Mortality and

Morbidity
FEBRUARY 28, 2020
GENERAL DATA

 IK
 31 year old female
 Chief complaint: labor pains
 G2P1 (1001) Pregnancy Uterine 35 4/7 Weeks
AOG, cephalic in preterm labor, placenta
previa without hemorrhage, to consider
placenta accreta
Past Medical History

 S/P 1* LTCS (2018) for cephalopelvic disproportion

under SAB
 (-) Hypertension
 (-) DM
 (-) Bronchial Asthma
 (-) Food and drug allergies
 Preoperative Course

Dexamethasone -
Dexamethasone Persistence of
fetal lung - Persistence
Presented with
Presented with fetal maturity
lung maturity uterine of
uterine
preterm
preterm Nifedipine, contractions ----
Nifedipine, contractions ----
contractions
contractions Terbutaline, REFERRAL FOR
STAT CESAREAN
Terbutaline,
Magnesium sulfate STATSECTION
CESAREAN
Magnesium
- tocolysis SECTION
sulfate - tocolysis
PHYSICAL EXAMINATION

 BP 120/80 || HR 80s || RR 18
 Awake, not in cardiopulmonary distress
 Anicteric sclerae, pinkish conjunctiva
 Symmetrical chest expansion with clear breath sounds
 Adynamic precordium with normal rate and rhythm
with no murmurs
 Abdomen gravid, uterine contractions every 2-3
minutes
 Peripheral pulses 2+, capillary refill time <2 seconds
Preoperative Labs
CBC Pre-Op Chemistry Pre-Op
Hemoglobin 133 Sodium 136.1
Hematocrit 0.40 Potassium 3.86
RBC 4.20 Creatinine 0.45
WBC 10.8 Protime 10 secs
Platelet 177 % Activity 91.5%
INR 1.09
OPERATIVE PLAN

 Planned Procedure: Cesarean Section, Classical Approach,

Possible Hysterectomy
 Planned Anesthesia: Subarachnoid Block
 Preoperative Preparation:
 3 units of blood
 2 large bore peripheral IV access
 Ranitidine 50 mg slow IV
 Metoclopramide 10 mg slow IV
 BASELINES: BP 120/80 HR 80s RR 18 O2Sat
100%
Estimated Blood Volume (65 kg): 4225 mL
1 u blood available; donor standby for addn 2
Induction: Subarachnoid Block: Lumbar Puncture at L3-
L4 interspace with G. 25 spinal needle: Bupivacaine
0.5% Heavy 20 mg + Morphine 0.2 mg. Block level at T4
Induction of General Anesthesia:
Midazolam 5 mg IV  Ketamine 50 mg
IV  Succinylcholine 90 mg IV  Direct
Laryngoscopy ETT size 7.0 cuffed level
21  Sevoflurane + O2
OPERATIVE SUMMARY

