Miao-Miao Chen, Yong-Chao He, Meng-Yuan Pei, Hua-Ting Zhang, Xiao-Yu Liu

1The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai 264000, China. 2Northwest Minzu University, Lanzhou 730000, China. 3Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250022, China. 4Qilu Children’s Hospital of Shandong University, Jinan 250022, China.

Abstract Objective: To summarize the first aid and nursing of the operating room due to serious complications caused by postpartum massive bleeding. Methods: One case of emergency hemorrhage was ineffective in emergency hysterectomy. Results: The uterus was successfully removed and the bleeding was successfully stopped. It was transferred to the ICU under general anesthesia. Conclusion: For pregnant women with postpartum massive bleeding and hemorrhagic shock and diffuse intravascular coagulation (DIC), targeted surgical treatment and complete operating room emergency care are of great significance to save maternal lives.

Keywords: postpartum bleeding; hemorrhagic shock; uterine artery embolization;hysterectomy; DIC; emergency care in the operating room

Background

Postpartum bleeding is a postpartum complication of bleeding greater than 500 ml within 24 hours after maternal termination of pregnancy[1], The vast majority of postpartum bleeding can be achieved by adopting conservative treatment methods (such as the application of oxytocin, hemostatic drugs, vaginal gauze filling, continuous uterine massage, and continuous external uterine compression, etc.) [2],However, some postpartum bleeding with conservative treatment methods cannot achieve hemostasis, the formation of refractory postpartum bleeding [3]. Surgical intervention requires uterine artery embolization, hysterectomy and other surgical methods. This kind of maternal postpartum bleeding is easily combined with hemorrhagic shock, DIC and even secondary multiple organ dysfunction syndromes(MODS), which is one of the important causes of maternal death [4].Coping with such maternal women, there are Targeted surgical rescue and complete operating room care are extremely important. In May 2020, our hospital successfully rescued a case of massive hemorrhage with hemorrhagic shock and DIC and emergency hysterectomy after ineffective uterine artery embolization. The emergency and nursing are reported as follows.

Clinical data

Case introduction

Maternal Yan X, female, 37 years old, was admitted in 2021-12-01 due to 38 weeks + 5 days and abnormal fetal heart monitoring, and underwent previous cervical colectomy. During pregnancy, our hospital conducted regular prenatal examination, stopped by ultrasound for more than 5 months, and the examination was still low placenta. The NST was atypical in our hospital 3 hours ago, and the review was still atypical. Obstetrical color ultrasound shows singleton,head position, BPD 9.1 cm, FL 7.3 cm, AF 9.4 cm, fetal weight estimation: 3586 g ± 524 g, fetal heartbeat 146 points, RI 0.64, PI 1.17, S/D 2.8, placenta in the posterior wall, grade I-, and the lower boundary is about 1.8cm from the inner cervix. After hospital admission, NST reaction type was re-examined. After the natural rupture of the membrane on 2021-12-10, she gave birth and the delivery process progressed smoothly. The orifice of the uterus was completely opened at 14:15, and a 3600-gram baby boy was delivered along with lateral episiotomy at 15:00. The Apgar scores were 10 points in 1 to 5 minutes. There was no deformity in appearance, clear amniotic fluid and medium volume. The umbilical cord was wound around the neck. The placenta and fetal membrane were delivered completely, with suboptimal uterine contraction and about 800 ml of bleeding. Two open venous pathways were given and the uterus was massaged by hand. Intravenous oxytocin 10 units were applied intravenously, one cervical injection was conducted with Carboprost Tromethamine Injection, and two vaginal plugs were used for improving the anus-in contraction. The cervical short contraction was checked, and the exposure was difficult. No obvious bleeding point was observed. There was still active bleeding out of the uterine cavity.The blood pressure was measured at 110/60 mmHg, and the heart rate was 110 times/min. ECG monitoring was conducted. Rapid fluid replacement was conducted, and oxytocin was added. The vaginal retractor was placed. When it was checked that no bleeding point was found at the external orifice of the cervix, and the uterine contraction was good, gauze was given to compress the cervix, and vaginal bleeding was reduced. 0/2 absorbable suture the perineal incision.The cervical filling gauze was removed, and there was still active bleeding from the uterine cavity, bright red, the patient's blood pressure decreased to 90/55 mmHg, and the heart rate was 140 times/minute. Rapid intravenous fluid rehydration, urgent blood type,cross blood matching, electrocardiogram and blood preparation.Considering the cause of bleeding, it should not be ruled out by low placental attachment hemorrhage or scar vascular rupture hemorrhage after cervical colectomy, decided to inform the emergency operating room for rescue, urgent anesthesiology department and gynecology consultation, planned to perform uterine artery embolization and find the bleeding point, and hysterectomy if necessary. To indicate the necessity and possible risks to the puerpera and relatives, the puerpera and relatives have agreed to the operation,express their understanding of the possible risks, and have signed the operation consent form. The operation was scheduled to be performed immediately, the operation was smooth, and the woman was transferred to the ICU under anesthesia. Patients agreed to this study,signed informed consent and voluntarily participated in the research process.

