This blog post contains graphic descriptions of obstetric surgery which you may find upsetting.
On Saturday night, the night I wrote that last email to you, it had been a particularly tough day at the hospital at the end of a particularly tough week. I lost another patient that night, a woman who didn’t know her age but looked to be about 35 years old.
She showed up at the hospital at about 1 pm with a history of having seizures at home. She was apparently home alone and woke up on the floor with a vague memory of losing control of her arms and legs and then losing consciousness. She was unaccompanied by family. Somehow she had managed to make it to the hospital by herself. This had never happened to her during her previous pregnancies.
Her blood pressure was 230/120, roughly double what it should be. She was having trouble focusing on us with her eyes and her conjunctivae, the pink skin under her eye inside her eyelid, was almost white which indicates a significant anemia. Her blood counts were low but not horribly low. We tried to check her urine for protein, a hallmark of eclampsia (seizures related to high blood pressure in pregnancy), but she wasn’t able to urinate. We placed a catheter but her bladder was empty. Her tongue and mouth were bone dry. We started two IVs and started hydrating her with IV fluids while starting her on Magnesium Sulfate to prevent more seizures. Then we started working on getting her blood pressure down.
It took large doses of labetolol to even begin to bring her blood pressure down. After four successively increasing doses we switched to hydralazine which seemed much more effective for her. Only after getting her blood pressure down into a safer range, about 150/90, did I look at the baby with ultrasound and found that it was dead. It measured about 34 weeks, roughly eight months, and the way the bones in its skull overlapped suggested that it had been dead for more than a brief time. I explained to her that the baby had died and she accepted it without much of a reaction. She had six living children at home.
After her consent we gave her medication to cause her to go into labor. An hour had passed since she arrived and she still hadn’t produced any urine even after two liters of IV fluids. We added more fluid after listening to her lungs to make sure she wasn’t having any problems with congestive heart failure. Her lungs were clear. I think it was somewhere about halfway through the third liter of fluid when she began to have a trickle of urine into the catheter bag.
She responded quickly to the medication we used to induce her labor, misoprostol. She had already been dilated to three centimeters with the baby floating high out of the pelvis. Within two hours of admission she was almost fully dilated. Her body seemed ready to get rid of the pregnancy. There was a huge gush of fluid when her bag of waters broke and then, to my dismay, I saw that the baby’s arm had prolapsed out of the vagina.
The arm could not be reduced so, after explaining the situation to her, she signed a consent to let us take her to the operating room (OR) to try and do an internal version, to find the baby’s feet and remove it as a breech. There was still no family with her. Her urine output was still slight but it was increasing as the IV fluids traveled through her vascular system and through her kidneys.
Under spinal anesthesia we were able to find the baby’s feet and the delivery was fairly quick. The baby’s skin was peeling which was consistent with a baby that had been dead for a while. The head was misshapen where the bones overlapped, also consistent with a not recent death. During the procedure she lost very little blood. It seemed that we had all bases covered.
But when we got her into the recovery room her blood pressures started to drop dramatically. They had been in the 100/60 range during the procedure in the OR. It’s not unusual to see the blood pressure drop after a spinal anesthetic so that range seemed appropriate but by the time she got to the recovery room her BP was dropping into the 60/30 range and then down into the 45/20 range. Remarkably she was still awake and alert for a while. We opened up her IV fluids and the anesthetist gave her medication to raise her BP but the results weren’t great and usually didn’t last long.
I pushed some large clots from her uterus, a significant amount of blood but not a huge amount. Even so, we repeated her hemoglobin to see where we stood and were surprised to find out that it was less than half of what it was on admission. In retrospect it’s easy enough to see that the hemoglobin of 7.5 that we got initially was due to hemoconcentration. The patient was severely dehydrated and that made her blood counts look higher than they actually were.
Jeremy, the anesthetist with whom I’ve worked closely for a month now, ordered blood for transfusion urgently, fighting to keep her blood pressure up. He barked at the blood bank when they were too slow getting the blood to us. He used volume expanders as IV fluids. He got two units of blood in pretty quickly and her hemoglobin went from 3.5 to 4.5.
And right about then she coughed hard and we lost every drop of blood we had transfused her with. A huge flood of blood poured out of her vagina and, to my dismay, there were only a few blood clots. It poured over the bed and onto the floor and continued to drip. I massaged her uterus until my hand hurt while giving her oxytocin and misoprostol to force her uterus to contract. Her uterus felt firm but she continued to bleed heavily.
The only sounds in the room were the machines taking her pulse and blood pressure and the steady drip of blood onto the floor. I did an ultrasound to make sure there was no blood in her abdomen, that we hadn’t ruptured the uterus during the removal of the baby but there didn’t appear to be any free fluid. I placed a Bakri balloon inside her uterus and inflated it with 500 ml of fluid to try to create enough pressure to stop the bleeding. Nothing worked.
There were several times when her breathing became long and protracted and we were sure she was going to die but we managed to bring her blood counts up a little by the third unit. Even though it was not optimal we knew we weren’t going to get any better if we planned to operate.
Her family had arrived by then. Even though I hadn’t had a chance to meet them I went out and explained to them that the patient was very sick and might very well die. They were unaware that she had delivered the baby and did not even know that the baby had not been born alive. I told them that we needed to try and save her life by removing her uterus but they misunderstood me and thought I was telling them that I had already removed her uterus.
Eventually I was able to make them understand through a translator that the reason she was in the OR was not because she’d had surgery but because she’d needed anesthesia so we could remove the baby. After that there was a long family discussion, phone calls to the patriarch of the family, and finally the decision that the patriarch would decide and call back in 20 minutes. During those 20 minutes the patient continued to bleed around the balloon I had placed in her uterus and her hemoglobin again dropped to less than 3.0, a quarter of what it should have been.
We finally heard from the uncle who was in charge and he gave permission to the husband’s mother to sign the consent form with her thumbprint. They were in a small area outside of the OR by then and we had to wheel the patient from the recovery room back to the OR, a path that took us directly past them. They could see the trail of blood that followed the gurney as the patient continued to bleed.
The patient died before we even had a chance to move her from the gurney to the OR table. She had one final, gasping breath and then nothing. There was no way to bring her back.
Five minutes after I had rolled the patient past the family I went back out to tell the family. One of them mistakenly assumed we had already finished the operation. When I told them that we had never had a chance to operate there was one who looked ready to pass out but the rest of the family, six women in all, seemed to accept it without question or anger.
We cleaned as much of the blood off of the patient as we could and then placed her in a body bag with only her face showing. She was taken to the morgue where the family will arrange for her body to be transported back to her village.
We have patients who die. Sometimes we save them but often we don’t. I’ve noticed a tendency I have to mainly write about the cases where the outcome is a good one. That’s often not the case. It’s so different from the medicine we practice back home.
I have lots of questions. I wonder if we had realized how low her blood counts were earlier, if we had transfused her earlier, if that might have made a difference. I don’t know. I think she went into disseminated intravascular coagulation, using up all her clotting factors as she continued to bleed but I don’t really know. The eclampsia might have caused her platelets to be abnormally low making it hard for her blood to clot but again, I don’t really know. The questions I have are never going to be answered.
I think what makes a patient like this woman especially hard to lose is that she didn’t seem that sick when she came in. Unlike the woman who comes in with a ruptured uterus I never could have predicted that this might be the last day of her life. It’s a humbling experience, one I don’t want to repeat even though that possibility seems to lurk behind every phone call I get to maternity.