UBP 2.1 (Long Form): Obstetrics – Massive Blood Loss Flashcards
Secondary Subject -- DIC/Jehovah’s Witness/Preoperative Neuropathy/Regional Anesthesia for Labor/ Unintentional Needle Stick/Pulmonary Edema
Intra-operative Management:
The baby is delivered vaginally, and there is an abnormal amount of bleeding.
The obstetrician suspects a uterine tear and wishes to go to the OR.
On the way, the patient loses in excess of 1,500 ml of visible blood and, to make matters worse, her IV is lost during transfer to the OR bed.
Moreover, you are unable to place a peripheral line.
What are you going to do?
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
I would immediately apply oxygen, place monitors, and attempt to place a central line.
If placement of the central line proved difficult, I would call for a surgeon capable of performing a cut down for intravenous access and/or attempt to place an interosseous line.
The interosseous line would provide access for drug administration and intravenous volume expansion while alternative intravenous access was obtained.
At the same time, I would call for help to arrange for volume expanders, prepare emergency drugs, and set up for intraoperative blood salvaging if the patient had originally agreed to this procedure.
Intra-operative Management:
Describe how you would place an intraosseous line.
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
In placing this line, I would insert an interosseous needle into the tibia at a 10-15º caudal angulation (to avoid the epiphyseal plate), at a location that is 1-2 cm below and 1 cm medial to the tibial tuberosity.
I would then advance the needle until I felt a “pop” or reduced resistance and confirm placement with the aspiration of bone marrow.
Finally, I would ensure that fluids flowed freely through the line without signs of extravasation.
Intra-operative Management:
What are some of the complications associated with intraosseous access?
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
Some of the complications associated with intraosseous access include:
- compartment syndrome (extravasation);
- muscle necrosis (extravasation of caustic or hypertonic medications, such as bicarbonate, calcium chloride, and dopamine);
- osteomyelitis;
- bacteremia;
- cellulitis; and
- growth plate injury (a concern with placement in pediatric patients).
Intra-operative Management:
After a couple of attempts, a central line is placed in the right internal jugular vein.
Would you place a pulmonary artery catheter and/or an arterial line?
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
I would certainly consider placing an arterial line and a pulmonary artery catheter, but I would not delay the case to do so, since immediate surgical intervention is critically important to stop the continued blood loss.
Given the amount of visible blood loss, the fact that there may be significant blood loss that is not visible, and because her religious faith prevents me from administering blood products, she may become extremely anemic before hemostasis is achieved.
And, although she is young and presumably healthy, the beat-to-beat blood pressure measurement provided by an arterial line may aid in intraoperative optimization of this patient who is at risk of developing life-threatening anemia during this difficult case.
While a pulmonary arterial catheter may also provide helpful information, such as cardiac output and peripheral vascular resistance, I would avoid placement unless absolutely necessary given the increased risk of pulmonary artery rupture in this patient who’s preeclampsia, exposure to amniotic fluid, and significant blood loss place her at increased risk of developing a coagulopathy (i.e. DIC).
Intra-operative Management:
How will you provide anesthesia?
- (See previous flashcard notes)*
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
Given her questionable intravascular status secondary to hemorrhage, I would prepare for a general anesthetic, recognizing that this places the patient at risk for aspiration, hemodynamic instability, and loss of airway (airway management is a concern due to her obesity, the physiologic changes that occur in pregnancy, and the edematous airway often associated with preeclampsia).
Therefore, in order to minimize these risks, I would –
- provide fluid resuscitation,
- administer a nonparticulate antacid,
- place the patient in the reverse trendelenburg position, and
- move the difficult airway cart in the room.
Finally, assuming her airway exam were reassuring (despite her obesity, pregnancy, and preeclampsia), I would apply cricoid pressure and perform a RSI using etomidate (to reduce the risk of hypotension).
Intra-operative Management:
Assume that the patient’s blood pressure is now 88/63 mmHg. Would you still perform a RSI?
