A 31-year-old woman delivers a healthy male child of 40 weeks’ gestation. First stage of labour is normal; however, soon after delivery, the patient experiences substantial blood loss. She becomes hypotensive. An urgent full blood count showed the following:
Hb 67 g/L
White cells 14.7 × 109/L – differential normal
Platelets 67 × 109/L.
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(a) What is the likely cause of the anaemia?
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Correct answer: She has suffered haemorrhage. She is also peri-partum with low platelets and may have disseminated intravascular coagulation (see Chapter 43); or haemolytic uraemic syndrome (see Chapter 41.
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(b) What is your immediate management?
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Correct answer: An urgent blood sample should be taken and a group and save, coagulation screen biochemistry with kidney and liver function requests should be made. She also requires resuscitation with intravenous fluid to maintain her blood pressure. This is a medical emergency and help from an intensive care team should be sought.
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(c) What other investigations would you do?
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Correct answer: A blood film should be requested to ensure there is no evidence of microangiopathic haemolytic anaemia. DIC, haemolytic uraemic syndrome (HUS), TTP and HELLP (haemolytic anaemia with elevated liver enzymes and low platelets) can all present in this acute perinatal setting. A coagulation profile must be obtained in this patient. There was evidence of DIC (prothrombin time 18 s and APTT 54 s – both prolonged), thrombin time 21 s (prolonged), fibrinogen 0.1 g/L (reduced), fibrin degradation products (FDP) markedly elevated. Immediate transfusion of blood component must be undertaken and all efforts taken to maintain the blood pressure. Crystalloid infusions should be commenced while awaiting blood. O-negative blood can be given urgently and compatible red cells must be transfused as soon as available.
Efforts must be taken to establish the cause of DIC. In this setting, it could be due to retained products of conception; the obstetrician may wish to organize an appropriate examination under anaesthetic with evacuation of these retained products. Intravenous antibiotic therapy should be administered.
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(d) What treatments would you institute?
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Correct answer: She requires red cell transfusion. Urgent obstetric review is required to stabilize her and ensure there are no retained products of conception. Further transfusion support should be administered. This would include infusion of fresh frozen plasma and platelets in order to replace consumed coagulation factors and platelets. Cryoprecipitate is a rich source of coagulation factors. Regular monitoring of full blood count, platelet count and coagulation parameters must be instituted. If bleeding persists despite replacement of platelets and clotting factors and cryoprecipitate, recombinant human factor VIIa should be considered. Other treatments that are of value in DIC include infusions of recombinant protein C and infusions of antithrombin.
An expert paediatric assessment of the neonate is also required and neonatal thrombocytopenia and anaemia should be excluded.
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(e) What are the implications for future pregnancies?
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Correct answer: She is at risk of developing antibodies to antigens on the transfused red cells and these could cross the placenta and cause haemolytic disease of the newborn (see Chapter 47 in future pregnancies. This is particularly the case if she is rhesus D negative; or negative for one of the other antigens that elicit IgG antibody responses (e.g. Kell, c).