 Operation Done: Classical Cesarean Section,

Hysterectomy, Bilateral Salpingectomy,
Cystorraphy
 Total Operation Time: 3 hours 45 minutes
 Total Blood Loss: 6 liters
 Total Fluids Infused:
 Crystalloids: 4 liters
 Colloids: 3.5 liters
 Blood: 3 units
CBC Pre-Op Immediate
Post Op
Hemoglobin 133 78
Hematocrit 0.40 0.24
ABG Immediately
RBC 4.20 2.44
Post-Op
WBC 10.8 13.9 pH 7.03
Platelet 177 104 PCO2 26
PO2 129
Chemistry Pre-Op Immediate
HCO3 10.9
Post Op
BE -15.1
Sodium 136.1 149.4
Oxygen 98% (at 100% FiO2
Potassium 3.86 4.32 Saturatio with RR of 20)
Creatinine 0.45 0.41 n
Protime 10 secs 15.6 secs
% Activity 91.5% 35%
INR 1.09 1.85
Magnesium 0.7
Calcium 5.72
POST-OPERATIVE COURSE
 Transferred to the ICU immediately post-op
 BP 90/60 mmHg | HR 120s | on mech vent: FiO2 100% RR 20 cpm
 BP drop to 60 palpatory after 2 hours
 6 units of blood and 4 units of fresh frozen plasma transfused in succession
 BP increased to 120-140/80mmHg; onset of rales all over  Furosemide 40
mg IV and Ambroxol nebulization
 Maintained on norepinephrine drip
 Tranexamic acid 1 gm IV every 6 hours, NaCO3 50 mEqs every 6 hours,
Tramadol 300 mg over 24 hours as drip, Paracetamol 600 mg every 6 hours
Midazolam 2mg/hour + Fentanyl 4 mcg/hour as drip
POST-OP DAY
1
(ICU Day 1)
S S/P CS Hysterectomy
Hemorrhagic Shock
Acute Pulmonary Congestion - resolving
On Controlled Ventilation
O Awake, alert BP 110/60 | HR 80s | Sats 100% | (-) rales ABG POST OP DAY
1
CBC POST OP POST CHEM POST OP
DAY 1 Transfusio DAY 1 pH 7.57 (7.03)
n Sodium 145.30 PCO2 29 (26)
Hemoglobin 82 (78) 97 (149.4) PO2 267 (129)
Hematocrit 0.24 (0.24) 0.30 Potassium 3.51 (4.32) HCO3 26.6 (10.9)
RBC 2.60 (2.44) 3.22 PT 11 secs (15) BE +5.1 (-15.1)
WBC 24.2 (13.9) 24.9 %act 65.4 (35%) O2 Sat 100% (FiO2
Platelet 92 (104) 88 INR 1.28 (1.85) 80%)
A/P Transfuse another 3 units of blood
NGT Feeding Started
Weaning from mechanical ventilator
POST-OP DAY
2
(ICU Day 2)
S S/P CS Hysterectomy
Hemorrhagic Shock - resolving
Acute Pulmonary Congestion - resolved
On Controlled Ventilation – Extubated Succesfully
O Awake, not in distress BP 100/60 mmHg HR 80 RR 18 Sat 99%
Chest Radiograph: no congestion, no infiltrates
Serosanginous drainage from JP drains
UO adequate

CHEM POST OP
DAY 2

Creatinine 4.05 (0.41)

A/P Successfully extubated

Monitor for acute kidney injury (increasing serum creatinine)
POST-OP DAY
3
(ICU Day 3)
S S/P CS Hysterectomy
Hemorrhagic Shock – resolving,
Acute Pulmonary Congestion - resolved
Pneumonia – beginning (?) Acute kidney Injury - beginning
O Awake, not in distress BP 110-120/70-80 mmHg HR 70 RR 15-16 Sat 99% (+) fine rales
Chest Radiograph: Basal infiltrates | adeq UO
CHEM POST OP DAY CHEM POST OP
3 DAY 3
Sodium 148.70
(145.30) Creatinine 5.95 (4.05)
Potassium 3.76 (3.51)
PT 12 secs (11)
%act 100% (65.4)
A/P INR 1.04 (1.28)
Tramadol discontinued
Monitor for AKI
POST-OP DAY
4
(ICU Day 4)
S S/P CS Hysterectomy
Pneumonia
Acute Kidney Injury, Hypokalemia
O Awake, not in distress BP 120-150/80-100 mmHg |HR 70-80 RR 16 Sat 98% (+) fine
rales
CBC POST OP
DAY 4
CHEM POST OP DAY
Hemoglobin 109 (97) 4
Hematocrit 0.32 (0.30) Sodium 140.8 (148.70)
RBC 3.51 (3.22) Potassium 3.25 (3.76)
WBC 15.4 (25.9) Creatinine 5.80 (5.95)
Platelet 113 (88)

A/P Transferred out of ICU to regular room

Monitor for AKI
POST-
OP DAY
5-6
S S/P CS Hysterectomy
Pneumonia
Acute Kidney Injury; Hypokalemia
Cerebrovascular Accident Right Middle Cerebral Infarct 2* to Hypoxic/Anoxic Injury
O UNREMARKABLE (POST OP DAY 5)
(POST OP DAY 6) (+) 1 episode of generalized tonic-clonic seizure ~15 secs -> diazepam 5
mg
CT SCAN: R MCA INFARCT || no neurologic deficits
CBC POST OP CHEM POST OP POST OP
DAY 6 DAY 5 DAY 6
Hemoglobin 94 (109) Sodium 138.5 137.70
Hematocrit 0.27 (0.32) (140.8)
RBC 3.15 (3.51) Potassium 3.30 (3.25)
WBC 21.4 (15.4) Creatinine 5.94 (5.80) 6.55
Platelet 238 (113) Magnesium 0.86 (0.7)

