A 12 Litre Post-Partum Haemorrhage
Phillips D.P.*
Obstetrics & Gynaecology Resident, DRANZCOG Candidate*
Centenary Hospital for Women and Children, Canberra, ACT, AUSTRALIA
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Introduction – What is a Post-partum haemorrhage (PPH)?
PPH is a complication following childbirth where heavy bleeding results in symptomatic hypovolaemia. Traditionally defined as blood loss >500ml post-vaginal delivery or
>1000ml post-caesarean section. While most are minor it remains a leading cause of maternal morbidity and mortality in Australia. There are four causes, known as the
four Ts of; Tone (uterine atony), Trauma (genital tract trauma), Tissue (retained products of conception) & Thrombin (coagulation abnormalities).
The following is a Case Report of a female who sustained a life threatening PPH due to genital tract trauma:
Presenting Complaint
A 35 year old primip presented at 39/40 for a planned induction of labour due to
pregnancy induced hypertension & diet-controlled gestational diabetes mellitus.
Background
She had a multinodular goitre, hypothyroidism in pregnancy and query βthalassemia trait. Her antenatal period was unremarkable with O+ ve blood, -ve
serology, normal 20 and 32 week ultrasounds with an anterior placenta and
normal growth parameters. Her pre-induction BP was 140/92, with Hb 133,
Platelets 196, Urate 374, eGFR >90, LFTs normal and UPC of 42.
Labour Progression
As her cervix was 1cm long and 1 cm dilated she was given prostin and had SROM
with first stage labour lasting 5½ hours. Due to no progress after 2 hours in second
stage labour a forceps (NBF) delivery with episiotomy was performed under spinal
anaesthesia. She sustained deep bilateral vaginal gutter tears and 3c perineal tear.
PPH Management
Her uterus was confirmed empty, she was given oxytocin and attempts were
made to repair her tears. She continued to bleed profusely and
decompensated. Obstetricians continued to repair her perineum, placed a Bakri
balloon, and applied vaginal packing. Concurrently Anaesthetists converted her
to general anaesthesia, placed central and arterial lines and gave her 21 units
packed RBCs, 11 units FFP, 20 units cryoprecipitate, 2 units platelets, 2 units
albumin, 5L normal saline and 2L Plasmalyte. In addition, ergometrine,
tranexamic acid, IV antibiotics and a metaraminol infusion were given. Est. total
blood loss 12L. She remained stable thereafter, was extubated in ICU and
discharged on day 9.
Discussion
This patient’s PPH was due to extensive genital tract trauma from a Forceps
delivery complicated by significant perineal oedema from prolonged nonprogressing second stage labour. As her haemorrhaging continued,
consumptive coagulopathy also occurred. Early Senior Obstetrics and
Anaesthetics team support enabled rapid effective resuscitation to occur.
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