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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 30  |  Issue : 1  |  Page : 116-119

Intensive care management of multi-systemic complications following major postpartum haemorrhage in a Resource-limited setting: A case report


1 Department of Anaesthesiology/Intensive Care, Irrua Specialist Teaching Hospital, Edo State, Nigeria
2 Professor of Obstetric Anaesthesiology/Consultant, Department of Anaesthesiology/Intensive Care, University of Benin Teaching Hospital, Edo State, Nigeria
3 Department of Surgery, Federal Medical Centre, Nguru, Yobe State, Nigeria

Date of Submission28-Oct-2020
Date of Decision19-Nov-2020
Date of Acceptance29-Dec-2020
Date of Web Publication15-Feb-2021

Correspondence Address:
Dr. Ifeanyichukwu Michael Chukwu
Department of Anaesthesia, ISTH, Irrua
Nigeria
Prof. Nosakhare Philomena Edomwonyi
Department of Anaesthesia, UBTH, Benin City
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_197_20

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  Abstract 


Postpartum hemorrhage with its attendant systemic complications can pose a challenge in the developing world, resulting in morbidity and mortality. We present a case of an unbooked 38-year-old para-3 woman, who had elective Cesarean section at term on account of placenta praevia type IV under spinal anesthesia in a private facility. She developed major obstetric hemorrhage that necessitated massive blood transfusion and emergency hysterectomy. She was managed in the intensive care unit for 43 days and remained unconscious for 35 days. She developed many systemic complications that necessitated a multi-disciplinary management with a favorable outcome. She was transferred to the general ward where she spent 30 days before she was discharged home in a satisfactory condition.

Keywords: Favourable outcome; Intensive care; Management; Postpartum haemorrhage


How to cite this article:
Chukwu IM, Edomwonyi NP, Ikhifa CE, Ojebo J, Ezeife BC, Adeaga MO, Obazenu LO. Intensive care management of multi-systemic complications following major postpartum haemorrhage in a Resource-limited setting: A case report. Niger J Med 2021;30:116-9

How to cite this URL:
Chukwu IM, Edomwonyi NP, Ikhifa CE, Ojebo J, Ezeife BC, Adeaga MO, Obazenu LO. Intensive care management of multi-systemic complications following major postpartum haemorrhage in a Resource-limited setting: A case report. Niger J Med [serial online] 2021 [cited 2021 Feb 25];30:116-9. Available from: http://www.njmonline.org/text.asp?2021/30/1/116/309513




  Introduction Top


Obstetric hemorrhage has continued to be a chief cause of maternal deaths in Nigeria and other developing countries.[1] Postpartum hemorrhage (PPH) is among the top three causes of maternal deaths worldwide.[2] PPH has been defined as bleeding per vaginam of >500 ml following vaginal delivery or an estimated blood loss >1000 ml and 1500 ml after Cesarean Section (C/S) and Cesarean hysterectomy, respectively. Some authors have extended the definition to also include postpartum bleeding that causes a 10% acute decrease in packed cell volume (PCV) or hemodynamic compromise which requires blood transfusion.[2],[3] Definition based on maternal hemodynamic compromise may be misleading since she can still maintain her cardiovascular parameters even after significant blood loss due to pregnancy physiology.[3] PPH can be classified as either primary or secondary if it occurs within 24 h or 6 weeks of delivery, respectively. It becomes a major PPH when the blood loss is >1000 ml.[3] Placenta praevia is a positional disorder of human placenta where the placenta overlies or is in close proximity to the internal cervical os, thereby preventing vaginal delivery. This can lead to a significant obstetric hemorrhage.

Management of major PPH with ongoing hemorrhage or clinical shock is very challenging, especially in resource-limited set-ups. It requires multi-disciplinary interventions which may include admission into the intensive care unit (ICU) for organ support and advanced monitoring.[2],[3] We report the management of a patient with major PPH in a resource-poor ICU facility.