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
Since her substantial loss of blood has potentially resulted in significant hypovolemia and anemia, my goal in inducing this patient would be –
- to treat her hypotension,
- avoid any further reductions in blood pressure, and
- safely secure her airway, while avoiding hypoxia and aspiration.
Therefore, I would not perform a RSI, which carries the risk of further hemodynamic instability (secondary to the administration of a large bolus of induction drug to rapidly obtain optimum intubating conditions).
I would, instead, administer fluids and phenylephrine to treat her hypotension, and perform a controlled induction using etomidate.
Since this method of induction may increase this obese and pregnant patient’s risk of aspiration, I would ensure the presence of difficult airway equipment (rapidly securing the airway is the best way to prevent aspiration), administer a nonparticulate antacid, place the patient in the sniff position to facilitate rapid intubation (the head-up position would now be less desirable due to the risk of worsening hypotension following a gravity-induced reduction in venous return to the heart), and apply cricoid pressure prior to inducing the patient.
Intra-operative Management:
The surgeons discover a uterine tear that extends beyond the old cesarean section scar, and bleeding continues as they struggle to achieve surgical hemostasis.
The patient is tachycardic and her hemoglobin is now 4.8 mg/dL.
What will you do? Will you give blood to this patient?
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
I would –
- inform the surgeon of her critically low hemoglobin,
- deliver 100% oxygen,
- ensure adequate volume replacement, and
- institute intraoperative blood salvage if she had previously allowed it (if not already in place).
I would not give any blood products or institute any procedures (such as intraoperative blood salvage) that she had not previously allowed as this would be unethical.
A patient has a legal right to decide to forego “clinically necessary” treatment if the patient is judged to be competent.
Physicians who have ignored this have suffered the legal consequences despite their good intentions.
Intra-operative Management:
You notice that the patient’s neck begins to swell where you previously attempted to place the central line in the internal jugular vein. What do you think?
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
Given the presence of several predisposing factors to the development of DIC, I would be concerned that this is the cause of renewed bleeding at the attempted central line site.
Her predisposing factors include:
- uterine rupture extending beyond the old scar (little to no vasculature within the old scar) with exposure of the vasculature to amniotic fluid rich in procoagulant thromboplastins that can lead to DIC;
- hypovolemia and subsequent low pressures which further increase the risk of amniotic fluid entering the intravascular system and make her less able to “wash out” the accumulation of intravascular coagulation factors; and
- the extensive vascular endothelial damage that occurs with preeclampsia which further predisposes her to DIC.
Intra-operative Management:
What is DIC?
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
Disseminated intravascular coagulation is a pathological activation of the coagulation cascade associated with a number of conditions (eg. burn, head trauma, preeclampsia, etc.).
Wide spread formation of small clots in blood vessels throughout the body results in consumption of coagulation factors, thrombocytopenia, hemolytic anemia, diffuse bleeding, and thromboembolic phenomena.
Intra-operative Management:
What lab work would confirm the diagnosis of DIC?
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
Lab work that supports the diagnosis of DIC includes –
- increased PT and PTT,
- decreased fibrinogen to < 100 mg/dL,
- thrombocytopenia,
- decreased antithrombin III levels, and
- the presence of fibrin degradation products (FDPs) and D-dimer.
Intra-operative Management:
Let’s assume for the rest of this discussion that she has no objections to blood products and you receive her most recent lab work. The PT and PTT are elevated, her fibrinogen level is 22 mg/dL, and her platelet level is 45,000. What will you do?
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
This lab work supports the diagnosis of DIC.
In addition to treating hypovolemia, low blood pressure, hypoxemia, or acidosis, all of which can contribute to and exacerbate DIC, I would begin administering cryoprecipitate, FFP, platelets, and PRBCs.
While cryoprecipitate is not always indicated, the relatively higher concentration of fibrinogen in cryoprecipitate is beneficial when severe drops in fibrinogen levels to < 50 mg/dL occur.