A/P 1 unit blood transfused

Hemodialysis access (IJ) obtained
Hemodialysis
POST-
OP DAY
7-10
S S/P CS Hysterectomy
Pneumonia - resolved
Acute Kidney Injury – resolving; Hypokalemia
Cerebrovascular Accident Right Middle Cerebral Infarct 2* to Hypoxic/Anoxic Injury
O Occasional headaches, difficulty sleeping, no other subjective complaints || (-) vaginal
bleeding || min. drainage
Headaches resolved at post-op day 9-10
CBC POST OP POST OP CHEM POST OP POST OP POST OP POST OP
DAY 7 DAY 10 DAY 7 DAY 8 DAY 9 DAY 10
Hemoglobin 110 (94) 91 Sodium 141.8 137.70
Hematocrit 0.32 (0.27) 0.27 (137.7)

RBC 3.67 (3.15) 3.00 Potassium 3.28

(3.30)
WBC 15.6 (21.4) 15.8
Creatinine 4.5 (6.55) 3.61 2.79 2.48
Platelet 353 (238) 406

A/P Hemodialysis Post Op Day 7-9

Discharge at Post-Op Day 11
DISCUSSION
MANAGEMENT OBSTETRIC HEMORRHAGE
MASSIVE TRANSFUSION PROTOCOL
Obstetric Hemorrhage

 Most common cause of maternal mortality worldwide

(25% of all maternal mortalities)
 Increasing rates of postpartum uterine atony and
abnormal placental implantation -- assoc with inc CS
rates?
 Majority of outcomes are reversible
 Failure to recognize risks
 Failure to accurately estimate blood loss
 Failure to initiate treatment in a timely manner
Mechanisms of Hemostasis
 Uterinecontraction is stimulated by
endogenous oxytocic substances released after
delivery  PRIMARY MECHANISM
 Tetanycreates shear forces cleave placenta
from uterine wall
 Contractionconstricts spiral arteries and
uterine veins
 Coagulationmechanisms include platelet
aggregation and plug formation, local
vasoconstriction, clot polymerization, and
fibrous tissue fortification
Placenta Previa

 Partof the placenta implants in advance of the

fetal presenting part
 Incidence  4.0 per 1000 pregnancies
 Exactcauses unclear; associated with prior
uterine trauma, multiparity, advanced maternal
age, smoking, male fetus, previous placenta
previa
 GOLD STANDARD FOR UTZ -> transvaginal
ultrasound
ANESTHESIA MANAGEMENT

 Initiate volume resuscitation

 Neuraxial anesthesia is preferred if without
active bleeding or intravascular volume deficit
 epidural assoc with more stable BP and
lower transfusion rates
 Increased intraop blood loss: injuring an
anteriorly located placenta during uterine
incision, lower uterine segment fails to
contract, associated placenta accreta
ANESTHESIA MANAGEMENT
 RSI IS THE PREFERRED TECHNIQUE FOR BLEEDING
PATIENTS
 May be accomplished without an induction agent if with
severe hypovolemic shock
 Avoid propofol in ongoing hemorrhage; may use ketamine
0.5-1.0 mg/kg or etomidate 0.3 mg/kg
 Administer oxytocin after delivery
 If placental separation difficult, consider placenta accrete,
consider cesarean hysterectomy
PLACENTA ACCRETA

 Placenta that in whole or part invades the uterine wall

and is inseparable from it
 Incidence rising primarily because of increasing CS
delivery rate
 Combination of placenta previa with previous CS
synergistically increases risk of coexisting placenta
accreta (11% with 1 prev CS, 40% in 2 prev CS, 60%
in 3 or more)
SURGICAL AND ANESTHETIC
MANAGEMENT
 Similar to cases of severe postpartum hemorrhage and peripartum hysterectomy
 Estimated blood loss can exceed 2000 mL in 66% of cases, 5000 mL in 15%,
10,000 mL in 6.5%, and 20,000 mL in 3%
 Definitive treatment: peripartum hysterectomy if postpartum hemorrhage is
unresponsive to medical or other invasive therapies
 Technically challenging: uterus enlarged, vessels engorged, rich collateral blood
supply
 Transfusion in 44% or more of patients  assoc increased blood loss, worse
coagulopathy, increased transfusion rates
 Single shot anesthesia unlikely sufficient duration of anesthesia
SURGICAL AND ANESTHETIC
MANAGEMENT
 Indications for general anesthesia
 Severely hypotensive patients for airway protection
 Large fluid shifts and massive transfusion adversely
affect oxygenation  controlled ventilation
 Fluid shifts increase airway edema
 Massive transfusion of blood products need
coadministration of pressors and calcium
chloride/sodium bicarbonate  central access 
easier to achieve under GA
IN RETROSPECT
 Mode of Anesthesia
 Singleshot subarachnoid blockade would not have
been sufficient given the anticipated hysterectomy
 Lumbar epidural
 Conversion to general anesthesia inevitable?
 Preoperative Preparation
 Availabilityof blood products: early availability of
sufficient amounts pre-op and access to more intra
and post op would have prevented sequelae from
severe hemorrhage
 Need for a massive transfusion protocol?
 Cesarean section  hysterectomy
Massive Obstetric hemorrhage