  Case Report Top


The patient was an unbooked para 3 with 3 alive who presented to our facility on account of bleeding per vaginam and loss of consciousness following an elective C/S delivery. She had antenatal care in a private hospital where she had elective C/S at term on account of placenta praevia type IV. She was delivered of a live baby with good Apgar score

The patient was noticed to have been bleeding per vaginam 4 h after the C/S for which she had balloon tamponade and vaginal packing. Due to persistent bleeding, she had a subtotal hysterectomy under general anesthesia with endotracheal intubation using a size 7.5 mm cuffed endotracheal tube (ETT) and received a total of 10 units of blood. The continuous bleeding necessitated her referral to Irrua Specialist Teaching Hospital for expert management.

On admission, she was unconscious, in shock and respiratory distress. Her Glasgow Coma Scale (GCS) score was 3T/15, pulse and blood pressure (BP) were not recordable, respiratory rate was 56 breaths/min. She had a PCV of 12%. She was resuscitated with fresh whole blood, colloid, adrenaline, dopamine infusion, and tranexamic acid. She was taken to the theater for exploratory laparotomy under general anesthesia with relaxant technique. Baseline vital signs were: Pulse Rate (PR) = 102b/m, blood pressure (BP) = 112/70 mmHg, Respiratory rate (RR) = 23 breaths/min and SPO2 was 97%. Her GCS had improved to 7T/15. Intra-operative findings revealed an injury to the bladder and a bleeding cervical stump. The urologist was invited for the repair of the bladder injury. The surgery lasted for about 4 h.

She was transferred to ICU for cardiorespiratory support. Oxygen was entrained through the ETT at 5 L/min while breathing spontaneously. She was attached to a multiparameter patient monitor for continuous monitoring. Baseline vital signs were PR = 85b/min, BP = 128/70 mmHg, axillary temperature = 36.6°C, RR = 18 breaths/min and SPO2 = 98%. Her GCS score remained 7T/15. In the ICU, she had a central line inserted. She received dopamine, adrenaline and 4 additional units of fresh whole blood.

Full blood count, electrolyte/urea/creatinine, and random blood sugar were done in the immediate postoperative period which showed a hemoglobin level of 9.8 g/dl, Na+ of 148 mmol/L and HCO3 of 12 mmol/L, other results were essentially normal.

She made good progress and was extubated on the 2nd day of ICU admission. The patient however developed multi-systemic complications as shown in [Table 1] and she was re-intubated on the 22nd day of ICU admission and mechanically ventilated using continuous mandatory ventilation mode (rate = 12 cpm, FiO2 = 0.4–1, tidal Vol. = 450 ml, PEEP = 10 cmH20). She was paralyzed with atracurium and sedated with midazolam. Weaning was commenced after 48 h of reintubation, and she was successfully extubated 5 days later.
Table 1: Multi-systemic complications and management

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She was unconscious for 35 days. Graded oral sips were attempted and well tolerated, and graduated to fortified meals. The physiotherapy team was also involved throughout the management of this patient. For thromboprophylaxis, subcutaneous enoxaparin was introduced after 72 h when bleeding was controlled.

On the 43rd day, she was transferred to the gynecology ward for continued care by the gynecological, urology, neurology, and physiotherapy teams. She was discharged home after 30 days in the ward when she had made a significant recovery and scheduled for follow-up at the urology, gynecology, neurology, and physiotherapy clinics.


  Discussion Top


Intensive care unit is a special unit in the hospital that is designated to offer comprehensive care to patients who are in critical and life-threatening conditions, with a key interest in resuscitation and stabilization, physiological optimization to prevent organ failure and support of failing organ systems.[4],[5],[6] This patient was managed in a 4-bedded general ICU that admits patients from all the departments.

In developed countries, admission of obstetric patients into the ICU is uncommon, and major PPH is one of the most common indications.[7],[8],[9],[10] In the United States, 0.07%–1.35% of women required ICU admission during pregnancy and postpartum periods.[9],[11] The National Maternity and Perinatal Audit[7] studied maternity admissions to ICU in England, Wales and Scotland in 2015/16, and reported that 0.22% of obstetric patients were admitted into the ICU, while an Australian study[10] reported 1.2%. The low ICU admission among pregnant women may be due to strict adherence to antenatal care attendance, the availability and timely administration of blood and blood products whenever indicated.

