The unstable patient with massive PV bleed

The Case

It was a quiet Sunday afternoon in a small ED (sounds like the start to a bad story, doesn’t it?)

I picked up the next chart…30-year-old, 13/40, light PV bleeding

History – otherwise healthy 30 year old, no medications, G2P1, 13/40, light bleeding since yesterday, some cramping low abdominal pain, USS at 10/40 single intrauterine gestation … so far so good

Examination – looks well, obs normal, abdo SNT… this all seem straightforward…

Take some bloods, organise an early pregnancy clinic appointment the following day, waiting for blood results when the nurse comes in, tells me the patient has passed some products into the toilet and is “just cleaning herself up” … 5 mins goes by – the patient is still cleaning herself up – when the patient collapses in the toilet cubicle and the extent of the bleeding becomes obvious. She is tachycardic, hypotensive, pale and unconscious so is taken to resus. A large bore IVC is established and fluid resuscitation commenced. I do a quick speculum to clear products from the os.  I need an Yankauer sucker to clear the vault to even see the os. Some syntocinon, TxA and blood is given…When all is said and done, the os is cleared, haemodynamics are stable, patient is awake, and I look around to find there is 800mL of blood in the suction canister, not to mention what was lost in the toilet and swabs…

The patient is transferred to the regional base hospital where she remains stable, has a D&C and a further blood transfusion and is discharged the following day.  She does well.

What can we learn from this?

There are a few basic questions to ask when we approach this type of patient

1. Is the patient pregnant?

Unlike in this case, the patient may not know.  When you are at the bedside with a patient with torrential bleeding, there is no time to wait for the lab to run a β-hCG, or for us to get a urine sample to check β-hCG.  In this case, take some blood (you’ll already be drawing blood to check FBC, crossmatch etc) and put a few drops of BLOOD on the standard URINE β-hCG strip and you’ll get a rapid answer.

2. Could this be an ectopic?

This question is key, because it determines how much we can do in the ED.  If the patient has an USS to demonstrate this already, this question may already be answered. If not, there are some clues on history and exam that might guide you (sudden iliac fossa pain preceding bleeding, risk factors for ectopic, shoulder tip pain etc), but keep in mind that this is poorly discriminative.  Bedside ultrasound is gaining traction, but be cautious calling a pregnancy intrauterine based on this unless you have had extensive training to enable you to do so. BUT…if you see free fluid in the abdomen, this is highly suggestive of ruptured ectopic

Management

This really depends on the answer to Question 2.  If this is an ectopic, then the priorities are haemostatic resuscitation (MTP etc) and transfer to OT for laparoscopy (for ectopic) +/- D&C if no ectopic is found.

If not, there is a lot we can do in ED to stop the bleeding and resuscitate the patient (esp if you don’t have rapid access to OT, like in the case above) –

• Speculum to remove products from the os (there are 2 indications for this – heavy bleeding/unstable patient in early pregnancy, where you can remove products from the os to help clear the uterine cavity to allow the uterus to contract, or bradycardic/hypotensive patient, where the problem might be cervical shock (vagal stimulus of a distended cervical os))
• Oxytocin 10U IV
• Ergometrine 500mcg IM
• Misoprostil 1000mcg PR
• Tranexamic Acid
• Reverse coagulopathy, anticoagulants etc
• Consider vaginal packing as a temporary measure
• OT if still bleeding

Massive Transfusion Protocol (MTP) in pregnancy

Keep in mind, if you are having to use MTP for pregnancy related bleeding regardless of whether it might be an ectopic, the MTP aims are different.  There are 2 key numbers to remember – 80 and 1.5:

Target Hb > 80
Target plt > 80
Target INR < 1.5
Target Fib > 1.5

Also…aim to keep the Ca > 1.12 and consider recombinant Factor VIIa if you have needed to use 10 units of PRBC

My thoughts on how to approach these patients

This patient bled much more than the hundreds of early pregnancy bleeding/incomplete miscarriage patients that we typically see. The question then becomes … who bleeds heavily in early pregnancy?  There are 3 main groups – ectopic pregnancy (they typically rupture at 6-10 weeks), 2^ndtrimester incomplete miscarriage (the uterus is MUCH more vascular in 2^nd trimester), and patients with coagulopathy (sometimes this is previously undiagnosed)

So, what do I take home from this?

• PV bleeding can be catastrophic
• Key questions are whether the patient is pregnant, what stage of pregnancy, and could this be an ectopic
• Bedside USS is useful but know the limits
• Patients with suspected ectopic need resuscitation and Theatre
• For patients with incomplete miscarriage there are a number of interventions that we can do in ED to stop the bleeding and resuscitate the patient.

Dr Adam Michael