Surgical progress was performed

After uterine artery embolization, the vaginal bleeding is still turbulent and the blood pressure is unstable. In order to save lives,after explaining the condition to the family members, the emergency department performed a total hysterectomy under general anesthesia from 2021-12-10, 18:25–21:00. intraoperative: uterus enlarged, soft,pale, smooth, lower edema, enlargement, bilateral accessories without abnormalities. Lift the uterus, pad the intestine, clamp, cut the bilateral uterine ligaments, 0#Silk suture; hole in the posterior lobe of the broad ligament, clamp and cut off bilateral fallopian duces and ovarian intrinsic ligament, 0#Tie two stitches; open the uterine bladder to reverse fold the peritoneal, push the bladder down to the external cervical level, treat the sacral ligament, push the rectum down to the external cervical level, separate the uterine tissue, expose the uterine vessels, cut the part of the uterine moving vein, 0#Tie two main ligaments, clamp, cut and sew, remove the uterus along with the vaginal vault, continuously suture the residues with no. 1 absorption line, check no bleeding, rinse metronidazole, continuously suture the pelvic peritoneal with no. 4 wire, hang bilateral attachment to the round ligament residue. Check no bleeding, place 1 drainage tube,plug 2 gauze in the vagina, and remove the uterus for pathology.

Surgical rescue and nursing

Preoperative preparation

When the personnel prepares the puerpera to enter the operating room, the operating room nurse, anesthesiologist, obstetrician, and gynecologists are all in place and ready for rescue.

Room temperature at about 25℃, prepare warm blanket and heater,and inject warm fluid during the operation. The surgical device and the autologous blood transfusion device are in the functional position,and the rescue vehicle and rescue drugs are in the standby state.

Monitoring of maternal

ECG monitoring immediately after entering the operating room, heart rate 145 times/min, blood pressure 60/41 mmHg, breathing 29 times/min. Aerological analysis of immediate action pulse puncture showed a maternal arterial blood lactate content of 2.2 mmol/L.Arterial blood lactate content is the exact indicator of tissue hypoxia and one of the sensitive indicators that reflect inadequate tissue perfusion. Continuous arterial blood gas lactate monitoring has positive implications for early diagnosis, guiding treatment, and prognostic assessment [5].

Early restricted fluid resuscitation

After the parturient entered the operating room, the roving nurses in the operating room immediately set up more than two venous pathways with intravenous indwelling needles of 20 G and above.Maternal postpartum bleeding and hemorrhagic shock and DIC. Before the bleeding is controlled, early restrictive liquid recovery can properly restore microcirculation perfusion, provide appropriate oxygen supply for tissues and organs, and reduce the impact of the body [6].

Application of washing autologous blood transfusion device

The application of washing autologous blood transfusion devices can minimize allospecific blood transfusion and reduce the occurrence of surgical complications [7]. However, the type of recycling lines used in the autologous blood transfusion device, the negative pressure attraction suction degree and the texture of the washing liquid will affect the quality of the blood after washing [8]. Therefore, it should be used in strict accordance with the operating procedures.

Intraoperative tumor-free technical management

Because it is an organ resection surgery that involves the uterus and its accessories, in order to avoid surgical complications of endometriosis and other diseases, the surgical instrument table should reasonably distinguish between tumor-free area and tumor area. The instruments that have contacted the uterus and its accessories should be strictly placed in the tumor area. The instruments and surgical materials in the two areas are strictly prohibited, so as to avoid surgical complications as far as possible.

Results

The operation time was 2 h 35 min, the operation was difficult, still smooth, anesthesia was satisfactory, postoperative blood pressure 110/60 mmHg, heart rate 130–140 times/minute, ureteral color dark red, about 550 ml urine volume, 4000 ml intraoperative bleeding,1320 ml of autologous blood, 11 U red blood, 1880 ml plasma, 10 U, 1 platelet treatment volume, to ICU observation.

Discussion

Early identification of postpartum bleeding to reduce maternal complications

In 2017, the American Association of Obstetrics and Gynecology explained postpartum bleeding as causing bleeding from the mother,along with hypovolemic symptoms and signs [9]. The main factors of postpartum bleeding include uterine contractile force, soft birth canal fracture, coagulation dysfunction, and placental causes. Even in today's relatively advanced medical technology level, postpartum bleeding is still an unpredictable and frequent emergency in obstetrics[10]. Therefore, the early identification of postpartum bleeding,foreseen and comprehensive medical care intervention, have a positive significance to reduce maternal postpartum bleeding complications.

Give full consideration to the surgical risks and prepare for surgical cooperation

Postpartum bleeding often has severe complications and rapid course of the disease, and severe death may even occur [11]. Targeted surgical cooperation and comprehensive operating room care preparation are particularly important. Operating room nurses,anesthesiologists, obstetricians and gynecologists are fully staffed and prepared; rescue equipment is in functional position; build ECG monitoring platform and establish at least two venous channels as soon as possible; rescue drug treatment and implement restrictive liquid recovery plan; operating room washing nurses are fully prepared and follow the principle of aseptic technology and tumor-free technology.

Make reasonable use of autologous blood back transfusion device to reduce the body blood transfusion reaction

The autologous blood transfusion device was treated after returning the intraoperative bleeding by anticoagulation, filtration,centrifugation and washing. The advantage of autologous blood retransfusion is that the retransfusion through its own blood treatment can effectively reduce the transmission of blood-related diseases and the transfusion reaction caused by allogeneic blood transfusion, and also reduces the tension of allogeneic blood use to a certain extent,and creates favorable conditions for maternal first aid [12]. It is worth noting that the use of autologous blood retransfusion devices should be strictly operated in accordance with the instrument use instructions, strictly control the use of indications and contraindications, and minimize the incidence of blood transfusion reaction in the body.

Summary

In the current medical background, obstetric bleeding, as an obstetric emergency, is still one of the main causes of maternal death [13].Therefore, the identification of risk factors, the accurate judgment of blood loss, the emergency treatment of postpartum blood transfusion and some targeted surgical rescue and complete operating room care are particularly important. Reduce the risk of postpartum bleeding complications as far as possible, shorten the maternal hospital time,accelerate the recovery of maternal diseases, and ensure the quality of life.