All available typed and MASSIVE

crossmatched blood used TRANSFUSIO
----- persistence of blood N PROTOCOL
loss/hemodynamic
instability
MASSIVE TRANSFUSION
PROTOCOL
Hsu Y, Haas T, Cushing M. Massive transfusion protocols: current best practice.  International Journal of
Clinical Transfusion Medicine. 2016;4:15-27
 Massive Transfusion is defined as: 1) total blood
https://doi.org/10.2147/IJCTM.S61916

volume is replaced within 24 hours, 2) 50%

of total blood volume is replaced within 3
hours, or 3) rapid bleeding rate is
documented or observed
 Rapid bleeding rate in adults can be defined as
more than 4 units of red blood cells (RBCs)
transfused within 4 hours with active major
bleeding or more than 150 mL/minute of blood
loss
MASSIVE TRANSFUSION
PROTOCOL
 No universally accepted protocol
 Trauma vs Non-trauma: trauma MTP used extensively
in the military, non-trauma in civilian centers with
crossover of trauma protocols
 “use of an MTP in a non-trauma setting was
associated with poor clinical outcomes, most probably
related to underlying disease, not the MTP itself” (Morse
BC, Dente CJ, Hodgman EI, et al. Outcomes after massive transfusion in nontrauma patients in
the era of damage control resuscitation. Am Surg. 2012;78(6):679–684 )
 Need for more studies for a definitive protocol
Massive Transfusion Protocol

 Key Advantages
 Early ability of blood products
 Effective lines of communication
 Require laboratory support
 Blood issued within 5-10 minutes after order
CRITERIA FOR TRANSFUSION

 No consensus
 Clinical assessment
 Rate and magnitude of blood
 Vital signs
 Hematologic indices
 Etiology and Amount of Blood Loss
 CLASS I CLASS II CLASS III CLASS IV
Blood Loss <750 mL 750-1500 mL 1500-2000 mL >2000 mL

Blood Loss (%) <15% 15-30% 30-40% >40%

Pulse Rate <100 bpm >100bpm >120bpm >140 bpm

Blood Pressure Normal Normal Decreased Decreased

Pulse Pressure Normal or Decreased Decreased Decreased

increased
Respiratory Rate 14-20 cpm 20-30 cpm 30-40 cpm >45 cpm

Urine Output >30 mL/hour 20-30 mL/hour 5-15 mL/hour Negligible

Mental Status Slightly anxious Mildly anxious Anxious and Lethargic

confused
Fluid Crystalloids Crystalloids Crystalloids + Crystalloids +
Rescucitation Blood Blood
(3:1)
BLOOD PRODUCTS: Red Blood
Cells
 Transfusion when hemoglobin is less than 7 g per dL and
maintenance of a hemoglobin level between 7 to 9 g per
dL
 Clinical effect of storage and transfusing older RBCs 
suggested that transfusing older blood is significantly
associated with an increased mortality risk.; significance
appears to vary with different patient populations
 Prospective randomized controlled trials (RCTs) have
shown that fresher RBCs do not significantly improve
clinical outcomes or mortality in various clinical settings
BLOOD PRODUCTS: Red Blood
Cells
 Immune-mediated hemolysis  routine pre-
transfusion testing is bypassed and
uncrossmatched Group O RhD negative RBCs
are often given
 ForType A, B, or AB patients, it is safest to
repeat the blood type, with particular
consideration of the reverse type, before
resuming transfusion of RBCs of the patient’s
own blood group
BLOOD PRODUCTS: Plasma
 Plasma transfusion is recommended in patients with active
bleeding and an International Normalized Ratio (INR)
greater than 1.6
 Acute nature of significant blood volume loss could lead to
uncompensated coagulopathy  early transfusion of
plasma-containing physiologic coagulation factors
 Fresh frozen plasma or plasma frozen within 24 hours is
thawed and stored for 24 hours, it can be relabeled as
thawed plasma (TP) with up to five more days of shelf life
 TP can be used besides FFP
 TP has relatively less factor V and factor VIII than fresh
frozen plasma and plasma frozen within 24 hours
BLOOD PRODUCTS: Platelets

