying cause(s) of the hemorrhage must be done.(5) Cardiopulmonary resuscitation (CPR) is an emergency procedure, performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest. It is indicated in those who are unresponsive with no breathing or abnormal breathing.(6) Ongoing bleeding secondary to an unresponsive and atonic uterus requires surgical intervention, i.e. vessels ligation, obstetric hysterectomy.
CASE REPORT: A 25 year old female with obstetric history of Gravida 3 Para 2 Live birth2,
presented with full term pregnancy with History of Gestational hypertension in labour. She delivered vaginally a live full term male baby at 6.45 AM.
DOI: 10.18410/jebmh/2015/632
CASE REPORT
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 30/July 27, 2015 Page 4485 minutes and T. misoprostol 1200 mg per vaginal. At around 7.55 AM PPH was not controlled and she developed drowsiness, tachycardia, hypotension, tachypnea and gynecologist planned for Emergency peripartum hysterectomy.
At 8.05 AM pre anesthetic evaluation was done, patient was drowsy, not responsive, severe pallor+++, pulse not recordable. HR-160/min, BP not recordable, SPO2- 10%. RR- 60/min. Urine output -10ml.Pt shifted immediately to OT, 2 large bore 18G IV lines secured and monitors attached. Patient premedicated with injection Glycopyrollate 0.2mg IV. Preoxygenated for 3 minutes with 100% O2. Rapid sequence induction was carried out. Injection pentazocine 30 mg IV, Injection midazolam 1 mg IV given and relaxed with Injection succinyl choline 100 mg IV. Anesthesia was maintained with O2+intermittent vecuronium and IPPV.IV fluids Ringer lactate and Normal Saline were rushed. One unit of whole blood transfusion was started. After 5 mintues of rushing blood, pulse was feeble And BP picked up to 80/46 mmHg. Heart rate comes down to 132/min. O2 Saturation improved to 100%.After 2 units of blood transfusion hemodynamic parameters was stable with HR- 120/Min. BP- 150/90 mmHg. Spo2- 100%. Urine output – 700ml. Peripartum hysterectomy was done. She had attempts and was reversed with Injection Neostigmine 1.5 mg and injection Atropine 0.6mg. After monitoring for 5 minutes on table for adequate efforts, patient was extubated after thorough oral suctioning. Patient was drowsy, maintained saturation with O2 face mask @ 5L/min and hemodynamically stable.
She was shifted to recovery room for monitoring at 9.15 AM. She was monitored for 2 hours. Her vital parameters on shifting were HR-106/min. BP- 140/90mm Hg. SPO2 – 100%. RR- 18/min.
DISCUSSION: The usual presentation of PPH is one of heavy vaginal bleeding that can quickly lead to signs and symptoms of hypovolemic shock. This rapid blood loss reflects the combination of high uterine blood flow and the most common cause of PPH, i.e., uterine atony.(2) Rapid recognition and diagnosis of PPH are essential to successful management. Resuscitative measures and the diagnosis and treatment of the underlying cause must occur quickly before sequelae of severe hypovolemia develop. The major factor in the adverse outcomes associated with severe hemorrhage is a delay in initiating appropriate management.
In our case after uneventful vaginal delivery, patient developed PPH which in initial stage was treated medically. In view of failure of these measures to control persistent bleeding and deteriorating condition of patient, decision for emergency hysterectomy was taken. Considering the hypovolemic shock we decided to take patient under general anesthesia in such a way that the drugs and techniques used to anesthetize the patient were optimally safe.(3) The pharmacological properties required of an intravenous induction agent that satisfy the aims of Rapid Sequence.
DOI: 10.18410/jebmh/2015/632
CASE REPORT
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 30/July 27, 2015 Page 4486
CONCLUSION: This case reemphasized that timely intervention at each stage of critical events with efficient and coordinated role-play of a team results in successful outcome with available resources at particular level, time and conditions.
REFERENCES:
1. Baskett TF. Complications of the third stage of labour. In: Essential Management of Obstetrical Emergencies. 3rd ed. Bristol, England: Clinical Press; 1999: 196-201.
2. American College of Obstetricians and Gynecologists. ACOG educational bulletin. Hemorrhagic shock. Number 235, April 1997 (replaces no. 82, December 1984).
4. American College of Obstetricians and Gynecologists. Int J. Gynaecol Obstet. 1997; 57(2): 219-26.
3. Chestnut DH Ed. Obstetric Anesthesia Principles and Practice Mosby-Year Book: St. Louis, Missouri, 1994.
4. Jameson, J. N. St C.; Dennis L. Kasper; Harrison, Tinsley Randolph; Braunwald, Eugene; Fauci, Anthony S.; Hauser, Stephen L; Longo, Dan L. (2005).
5. Harrison's principles of internal medicine. New York: McGraw-Hill Medical Publishing Division. ISBN 0-07- 140235-7.
6. Stainsby D, MacLennan S, Hamilton PJ. Management of massive blood loss: a template guideline. Br J Anaesth. Sep 2000; 85(3): 487-91.
4. Post Graduate, Department of Anesthesia, JJM Medical College, Davangere, Karnataka.
NAME ADDRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. Ravishankar R. B, 4798, Second Cross,
S. S. Layout, Davangere-577004, Karnataka.
E-mail: rbravi2006@gmail.com
Date of Submission: 21/07/2015. Date of Peer Review: 22/07/2015. Date of Acceptance: 24/07/2015. Date of Publishing: 27/07/2015.
AUTHORS:
1. Ravishankar R. B. 2. Praveen P. V. 3. Shruti Hiremath 4. Keerthana D. S.
PARTICULARS OF CONTRIBUTORS:
1. Professor, Department of Anesthesia, JJM Medical College, Davangere, Karnataka.
2. Post Graduate, Department of Anesthesia, JJM Medical College, Davangere, Karnataka.
