Carol Asks: A woman has a baby in a major US city. Right now I've got her basically bleeding to death when they can't stop post partum hemorrage. I don't know why she's hemorraging [and in the text I've left it at 'we can't stop the bleeding'] and the doc takes her to have a hysterectomy [which her hubby is told will take a couple hours?]. She then dies in surgery. I've left it pretty vague because I can't find any stats or anything. I'm glad in one sense because that means it doesn't happen very often, but doesn't help me with research.
Do you have any suggestions? Or if I leave it vague [it's his memory - it's gonna be blurry at best] is that good enough?
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1. Uterine atony: After a child is delivered, the uterus should contract down to "clamp off" all the blood vessels that are bleeding. This is what the OB nurse is checking for after delivery. The uterus should feel "hard as a rock". If it doesn't, it may feel boggy (mushy), and the OB nurse will massage it to get it to firm up. If the uterus won't firm up, clamp down on those blood vessels, the patient will continue to bleed.
http://www.uptodate.com/contents/overview-of-postpartum-hemorrhage
2. Other causes: Retained placental tissue (where parts of the placenta stay inside the uterus), laceration of tissues or blood vessels in the pelvis and genital tract (a laceration would be a cut), and maternal coagulopathies (some sort of bleeding disorder in the mother where the blood is unable to clot). An additional, though uncommon, cause is inversion of the uterus during placental delivery (this is where the uterus would be turned inside out).
This is a good overview:
http://emedicine.medscape.com/article/796785-overview
Photo from: http://blog.timesunion.com/parenting/1626/the-line-on-your-pregnant-belly-will-go-away-%E2%80%94-eventually/
Hope this is helpful. What suggestions do you have for Carol? We'll have to see if Heidi is able to weigh in!
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Great post! Love the picture of the footprint. So cute.
ReplyDeleteJust to clarify, uterine atony happens when the muscles of the uterus basically get tired and worn out so they won't contract...can happen most commonly when labor has been long or the mom has recieved lots of pitocin to supplement labor. The pitocin causes the uterus to strongly contract. The treatments are uterine massage--just stimulating the uterus can cause it to contract and the bleeding stops or giving pitocin or methergine. If that doesn't work, the life saving choice is an immediate hysterectomy which is more difficult because the tissue is so engorged from pregnancy, everything bleeds. You end up with bleeding on top of bleeding. Very difficult position for a doctor to be in, but really the only choice to save the life of the mother.
ReplyDeleteCoagulopathy issues like DIC can occur with instances of large amts of blood loss. All the bodies clotting factors get "used up" trying to stop the bleeding and the patient begins to bleed from everywhere--IV sticks, the incision, everywhere. It is life threatening and the treatment is to infuse clotting factors which normally have to be gotten from a large blood bank or whole blood which is rare these days (most blood is broken down into the different products to make it go further).
Retained placental fragment is often seen later--usually it is small, the uterus fills up with clots from a slow bleed and then the clots are expelled at some point, and the process starts all over. Sometimes, surgery is needed to removed the fragment (a D&C) and sometimes methergine can be given by mouth and the uterus contracts (like really hard menstrual cramps) and expells the fragment.
If the woman has been in labor a long time or is a multip (has had multiple pregnancys and births), a uterine tear is possible. Basically, the uterus that has thinned out from the process of labor, tears open and that is a true emergency and life threatening. There is a HUGE blood supply to the uterus and it is a short time until the woman can bleed out from a tear.
I have seen an inversion of the uterus but a lot of times it has to do with maternal health. I saw it in Honduras where prenatal care is not great. If you need the woman to bleed and die in the OR, uterine atony or a uterine tear are your most likely scenarios.
I am a CRNA with over 30 years experience in OB from the OR side as well as doing labor epidurals. If I can answer questions, I'd be glad to.
Kim,
ReplyDeleteThanks so much for stopping by and adding your expertise. Great info!!
I agree with Kim, I'd say the KISS answer is a complete uterine rupture. There could also be complications with aorta spliting-that's not at all pretty when that happens, but it's a quick kill if you want your patient to bleed to death. Aortic dissections can be done when the patient is still pregnant (albeit don't call me, I'm staying home that day), sometimes condition is not caught and wa-la along with your uterine rupture, aortic tear/rupture=(most of the time) sudden death.
ReplyDeleteIf you want any more info on it I'd be glad to share what I know, what I've experienced, I've never googled it but I'm sure it's online too. Hope this helps
Heidi