Cardiac output and fluid replacement in a Jehovah’s Witness with severe postpartum hemorrhage

Abstract

In the 2003–05 Confidential Enquiry into Maternal and Child Health report hemorrhage was the second leading cause of direct maternal death and included 14 women who declined blood transfusion. 1 Lewis, G. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer-2003–2005. The seventh report on confidential enquiries into maternal deaths in the United Kingdom. London: CEMACH; 2007. Google Scholar We report the usefulness of a continuous cardiac output monitor to assess tissue oxygen delivery (DO2) in severe postpartum anemia. A 24-year-old (163 cm, 51 kg) primiparous Jehovah’s Witness with a baseline hemoglobin of 16.3 g/dL, had a term vaginal delivery accompanied by an estimated blood loss of 1450 mL. Ongoing bleeding required vaginal packing and surgery 10 h postpartum. A FloTrac™/Vigileo™ (software 1.07) was placed in the radial artery to assess cardiac index (CI) and stroke volume variation (SVV). Blood loss was replaced with colloids and crystalloids to maintain a target of CI > 3 L/min/m2 and SVV < 10%. On post-operative day (POD) 1, the patient had a Hb of 3.0 g/dL was tachypneic (22–24 breaths/min) and was given oxygen by facial Venturi mask. The oxygen delivery (DO2) was calculated as 360 mL/min. A slight respiratory alkalosis (pH 7.49, pCO2 34 mmHg) with hyperthermia (39°C) and transient episodes of hypotension (BP 70/40 mmHg) were present and treated with fluids as indicated by CI and SVV. The patient’s electrocardiogram indicated tachycardia and S–T segment depression (1 mm) in the anterior and lateral leads; slight increases in serum lactate levels (0.22 mmol/L) and T troponin increase (0.13 mcg/L; myocardial infarction threshold 0.20 mcg/L) were recorded. Creatinine, transaminases, serum lactate, and urea were sampled daily and remained within normal limits. On POD 5 she was discharged from ICU (Hb 4.5 g/dL) with a DO2 of 700 mL/min and was discharged on POD 14 with a Hb of 6.8 g/dL. Throughout the patient’s ICU stay, her CI and SVV were maintained (range of 3.9–4.3 L/min/m2 and 7–12%, respectively) without the use of vasoactive drugs and she maintained normal cognitive function.