Banner, S. and Crossan, D.
CASE STUDIES
Massive Transfusion Protocol: Saving Our Patients Lives
Amy Dempsey, MSN, RNC, Background
Exempla Lutheran Medical ostpartum hemorrhage remains the single
Center, Arvada, CO
Keywords
P most significant cause of maternal death
worldwide. It occurs in 2% to 6% of women who
postpartum hemorrhage deliver vaginally. It can occur early (<24 hours
massive transfusion protocol after birth) or late (>24 hours and <6 weeks af-
DIC
ter birth). The primary cause of early postpartum
Code White
hemorrhage is uterine atony, and it is typically de-
fined as >500 ml blood loss following vaginal de-
livery, >1,000 ml following cesarean, or a 10%
Childbearing
decrease in hematocrit (HCT). Interventions for
Poster Presentation postpartum hemorrhage include treating the un-
derlying cause and managing the symptoms with
medications, surgical interventions, placement of
uterine tamponade devices, and blood volume re-
placement. Improved outcomes are seen with co-
ordinated team efforts and established hospital
processes.
Case
A 45-year-old, G4P1 presented to labor and de-
livery in early labor at term. On admission her
HCT was 39.9. Her labor was augmented, and
she progressed quickly and delivered vaginally.
Following delivery of her placenta, she began
to hemorrhage. The patient was treated in the
delivery room with fundal massage, Misoprostol,
Hemabate, placement of Foley catheter, and Bakri
balloon. Anesthesia and a second obstetrician
were consulted and a disseminated intravascular
coagulation (DIC) panel and two units of packed
red blood cells were ordered. The patient became
symptomatic and was transferred to the operat-
ing room (OR). A Code White was called and an
interdisciplinary team of obstetricians, laboratory,
Mirror Syndrome in Pregnancy: Two Patients, One Disease
Sheryl Banner, BSN, RNC, Background
Christiana Care Health System, irst described in 1892 by John W. Ballantyne,
Hockessin, DE
Dawn Crossan, RN, Christiana
F Mirror Syndrome is a preeclampsia-like dis-
ease characterized by fetal or placental hydrops,
Care Health System, Newark, maternal anemia, edema, hypertension, liver dys-
DE function, and poor fetal outcome. It is called Mir-
Keywords ror Syndrome because the maternal pathology
Mirror Syndrome mirrors that of the fetus. This is a rare condition
preeclampsia whose etiology is not known. Some of the poten-
ascites tially critical maternal sequelae of Mirror Syndrome
hydrops include pulmonary edema, adult respiratory dis-
tress syndrome, pericardial effusions, and renal
failure.
Childbearing
Poster Presentation
JOGNN 2013; Vol. 42, Supplement 1
Proceedings of the 2013 AWHONN Convention
intensive care unit (ICU), and spiritual care per-
sonnel responded.
After intubation in the OR, the patient continued to
hemorrhage. The decision was made to proceed
with a hysterectomy. A massive transfusion proto-
col was initiated with the blood bank to facilitate
preparation and thawing of blood products. Dur-
ing the surgical procedure, the patient developed
ventricular tachycardia, and a Code Blue was acti-
vated. Additional interdisciplinary team members
from the emergency department, pharmacy, and
ICU responded. At this time, the patient’s HCT
dropped to 21.9, fibrinogen <60, PT = 40, INR
= 4.15, and arterial blood gas pH 6.97. During the
surgical case, the patient received 11,440 ml fluid
and 11 units PBRC, 7 units fresh frozen plasma,
3 units of platelets, 4 units cryoprecipitate. Her
DIC stabilized and her heart rhythm returned to
sinus tachycardia. She remained intubated and
was transferred to ICU. The following day she was
extubated and transferred to postpartum and she
was discharged home on postoperative day 4. The
patient is now a spokesperson for the community
blood bank.
Conclusion
To efficiently manage massive postpartum hemor-
rhage, early treatment must be initiated, interdisci-
plinary teams should be utilized, and in this case
our massive transfusion protocol was activated.
Coordination of care with the blood bank was crit-
ical to receive the necessary blood products in a
timely manner.
Case
A patient was transferred to us at 27-week ges-
tation for severe preeclampsia but was later
diagnosed with Mirror Syndrome. The patient
complained of flu-like symptoms lasting 3 days,
headache, and decreased fetal movement. Signs
and symptoms included hypertension, oliguria,
proteinuria, pitting edema, and abnormal lab val-
ues. Acute right-sided abdominal pain developed
during transfer. The pregnancy was known to
be complicated by hydrops, ascites, and multi-
ple fetal anomalies thought to be incompatible
with life. She was treated with magnesium sul-
fate, antiemetics, narcotic pain control, and intra-
venous hydration. A 24-hour urine collection and
pregnancy-induced hypertension labs were initi-
S97
CASE STUDIES
Proceedings of the 2013 AWHONN Convention
ated. A magnetic resonance imaging (MRI) scan
and a surgical consult were ordered to rule out ap-
pendicitis. The MRI verified mild anasarca within
the abdomen and pelvis, but the appendix was
not adequately visualized.
