Timing of events, clinical and laboratory assessments, and corresponding actions
| Time . | Assessment . | Laboratory and TEG results . | Action . |
|---|---|---|---|
| 18.40 | Pain increasing, contractions every 5 min, cervix distended with blood clot | Hb, 93 g/L, Platelets, 227 × 109/L | Blood loss measured by weighing sanitary towels and sheets = 900 mL |
| 19.20 | Blood loss ongoing, uterus hard, tender and contracting | MOH declared and plans made for emergency caesarean delivery | |
| 19.50 | General anesthetic given, transfusion started with emergency group O-negative red cells | ||
| 20.07 | Stillborn baby delivered, unresponsive to resuscitation | ||
| 20.08 | The uterus contained 800 mL of clot, the majority being behind the placenta, confirming placental abruption in addition to the placenta previa | Manual delivery of placenta and membranes undertaken with prophylactic antibiotics Uterotonics administered: 2 × 5 IU bolus doses of syntocinon (oxytocin), 5 min apart followed by an intravenous syntocinon infusion Blood sample sent for PT, APTT, and fibrinogen | |
| 20.15 | Ongoing active bleeding from lower uterine segment | TXA Ig IV over 10 min | |
| 20.20 | 4 units compatible packed red cells arrive in theater | Transfusion commenced immediately | |
| 20.33 | TEG (Figure 1) showed prolonged r and k times indicating depletion of clotting factors, and significantly reduced maximum amplitude indicating diminished clot strength | Hb, 80 g/L by HemoCue R time: 10.1 min, K time: 11.8 min, α angle: 24.6°, maximum amplitude: 21.3 mm Platelets: 168 × 109/L, Hb: 80 g/L, Fibrinogen: 0.2, INR: 3.1, PT: 32 s, APTT: 69.9 s, APTT ratio: 2.3 (although these results were not available until later) | MHP2 requested to contain 4 pools cryoprecipitate, 1 adult dose platelets, 4 units FFP, further 4 units red cells |
| 20.40 | Bleeding continuing | Bakri balloon placed in the uterus via the uterine incision and filling port fed down through the cervix and vagina. Uterus closed in 2 layers and the balloon inflated with 450 mL of saline | |
| 20.45 | Continued constant active bleeding from all surfaces, indicating worsening coagulopathy | Multiple measures taken to arrest the bleeding; local pressure to the uterine surface, diathermy to larger vessels and Surgicel, an absorbable oxidized cellulose polymer, was applied to the bladder base, with closure of the visceral peritoneum in order to create a tamponade effect. Additional uterotonics administered by way of 2 doses of Carboprost 250 mcg 15 min apart Further 1g IV TXA administered over 10 min | |
| 21.15 | MHP 2 arrives in theater | Two 5-U pools of cryoprecipitate, 1 platelet pool, and 3 units of FFP transfused | |
| 21.35 | TEG (Figure 2) showed slight improvement in the coagulopathy, determined by the R and K times MA still low | R time: 9.1 min, K time: 6.8 min, α angle: 19.1°, maximum amplitude: 29.8 mm | Further two 5-U pools of cryoprecipitate transfused |
| 22.00 | Laboratory results available from 20.30 sample, showing fibrinogen had been severely reduced at 0.2 g/L. Hb was 80 g/L, platelets: 168 × 109/L, and PT and APTT prolonged to 3.1 and 2.3× normal, respectively | ||
| 22.30 | Bleeding continuing but rate slowing | Further two 5-U pools of cryoprecipitate, 3 units of FFP and 1 adult platelet pool transfused | |
| 22.56 | TEG (Figure 3) demonstrated correction of coagulopathy | R time: 5.6 min, K time: 1.7 min, α angle: 50.8°, maximum amplitude: 40.2 mm | Cell salvaged blood was processed 195 mL transfused |
| 23.45 | No further bleeding. Laboratory results showed Hb of 108 g/L, platelets 96 × 109/L and a corrected coagulopathy (PT ratio: 15.2 s, APTT ratio: 1.1) | Transferred to ITU, kept sedated and ventilated | |
| Day 2 | Hb dropped again to 81 g/L Vaginal pack soaked and Bakri balloon prolapsing into the vagina | 2 units of packed red cells Bakri balloon and vaginal pack were repositioned. Interventional radiology assistance sought | |
| 3-cm clot present at the uterine fundus | Embolization of the uterine arteries performed via a femoral catheter | ||
| Day 3 | No bleeding | Extubated and commenced on thromboprophylaxis with LMWH | |
| Day 5 | Good recovery | Discharged on oral iron for 4 mo Follow-up arranged for debriefing, counseling, and discussion about future pregnancies |
| Time . | Assessment . | Laboratory and TEG results . | Action . |
