Post Partum Haemorrhage Case History

History
Introduction

34 year old mother P3C2 Uncomplicated pregnancies POA:- 39/52 +6/365 DOA:- 9:7:2012 Admitted as requested for confinement On addmission she had on and off mild lower abdominal pain,other than that she had no other symptoms of labour

T 1 :- Mumps at 12/52 T 2 :- Uneventful T 3 :- USS done and Placenta praevia excluded.Posterior fundal placenta. Generalised body itching-S.Bile acids marginally elevated.

Past Obs History P1:- NVD Baby girl B.W-3.2kg p2:- NVD Baby boy B.W-3.6kg Uncomplicated pregnancies PMH } Not significant PSH } Not significant FH } Not significant

Examination
General examination Not pale CVS:- HR-88/min BP-100/70mmHg DR no murmurs RS :- B/L VB ABD :- SFH=40cm CP HNE FHS good VE :- os-2cm 20% effaced High head

10:7:2012
Mother was seen by VOG Clinically Polyhydramnios Decision taken to induce the labour on following day. PG pessary inserted in the night.

11:7:2012 LR
5.30am :Mother was sent to LR On and off severe abdominal pain VE :- OS-4.5 cm 90% effaced station -1 ARM done Syntocinon 2U into NS drip started Mother delivered a baby girl of 3.6kg Active management of third stage done Immediately following delivery mother started to bleed PR:-80/min BP:-100/70mmHg uterus not hard.

9.20am :-

Management 2 widebore cannulae 40 units IV Syntocinon drip Hartmans 1 pint IV Ergometrine 0.5mg Uterine massage Blood was sent for DT

10.25am :- Sweating,Pallor,Peripheries cold Pulse low volume,thready BP:-80/50 mmHg

VOG opinion :- Mother sent to MOT for surgical management

At the Casualty Theatre

10.30am :- Patient was brought to the casualty theatre Conscious,sweating, pale,peripheries cold Pulse:- feeble,thready BP:Unrecordable Induction :- Rapid sequence induction Ketamine :-80mg Suxamethonium:-100mg ETT:-7.5mm cuffed, Lip level 22cm

Maintenance :- 50% Oxygen Isoflurane 0.5 IPPV via circle circuit Monitoring :-ECG,HR,NIBP,SPO2,ETCO2 UOP,Blood loss

10.30
HR NIBP 130 _

11.00
135 58/40

11.30
129

12.00
139

12.30
120

1.00
115

1.30
112 120/7 4

_ 60/40 Ephed rine 15mg <80% _ 98% _

115/6 100/6 5 0 Morph ine6m g 99% _ 99% _

SPO2 UOP Blood loss Maintenance others

<80% _

96% _

98% _

Inputs

2UCB 2CB

1CB 1FFP 1PLT

1CB 1FFP 1PLT

1CB 1FFP 1PLT

1CB 1FFP 1PLT

1CB Cryo

Surgical Management
Bukri Tamponade Balloon tried and failed Ultimately TAH done Acute bleeding arrested Patient sent to SICU for further management and monitoring for complications Ventilated for 24 hours and following day extubated

DIAGNOSIS
Primary PPH due to uterine atony, lower uterine and upper cervical tears.

Immediate Post-op Ix

VBG PH-7.07 PCO2-63 mmHg PO2- 30mmHg HCO3- 16.3 BE-15.1 K 6.6 Na-143 APTT-37.1S INR- 2 Hb- 11.3 WBC-22500 PLT- 154000 Plasma fibrinogen -150mg/dl(150-350) D-dimers-positive

SICU Management
11/7 Hb(g/dl) 11.3 12/7 9.4 13/7 9.4 14/7 9.5 15/7 9.6 16/7 9.6

WBC
PLT BU/SC Na/K SGOT/SGPT UOP(ml/kg/hr)

12900
63ooo 4.6/94 143/6.6

13500
55ooo 14/211 145/4.5 57.3/19

13100
69ooo 22.4/29 5 140/4.4 45/24 1.2 20mg 8H

10600
95000 22.4/42 5 136/4.2 123000 30.3 138/5.4 158000 36.6/523

Frusemide

0.4 5mg/hr

0.81

0.92

1.5

1.7

Special problems

Renal functions derangement

Low Hb -4 pints blood FFP-4,PLT-4 Cryo-800IU Blurring of vision,gidiness-CT Brain Neurology refferal done-no papilloedema

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