Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
LETTER TO EDITOR  
Year : 2021  |  Volume : 14  |  Issue : 4  |  Page : 249-250
Complete maternal recovery after prolonged cardiac arrest due to atonic postpartum hemorrhaging


1 Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
2 Department of Obstetrics and Gynecology, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
3 Aestheology, Shizuoka Hospital, Juntendo University, Shizuoka, Japan

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Date of Submission28-Jun-2021
Date of Acceptance04-Jul-2021
Date of Web Publication24-Dec-2021
 

How to cite this article:
Yanagawa Y, Tanaka T, Kaneda H, Omae T. Complete maternal recovery after prolonged cardiac arrest due to atonic postpartum hemorrhaging. J Emerg Trauma Shock 2021;14:249-50

How to cite this URL:
Yanagawa Y, Tanaka T, Kaneda H, Omae T. Complete maternal recovery after prolonged cardiac arrest due to atonic postpartum hemorrhaging. J Emerg Trauma Shock [serial online] 2021 [cited 2022 Aug 19];14:249-50. Available from: https://www.onlinejets.org/text.asp?2021/14/4/249/333695




Dear Editor,

Postpartum hemorrhage is the leading cause of maternal morbidity and mortality worldwide.[1] Previous original reports treating maternal cardiac arrest only described the mortality rate and did not describe the cerebral performance category.[2],[3] A 26-year-old woman delivered the second child at the other hospital (day 1). She had no remarkable personal or family history. She had postpartum continuous hemorrhaging from an injury at the cervical canal and atonic uterus. Continuous vaginal hemorrhaging over 3000 ml that failed to respond to fluid resuscitation, suturing of the injury or uterine massage resulted in a shock index of 2.0, tonic convulsion, and a coma state. She was transported and arrived at our hospital 4 h after the delivery. Upon arrival at midnight (day 2), she showed a coma state with dilated nonreactive pupils. Her vital signs were as follows: blood pressure, unmeasurable, and heart rate, 128 beats/min. The results of blood test were shown in [Table 1]. She urgently underwent infusion of oxytocin and antifibrinolytic tranexamic acid and a massive transfusion protocol by a rapid response team. She also underwent tracheal intubation. Infusion of oxytocin, antithrombin III, and noradrenaline as well as the application of uterine balloon tamponade failed to achieve stable circulation with stanching of continuous vaginal bleeding. Obstetricians decided to perform hysterectomy. Before entering the operation room, she received 20 units of packed red blood cells, 22 units of fresh-frozen plasma, 4 units of cryoprecipitate, and 7 bottles of albumin products, and the estimated amount of vaginal bleeding was 9100 g in total, including the referral hospital's values. During the operation, she repeatedly suffered cardiac arrest and achieved return of spontaneous circulation, requiring chest compression over 30 min, 12 mg of adrenalin infusion in total and an additional 22 units of packed red blood cells, 12 units of fresh-frozen plasma, and 10 units of platelets. After the operation, her circulation was still unstable under use of vasopressors, and she remained in a deep coma with dilated nonreactive pupils and accidental hypothermia (33°C) due to massive transfusion. Subsequently, she underwent induced hypothermic therapy for hypoxic encephalopathy for 24 h. The target temperature was 34.0°C. When sedatives were temporarily ceased, she became able to respond to simple commands. Her postoperative course was eventful including delayed bleeding from the right ovarian artery, pseudo-aneurysmal formation at the left iliac artery, thrombosis in the right common iliac vein and inferior vena cava, right thin subdural hemorrhage, and intra-abdominal abscess, treated by a multidisciplinary approach. On day 20, she was discharged without any neurological sequelae.
Table 1: Laboratory data at the time of deterioration

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The first key point influencing the survival outcome might be our adherence to the postpartum hemorrhaging care bundle, including rapid team management.[4] The second key point influencing the favorable neurological outcome might have been the accidental and subsequent induced hypothermic therapy for hypoxic encephalopathy.[5] The further accumulation of cases is necessary to evaluate the efficacy of this approach to managing patients with cardiac arrest due to massive postpartum hemorrhaging and the final cerebral performance category.

Acknowledgment

This work was supported in part by a Grant-in-Aid for Special Research in Subsidies for ordinary expenses of private schools from the Promotion and Mutual Aid Corporation for Private Schools of Japan.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Watkins EJ, Stem K. Postpartum hemorrhage. JAAPA 2020;33:29-33.  Back to cited text no. 1
    
2.
Schaap TP, Overtoom E, van den Akker T, Zwart JJ, van Roosmalen J, Bloemenkamp KW. Maternal cardiac arrest in the Netherlands: A nationwide surveillance study. Eur J Obstet Gynecol Reprod Biol 2019;237:145-50.  Back to cited text no. 2
    
3.
Zelop CM, Shaw RE, Edelson DP, Lipman SS, Mhyre JM, Arafeh J, et al. Factors associated with non-survival from in-hospital maternal cardiac arrest: An analysis of Get With The Guidelines® (GWTG) data. Resuscitation 2021;164:40-5.  Back to cited text no. 3
    
4.
Althabe F, Therrien MN, Pingray V, Hermida J, Gülmezoglu AM, Armbruster D, et al. Postpartum hemorrhage care bundles to improve adherence to guidelines: A WHO technical consultation. Int J Gynaecol Obstet 2020;148:290-9.  Back to cited text no. 4
    
5.
Shi J, Dai W, Carreno J, Zhao L, Kloner RA. Therapeutic hypothermia improves long-term survival and blunts inflammation in rats during resuscitation of hemorrhagic shock. Ther Hypothermia Temp Manag 2020;10:237-43.  Back to cited text no. 5
    

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Correspondence Address:
Youichi Yanagawa
1129 Nagaoka Izunokuni City Shizuoka, Japan, 410-2295
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jets.jets_85_21

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