|---|---|---|---|
| 18.40 | Pain increasing, contractions every 5 min, cervix distended with blood clot | Hb, 93 g/L, Platelets, 227 × 109/L | Blood loss measured by weighing sanitary towels and sheets = 900 mL |
| 19.20 | Blood loss ongoing, uterus hard, tender and contracting | MOH declared and plans made for emergency caesarean delivery | |
| 19.50 | General anesthetic given, transfusion started with emergency group O-negative red cells | ||
| 20.07 | Stillborn baby delivered, unresponsive to resuscitation | ||
| 20.08 | The uterus contained 800 mL of clot, the majority being behind the placenta, confirming placental abruption in addition to the placenta previa | Manual delivery of placenta and membranes undertaken with prophylactic antibiotics Uterotonics administered: 2 × 5 IU bolus doses of syntocinon (oxytocin), 5 min apart followed by an intravenous syntocinon infusion Blood sample sent for PT, APTT, and fibrinogen | |
| 20.15 | Ongoing active bleeding from lower uterine segment | TXA Ig IV over 10 min | |
| 20.20 | 4 units compatible packed red cells arrive in theater | Transfusion commenced immediately | |
| 20.33 | TEG (Figure 1) showed prolonged r and k times indicating depletion of clotting factors, and significantly reduced maximum amplitude indicating diminished clot strength | Hb, 80 g/L by HemoCue R time: 10.1 min, K time: 11.8 min, α angle: 24.6°, maximum amplitude: 21.3 mm Platelets: 168 × 109/L, Hb: 80 g/L, Fibrinogen: 0.2, INR: 3.1, PT: 32 s, APTT: 69.9 s, APTT ratio: 2.3 (although these results were not available until later) | MHP2 requested to contain 4 pools cryoprecipitate, 1 adult dose platelets, 4 units FFP, further 4 units red cells |
| 20.40 | Bleeding continuing | Bakri balloon placed in the uterus via the uterine incision and filling port fed down through the cervix and vagina. Uterus closed in 2 layers and the balloon inflated with 450 mL of saline | |
| 20.45 | Continued constant active bleeding from all surfaces, indicating worsening coagulopathy | Multiple measures taken to arrest the bleeding; local pressure to the uterine surface, diathermy to larger vessels and Surgicel, an absorbable oxidized cellulose polymer, was applied to the bladder base, with closure of the visceral peritoneum in order to create a tamponade effect. Additional uterotonics administered by way of 2 doses of Carboprost 250 mcg 15 min apart Further 1g IV TXA administered over 10 min | |
| 21.15 | MHP 2 arrives in theater | Two 5-U pools of cryoprecipitate, 1 platelet pool, and 3 units of FFP transfused | |
| 21.35 | TEG (Figure 2) showed slight improvement in the coagulopathy, determined by the R and K times MA still low | R time: 9.1 min, K time: 6.8 min, α angle: 19.1°, maximum amplitude: 29.8 mm | Further two 5-U pools of cryoprecipitate transfused |
| 22.00 | Laboratory results available from 20.30 sample, showing fibrinogen had been severely reduced at 0.2 g/L. Hb was 80 g/L, platelets: 168 × 109/L, and PT and APTT prolonged to 3.1 and 2.3× normal, respectively | ||
| 22.30 | Bleeding continuing but rate slowing | Further two 5-U pools of cryoprecipitate, 3 units of FFP and 1 adult platelet pool transfused | |
| 22.56 | TEG (Figure 3) demonstrated correction of coagulopathy | R time: 5.6 min, K time: 1.7 min, α angle: 50.8°, maximum amplitude: 40.2 mm | Cell salvaged blood was processed 195 mL transfused |
| 23.45 | No further bleeding. Laboratory results showed Hb of 108 g/L, platelets 96 × 109/L and a corrected coagulopathy (PT ratio: 15.2 s, APTT ratio: 1.1) | Transferred to ITU, kept sedated and ventilated | |
| Day 2 | Hb dropped again to 81 g/L Vaginal pack soaked and Bakri balloon prolapsing into the vagina | 2 units of packed red cells Bakri balloon and vaginal pack were repositioned. Interventional radiology assistance sought | |
| 3-cm clot present at the uterine fundus | Embolization of the uterine arteries performed via a femoral catheter | ||
| Day 3 | No bleeding | Extubated and commenced on thromboprophylaxis with LMWH | |
| Day 5 | Good recovery | Discharged on oral iron for 4 mo Follow-up arranged for debriefing, counseling, and discussion about future pregnancies |
APTT, activated partial thromboplastin time; FFP, fresh frozen plasma; ITU, intensive care unit; MHP, major hemorrhage blood component packs; PT, prothrombin time; TEG, thromboelastography; TXA, tranexamic acid.