key: cord-1052007-5bqghq8j
authors: Joshi, K.; Depala, A.; Pandya, S.; Harrison, S.; Kidel, C.
title: P.147 Management of coagulopathy induced by postpartum haemorrhage utilising thromboelastography in a COVID positive patient with liver cirrhosis and portal hypertension
date: 2021-06-09
journal: Int J Obstet Anesth
DOI: 10.1016/j.ijoa.2021.103145
sha: 3ea1f9950b8fbb9ffdfdf0d2f104329ad5460c82
doc_id: 1052007
cord_uid: 5bqghq8j

nan

reduced sensation with tenderness and swelling around the cannula site. Plastic surgery recommended limb elevation, IV antibiotics and a CT angiogram. This showed no vascular damage or collection but an incidental pulmonary embolism (PE) that was treated with low molecular weight heparin. By day 4 the limb had improved and the patient was discharged with no sequalae.

Discussion: Risk factors associated with IA injection include antecubital fossa placement and drug administration during anaesthesia induction. Hypotension has been described as a risk factor for IA injection but despite a total blood loss of 3 L there were no periods of hypotension. The inability to infuse fluid intra-arterially if not under pressure and an obvious back flow of blood into the infusion line has been described previously but as in this case is not universal. 2 Comparative blood sample gases were taken, however transducing the cannula would have helped confirm IA placement. Propofol has been described as causing hyperaemia and blanching and rocuronium causing tissue ischaemia. 3 Thankfully there was no long term sequalae and a potentially life-threatening condition of PE was detected incidentally. Introduction: Tipping normal haemostatic balance in any direction can result in either thrombosis or bleeding. The influence of liver cirrhosis and COVID-19 on coagulation can compound complexity in the management of coagulopathy after postpartum haemorrhage (PPH) and the decision on postoperative thromboprophylaxis. Thromboelastography (TEG) can be a useful adjunct to the routine coagulation tests to formulate a strategy.

Case Report: A 26-year-old multigravida with a history of liver cirrhosis, portal hypertension, splenomegaly and oesophageal varices was planned for an urgent caesarean section for fetal distress. She had tested positive for COVID-19 before surgery. Admission bloods showed platelet count of 24 × 10 9 /L, INR 1.1, fibrinogen 1.6 g/L whereas TEG showed low kaolin activated maximum amplitude (CK MA 36.4, normal range 52-69), normal R time and low functional fibrinogen (CFF MA 5.2, normal range 15-32). General anaesthesia was chosen over a neuraxial block in view of a hypocoagulable state. Atonic PPH post-delivery resulted in a 2 L blood loss. The patient received fibrinogen 2 g and two pools of platelets guided by TEG and platelet count. TEG was repeated postoperatively at 8 h and fibrinogen 2 g was administered based on the findings of CK MA 39.5, CFF MA 8.1 and normal a R time.

The following day CK MA remained low at 41.6 albeit near normal CFF MA. Her platelet count was 35 × 10 9 /L, almost reaching antenatal levels. There was no vaginal bleeding at this time. Usual postoperative pharmacological thromboprophylaxis for six weeks was omitted. At a discharge on day three, the patient was advised to actively mobilise and to wear anti-embolic stockings.

Discussion: Pregnancy is a hypercoagulable state resulting from an increase in procoagulants (factors 7, 8, 9, 10, 11 and fibrinogen) with a decrease in anticoagulants (Protein C / Protein S) and can be demonstrated by hypercoagulable TEG. A prothrombotic state is induced by COVID-19 infection showing hypercoagulable TEG in recent studies. 1 In chronic liver cirrhosis however, a state of coagulation is often re-balanced with a low reserve of procoagulants and anticoagulants. Bleeding can tip this balance towards hypocoagulable state. 2 TEG can evaluate a global haemostatic function with a rapid turnaround time which assisted our decisions regarding transfusion of blood products. Despite having two prothrombotic conditions of pregnancy and COVID-19, low platelets and hypocoagulable TEG empowered our decision to omit pharmacological thromboprophylaxis for our patient. The patient did not have thromboembolic events in postnatal period. Introduction: Uterine rupture is a rare but life-threatening event with a quoted incidence of 5.1 per 10,000 deliveries in scared uteri. 1 It only rarely occurs in a non-labouring parturient. 2 We describe a case of uterine rupture in a non-labouring multigravida with resultant major haemorrhage requiring a number of surgical interventions.

Case Report: A 35-year-old G4P2 woman presented for an elective caesarean section (CS) on a background of two previous uneventful CS. In theatre prior to neuraxial blockade she complained of sudden onset severe lower abdominal pain. On opening of the intra-abdominal cavity the fetus was found to be extra-uterine and a spontaneous uterine rupture was diagnosed. Following successful delivery of the fetus, the uterus was repaired and the abdomen closed in the usual manner. Point-of-care (POC) haemoglobin was noted to be 111 g/L. Post-operatively the woman developed cardiovascular instability and vaginal blood loss. This necessitated an EUA of the vagina and a blood transfusion. Despite reported haemostasis and a reassuring POC haemoglobin of 146 g/L, she continued to deteriorate. Concern shifted to other possible causes of her instability, which was complicated by hyperkalaemia with ECG changes. With no clear diagnosis, supportive measures were taken and she was transferred, intubated, to the ICU. On the ICU, progressive abdominal distension was noted which warranted CT imaging. This revealed intra and extra uterine haematoma formation. A subsequent laparotomy found scar dehiscence and arterial bleeding which was repaired alongside a haemostatic transfusion. Overall blood loss was estimated at 4480 mL. She was transferred back to the ICU and extubated the following morning after correction of physiology. Thankfully, she recovered well with no reported morbidity. The baby required limited supportive therapy only.

Discussion: This case has led to a number of learning points. Firstly, despite the rarity of uterine rupture in a non-labouring parturient, it must be considered as a cause of sudden and severe abdominal pain. This is especially true in an at risk patient population and prompt delivery must be achieved. Secondly, use of haemoglobin testing in the acute

International Journal of Obstetric Anesthesia 46 (2021) 102988

COVID-19 infection-related coagulopathy and viscoelastic methods: a paradigm for their clinical utility in critical illness

Point-of-care testing in liver disease and liver surgery