Post-operative Management:
The resident working with you left one of the hollow point needles used when attempting to obtain IV access on the anesthetic table. While cleaning the table you stick yourself. What should you do?
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
I should immediately wash the wound with soap and water.
Since all blood or bodily fluids should be treated as potentially dangerous, I would then report the incident to employee health to initiate post-exposure prophylaxis and testing to rule out HIV, HBV, HCV, and other possible blood-borne diseases.
It would also be helpful to obtain the patient’s consent to draw additional blood so she could be tested for the presence of blood-borne disease.
Post-operative Management:
You visit the patient a few hours later. She is breathing easily, but her CXR is showing pulmonary edema. What do you think is the etiology of her pulmonary edema?
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
Given the significant volume resuscitation that likely occurred following her massive blood loss and severe anemia, her pulmonary edema is most likely a form of cardiogenic pulmonary edema resulting secondary to volume overload (i.e. crystalloids, colloids, or transfusion-associated circulatory overload (aka TACO)).
The increased pulmonary blood flow that occurs with severe anemia and/or fluid overload can raise pulmonary capillary pressures to a point where pulmonary edema occurs.
A likely contributory factor in this case, is the increased pulmonary capillary permeability associated with preeclampsia (a form of noncardiogenic pumonary edema).
Other possibilities would include the development of acute respiratory distress syndrome (ARDS), which is sometimes associated with massive blood transfusion (assuming blood was administered) and low-perfusion states, or transfusion related acute lung injury (TRALI), which may occur following the administration of blood products (again, assuming blood were administered).
Post-operative Management:
What is transfusion related acute lung injury (TRALI)?
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
This is noncardiogenic pulmonary edema that may occur within 1-6 hours following the transfusion of any blood component, but more frequently following the administration of plasma-containing products, such as fresh frozen plasma (FFP) and platelets.
The signs and symptoms, including frothy pulmonary secretions, fever, tachycardia, dyspnea, cyanosis, chills, noncardiogenic pulmonary edema, and hypotension, are clinically indistinguishable from ARDS (acute respiratory distress syndrome), but the mortality rate is significantly lower for TRALI, at around 5-10%.
The diagnostic criteria for TRALI includes:
- acute onset of hypoxemia
- (PaO2/FiO2 < 300,
- SpO2 < 90%, or
- other clinical evidence of hypoxemia) and
- pulmonary edema (bilateral chest infiltrates on CXR) within 6 hours of transfusion,
- in the absence of cardiac failure or fluid overload (i.e. a pulmonary artery occlusion pressure = 18).
Treatment is supportive (similar to ARDS) and most patients recover within 96 hours (the use of diuretics and steroids has NOT been proven to be beneficial).
Post-operative Management:
What is the pathophysiology of TRALI?
- (A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural and wants to talk to you about options for pain control.*
- HPI: The patient is 37 weeks pregnant and has complained of a swelling in her ankles and hands for the past week. The FHR tracing is reassuring. Her pressures have been elevated and she is currently receiving magnesium and lasix.*
- PMH: The patient is a Jehovah Witness and says she will not accept blood no matter what the consequences. She is also a type II diabetic whose blood sugar is currently controlled with diet and has smoked 1 pack of cigarettes per day for the past 15 years. Previous pregnancies have been complicated by pre-eclampsia during her 1st and 2nd pregnancy, prolonged weakness and loss of sensation following the epidural she received for her fourth vaginal delivery, and a prolonged decrease in FHR secondary to cord compression with her last pregnancy resulting in an emergency C/S.*
- PE: Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC*
- Airway: Mallampati I*
- CV: RRR*
- Lungs: CTA Bilaterally*
- General: Edema of the face and extremities noted*
- Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein)*
While the pathophysiology is not fully understood,
it is believed that the transmission of donor leukocyte antibodies during the transfusion of blood products (especially plasma-rich blood products) leads to the activation of neutrophils on the pulmonary vascular endothelium.
The subsequent release of activating factors lead to endothelial damage, capillary leakage, and acute lung injury.