The 24-hour urine had nearly 5 grams of pro-
tein. The patient became increasingly uncomfort-
able with bilateral 3+ pitting edema from her feet
through her thighs. Induction was recommended
due to worsening maternal status, and the po-
tential for other morbidities associated with Mir-
ror Syndrome. Fetal paracentesis of 600 ml was
performed to facilitate vaginal breech delivery.
An Unusual Case: Testing for Fetal Trisomy Abnormalities
in Maternal Blood at 33-Week Gestation
Background
n 1997, the detection of fetal deoxyribonucleic
I acid (DNA) in maternal circulation suggested
the future of noninvasive prenatal testing. It is es-
timated that 95% of all women opt for prenatal
screening. Reasons may include the desire to pre-
pare for the birth of an affected child; prepara-
tion for the possibility of an in utero or neonatal
death; planning for the time, mode, and place of
delivery; planning for specialists to care for the
affected child; and options for termination. Inva-
sive tests carry a risk of injury to the fetus and
are not 100% accurate. Fetal DNA testing for ane-
uploidy has been reported to have 98% to 99%
specificity.
Case
Our patient was transferred to us at 33-week ges-
tation when an ultrasound detected anhydram-
nios. Genetic testing was offered multiple times
due to known fetal anomalies, but she declined.
Amniocentesis was no longer an option secondary
to anhydramnios; however, trisomy 18 was sus-
An Unusual Case of Infectious Endocarditis in Pregnancy
Background
nfectious endocarditis during pregnancy is
I rare, occurring in an estimated 0.006% of
pregnancies. Right-sided endocarditis is most
commonly associated with heart and valvular
diseases, whereas left-sided endocarditis is as-
sociated with intravenous (IV) drug use. Maternal
mortality rates are high (33%) due to complica-
tions of heart failure and embolic events, and fe-
tal mortality rates are between 14% and 33%. In-
fectious endocarditis presents unique challenges
S98 JOGNN, 42, S92-S110; 2013. DOI: 10.1111/1552-6909.12196
A stillborn female infant with multiple anoma-
lies, generalized edema, and ambiguous geni-
talia was delivered weighing 3 pounds 2 ounces.
Magnesium sulfate continued postpartum for 24
hours. The postpartum course was unremarkable,
and the patient was discharged 48 hours after
delivery.
Conclusion
Careful evaluation is needed to differentiate be-
tween preeclampsia and Mirror Syndrome be-
cause the maternal morbidity may be more
extensive.
pected, so prenatal diagnosis for confirmation Sheryl Banner, BSN, RNC,
of diagnosis was recommended. Transabdominal Christiana Care Health System,
chorionic villi sampling (CVS) was attempted but
unsuccessful because only maternal cells were
Hockessin, DE
Deborah Harvey, BSN, RNC,
obtained. A relatively new procedure to test the Christiana Care Health System,
maternal blood for fetal DNA to detect aneuploidy Boothwyn, PA
abnormalities was considered a solution. Ultra- Keywords
sound indicated a single umbilical artery, cleft fetal DNA
lip, abnormal kidneys, absent bladder, and rocker trisomy
bottom feet. The patient was counseled regarding fetal anomaly
the significant risk of neonatal death in the case of
trisomy 18 but insisted on full resuscitative mea-
sures and a cesarean section for fetal distress. Childbearing
Ironically, she had a Category I fetal monitor strip,
and the biophysical profile score was 2/10. Kary- Poster Presentation
otyping of the newborn indicated Turner Syndrome
and trisomy 16.
Conclusion
This was our first encounter with transabdominal
CVS and fetal DNA testing in maternal blood. We
are interested in the impact on the future.
in patient care management, such as antibiotic Kimberly Francis, RNC,
treatment, timing of delivery, and timing of cardiac Christiana Care Health System,
surgery if required. Wilmington, DE
Dina Viscount, MSN, CNS,
RNC-OB, Christiana Care
Case Health System, Newark, DE
A 30-year-old G4P1 at 26 5/7 weeks gestation
was transferred to labor and delivery from an-
other facility with a 2-week history of fever, chills,
nausea, vomiting, and cough. Her medical history
included, methicillin-resistant Staphylococcus au-
reus, Hepatitis C, anemia, and IV drug abuse
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