In Nigeria, Okojie et al.[3] reported that approximately 2% of all deliveries had PPH. Embu et al.[12] in their study stated that 2.05% of deliveries required ICU services which contributed 17.29% of the total ICU admission. Obstetric hemorrhage was one of the commonest indications. Mortality rates of obstetric cases in the ICU are also higher in developing countries than the developed nations. Advanced maternal age, previous C/S and sponge-like tissue in the cervix in placenta praevia cases are risk factors for increased bleeding during cesarean delivery.[3] The patient reported was 38-year-old and had one previous Caesarean section. Operative delivery, high parity, increased blood loss during delivery, unbooked status, low socioeconomic status, and the presence of background medical conditions have been identified as risk factors for admission into the ICU.[13],[14] These factors except high parity and background medical condition were present in the index case. Even though the blood loss could not be quantified, it was significant enough to cause cardiopulmonary and neurologic compromise and required the transfusion of 16 units of blood. High mortality has been associated with the development of multiple organ failure, and the requirement for mechanical ventilation connotes bad prognosis unless it is only used in the immediate postoperative period.[13] The patient also developed gluteal ulcer, wound breakdown and sepsis with severe hematologic, neurologic, pulmonary, and renal complications. Due to massive and acute blood loss, she presented to ICU in shock with unconsciousness and poor respiratory efforts as a result of cerebral hypoperfusion/ischemia. Cerebral ischemia generates an exaggerated sympathetic surge.[3] This could explain why the patient developed hypertension from the 3rd day of admission. The patient also developed difficulty with breathing and hypoxia on the 22nd day of admission for which she was mechanically ventilated for a few days.

The challenges encountered in the management of the index patient were enormous as a result of the complications in almost all the organs. The patient presented in severe shock due to massive blood loss and later developed septic shock and other complications as listed in [Table 1]. Fresh frozen plasma and other blood products were not readily available. However, fresh whole blood was always available when needed. Fresh whole blood was essential for volume replacement and clotting factors. Some of the prescribed antibiotics were not available as required due to financial constraint. The arterial blood gases were not estimated because the arterial blood gas analyzer was not functional. When the patient was on ventilatory support, we ensured adequate oxygenation (with the use of peripheral pulse oximeter) and adequate carbon dioxide elimination (based on ventilator settings). Blood biochemistry was done daily to elicit and treat electrolyte imbalances. Intravenous Vitamin C, 1 g in intravenous infusion was administered daily. Astymin (contains essential Vitamins-A, C, E) was given through the nasogastric tube and discontinued as a result of finance.

The hospital is endowed with experienced specialists in their different disciplines. Frequent evaluation of the patient, early recognition of complications, and prompt intervention by the multi-disciplinary team accounted for the favorable outcome. Total parenteral nutrition was considered for the patient but the products are expensive and were not available in the hospital and the only place that had it was in Lagos. The transportation of the products requires some logistics. We recommend early referral to the relevant discipline whenever such a challenging case is encountered and also making use of available substitutes.


  Conclusion Top


Major PPH with resultant multiple organ dysfunction is one of the top causes of maternal morbidity and deaths worldwide. Early ICU admission is important for organ support and advanced monitoring. Available resources should always be maximized to improve the patients' chances of survival.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sageer R, Kongnyuy E, Adebimpe WO, Omosehin O, Ogunsola EA, Sanni B. Causes and contributory factors of maternal mortality: Evidence from maternal and perinatal death surveillance and response in Ogun state, Southwest Nigeria. BMC Pregnancy Childbirth 2019;19:63.  Back to cited text no. 1
    
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Foley MR, Strong TH, Garite TJ. Obstetric Intensive Care Manual. Pennsylvania (NY): McGraw Hill Professional; 2018. Available from: https://obgyn.mhmedical.com/book.aspx?bookID=2379. [Last accessed 2020 Apr 30].  Back to cited text no. 2
    