 Spontaneous bleeding through intact endothelium

does not occur unless the platelet count is no greater
than 5 × 103 per μL
 Refrigerated platelets have a shortened half-life in
circulation, shown to more readily aggregate in vitro
and to have a better metabolic profile
 Clinical emphasis often weighs more in favor of
achieving rapid hemostasis rather than a durable
increase in platelet count
BLOOD PRODUCTS: Whole Blood

 Major hurdle preventing the widespread use of

platelet-sparing WB products is the lack of consensus
on the optimal storage condition
 Use of WB is the requirement for type-specific blood,
as the patient blood type is frequently unknown during
the early phase of resuscitation
 Transfusion Related Lung Injury
(TRALI)
 1 in 5,000 components, 1 in 7,900 units of fresh frozen plasma. and 1 in 432 units of whole
blood-derived platelet concentrates
 Acute lung injury that occurs during or within 6 h of transfusion, and with no
temporal relationship to an alternative risk factor for ALI
 Leading cause of transfusion-related mortality worldwide
 Respiratory distress, hypoxemia, rales on auscultation, and diffuse bilateral
infiltrates on chest radiograph, hypotension, fever, and transient leukopenia
 Treatment is aggressive respiratory support depending on the degree of
respiratory distress
 5 to 25% of cases are fatal, but most patients fully recover within 3 days
Transfusion Related Lung Injury
(TRALI)
 Immediate
management is to STOP
TRANSFUSION
 Screendonor unit(s) for antileukocyte
antibodies, anti-HLA, or anti-neutrophil-specific
antibodies
 Supportive measures  pathology is similar to
acute respiratory depression (ARDS) 
adequate oxygenation, lung protective
strategies (low tidal volumes), diuresis
Transfusion Associated Circulatory
Overload (TACO)
 1 in approximately 3000 transfusions to 8% of transfusions
depending upon patient population and reporting method
 No universally agreed-upon definition
 During or within several hours of transfusion, patients develop
respiratory distress, and may develop orthopnea, cyanosis,
tachycardia, and hypertension, with rales, JV distention, edema
 Pathogenesis of TACO is felt to be similar to other causes of acute
congestive heart failure: an increase in central venous pressure
and pulmonary blood volume causes an increase in hydrostatic
pressure leading to fluid extravasation into the alveolar space
 D/C transfusion, supportive
Hemostatic Therapies
 Tranexamic Acid
  Inhibit the formation of plasmin
 Clinically beneficial in achieving hemostasis and reducing MT in
exsanguinating trauma patients
 first prospective RCT on the effectiveness of high-dose TXA (4 g loading
dose with 1 g h−1 over 6 hours) in women with postpartum hemorrhage was
conducted in France  TXA significantly reduced blood loss and
transfusions
Hemostatic Therapies

 Recombinant FVIIa  not recommended due

to inc risk of adverse outcomes
 Cryoprecipitate
 Most common blood product used to replace
fibrinogen
 Delayed availability and increased product wastage
 Cheaper to use than fibrinogen
What is the ideal ratio?
Blood Product Ratio
(Plasma:Platelets:RBC)
 Earlier hemostasis, lower transfusion requirements, and less
death due to exsanguination at 24 hours in the 1:1:1 ratio
 Was mode of anesthesia appropriate?
 Noand yes  single shot spinal inadequate, general
anesthesia probably unavoidable
 Was patient preparation adequate?
 Securing
of blood products prior to surgery would have
decreased likelihood of morbidity
 Was hemorrhage appropriately managed?
 Yes, massive transfusion was necessary
 Would an existing institutional massive transfusion
protocol be of use?
 Yes!