Another day in the life…
Few things in my profession are more terrifying than obstetrical hemorrhage. Every year more than 144,000 pregnant women bleed to death, even here in the U.S. Sometimes we anticipate problems; more often we have no warning.
I aged ten years one afternoon treating one such woman.
Marylou was in labor with her third child and everything was going well. Her cervix had dilated to 6cm and I thought she’d deliver in the next two hours or so. Suddenly, she said, “I can’t breathe,” and the baby’s heart rate dropped to 60 beats per minute or bpm (normal baby heart rate is 110-160 bpm). Her cervix was completely dilated but the baby wasn’t looking any better and too high in the birth canal to deliver with forceps, so we took her to the operating room.
The baby came out screaming and we were all relieved…for the moment. We closed the uterus but the suture line slowly oozed blood. The bleeding seemed to improve after a few minutes, so we finished. We noticed a little bit of blood around the staples that closed her skin, but it wasn’t unusual. The nurse pushed on her uterus to expel any remaining blood before taking Marylou to the recovery room. Everything seemed fine.
Blood started gushing from Marylou’s vagina about 30 minutes later and it wasn’t clotting. I ordered another four units of blood—we had two units already waiting from before surgery—while her nurse started a second IV. We then wheeled her to the Intensive Care Unit (ICU) and called one of the critical care specialists.
The specialist was a man of few words who, until that day, wasn’t known for anxiety under pressure. When he pulled the sheet off Marylou, blood was visibly welling up between her thighs. His eyes widened as he quietly said, “We need more blood.” That’s when we knew Marylou was in trouble.
I ran to the blood bank and came back with four units, but her blood was pouring out as fast as we replaced it. I was starting to worry she might bleed to death and took her back to the operating room. I asked a physician on the unit, who had also been my senior resident in training, for help. We tried packing her vagina with laparotomy sponges, but the blood soaked through them and ran onto the floor. He looked at me and said, “I think it’s time to give up and take it out.” We quickly prepared her for surgery.
One of the hospital’s hematologists brought a portable refrigerator to the operating room and directed the transfusion while we took her uterus out. We emptied the hospital blood bank of Marylou’s blood type; then we emptied out the local Red Cross. By the time Marylou was stable and out of danger, she’d received 30 units of blood and several liters of IV fluids.
Marylou suffered from the “anaphylactic syndrome of pregnancy,” something we used to call an “amniotic fluid embolism.” Baby’s skin cells and amniotic fluid get into the mother’s circulation, causing a severe reaction in a small number of women, much like that in someone with an allergy to penicillin, peanuts or bee stings. The afflicted patient has trouble breathing and her blood pressure can fall low enough to put her into shock.
Marylou’s blood wouldn’t clot because the reaction used up most of the blood’s clotting factors, creating a potentially fatal complication called disseminated intravascular coagulation (DIC). Red blood cell packs lack those clotting factors, so we need to transfuse other blood products—fresh frozen plasma, cryoprecipitate and platelets—to treat massive hemorrhage. Since then hospitals have developed transfusion protocols based on the military’s battlefield experience.
The survival statistics for amniotic fluid embolism have never been good. One hundred percent of women with an amniotic fluid embolism who aren’t treated die; up to seventy percent die in spite of treatment. Sometimes babies have been delivered by Cesarean section after the mother has gone into cardiac arrest and died.
Marylou woke up in the ICU four days later and asked me, “Did I scare you?”
More than you will ever know.
Image:© Can Stock Photo Inc. / Frankljunior
Your awesome Dave.i always knew I was in good hands
Marylou was lucky and lucky to have you. I have seen this with devastating neurological results for the women that did survive. I worked in Blodgett’s NICU when you were a resident David. Have now moved on to other NICU’s. Good work.