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Okojie NQ, Edomwonyi NP, Oham A, Agbonkhese G. The management of massive postpartum haemorrahage in a tertiary hospital in Nigeria. A report of two cases. Tropical Journal of Obstetrics and Gynaecology. 2014;31(2):108-14.  Back to cited text no. 3
    
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Poluyi EO, Fadiran OO, Poluyi CO, Alabi EO, Falohun SA. Profile of intensive care unit admissions and outcomes in a tertiary care center of a developing country in West Africa: a 5 year analysis. J Intens Crit Care. 2016;2:29:1698-9465. Available from: https://criticalcare.imedpub.com/profile-of-intensive-care-unit-admissions-and-outcomes-in-a-tertiary-care-center-of-a-developing-country-in-west-africa-a-5-year-a.php?aid=9815. [Last. [Last accessed on 2020 Apr 25].  Back to cited text no. 4
    
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Aitkenhead AR, Moppett IK, Thompson JP, editors. Smith & Aitkenhead's Textbook of Anaesthesia. 4th ed.. Nottingham, UK: Chrchill Livingstone Elsevier; 2013. p. 902.  Back to cited text no. 5
    
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Hebballi R, Chauhan M. Intensive Care Management after Major Postpartum Hemorrhage. London. The Global Library of Women's Medicine; Available from: http://glowm.cms12.ama.uk.com/pdf/PPH_2nd_edn_Chap-62.pdf. [Last accessed 2020 Apr 24].  Back to cited text no. 6
    
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Jardine J, Aughey H, Blotkamp A, Carroll F, Gurol-Urganci I, Harris T, et al. Maternity Admissions to Intensive Care in England, Wales and Scotland in 2015/16: A report from the National Maternity and Perinatal Audit. Available from: https://maternityaudit.org.uk/FilesUploaded/NMPA%20Intensive%20Care%20sprint%20report.pdf. [Last accessed on 2020 Apr 29].  Back to cited text no. 7
    
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Vargas M, Marra A, Buonanno P, Iacovazzo C, Schiavone V, Servillo G. Obstetric admissions in ICU in a tertiary care center: A 5-years retrospective study. Indian J Crit Care Med 2019;23:213.  Back to cited text no. 8
    
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Clardy PF, Reardon CC, Lockwood CJ, Hepner MD. Critical Illness During Pregnancy and the Peripartum Period. UpToDate; 2014 Sep. Available from: https://www.uptodate.com/contents/critical-illness-during-pregnancy-and-the-peripartum-period?topicRef=1599&source=see_link. [Last accessed on 2020 Apr 30].  Back to cited text no. 9
    
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Paxton JL, Presneill J, Aitken L. Characteristics of obstetric patients referred to intensive care in an Australian tertiary hospital. Aust N Zealand J Obstetr Gynaecol 2014;54:445-9.  Back to cited text no. 10
    
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Wanderer JP, Leffert LR, Mhyre JM, Kuklina EV, Callaghan WM, Bateman BT. Epidemiology of obstetric-related intensive care unit admissions in Maryland: 1999–2008. Crit Care Med 2013;41:1844.  Back to cited text no. 11
    
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Embu HY, Isamade ES, Nuhu SI, Oyebode TA, Kahansim ML. Obstetric admissions in a general intensive care unit in north-central Nigeria. Trop J Obstetr Gynaecol 2016;33:14-20.  Back to cited text no. 12
    
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Faponle AF, Adenekan AT. Obstetric admissions into the intensive care unit in a sub-urban University Teaching Hospital. Nepal J Obstetr Gynaecol 2011;6:33-6.  Back to cited text no. 13
    
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Abubakar AS, Bako B, El-Nafaty AU, Mulima B, Muhammed A, Dibal JY. Obstetrics admissions to the intensive care unit at the Nigerian teaching hospital: A four year review. J Sci Res Stud 2014;1:81-6.  Back to cited text no. 14
    



 
 
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