Complete Maternal Recovery after Prolonged Cardiac Arrest Due to Atonic Postpartum Hemorrhaging.

Dear Editor,

Postpartum hemorrhage is the leading cause of maternal morbidity and mortality worldwide.[1] Previous original reports treating maternal cardiac arrest only described the mortality rate and did not describe the cerebral performance category.[23] A 26-year-old woman delivered the second child at the other hospital (day 1). She had no remarkable personal or family history. She had postpartum continuous hemorrhaging from an injury at the cervical canal and atonic uterus. Continuous vaginal hemorrhaging over 3000 ml that failed to respond to fluid resuscitation, suturing of the injury or uterine massage resulted in a shock index of 2.0, tonic convulsion, and a coma state. She was transported and arrived at our hospital 4 h after the delivery. Upon arrival at midnight (day 2), she showed a coma state with dilated nonreactive pupils. Her vital signs were as follows: blood pressure, unmeasurable, and heart rate, 128 beats/min. The results of blood test were shown in Table 1. She urgently underwent infusion of oxytocin and antifibrinolytic tranexamic acid and a massive transfusion protocol by a rapid response team. She also underwent tracheal intubation. Infusion of oxytocin, antithrombin III, and noradrenaline as well as the application of uterine balloon tamponade failed to achieve stable circulation with stanching of continuous vaginal bleeding. Obstetricians decided to perform hysterectomy. Before entering the operation room, she received 20 units of packed red blood cells, 22 units of fresh-frozen plasma, 4 units of cryoprecipitate, and 7 bottles of albumin products, and the estimated amount of vaginal bleeding was 9100 g in total, including the referral hospital's values. During the operation, she repeatedly suffered cardiac arrest and achieved return of spontaneous circulation, requiring chest compression over 30 min, 12 mg of adrenalin infusion in total and an additional 22 units of packed red blood cells, 12 units of fresh-frozen plasma, and 10 units of platelets. After the operation, her circulation was still unstable under use of vasopressors, and she remained in a deep coma with dilated nonreactive pupils and accidental hypothermia (33°C) due to massive transfusion. Subsequently, she underwent induced hypothermic therapy for hypoxic encephalopathy for 24 h. The target temperature was 34.0°C. When sedatives were temporarily ceased, she became able to respond to simple commands. Her postoperative course was eventful including delayed bleeding from the right ovarian artery, pseudo-aneurysmal formation at the left iliac artery, thrombosis in the right common iliac vein and inferior vena cava, right thin subdural hemorrhage, and intra-abdominal abscess, treated by a multidisciplinary approach. On day 20, she was discharged without any neurological sequelae.

Table 1

Laboratory data at the time of deterioration

Variable	level
White blood cell/μL	14,600
Hemoglobin (g/dL)	1.6
Platelet (/μL)	4.9 × 104
Total protein (g/dL)	1.4
Albumin (g/dL)	0.7
Total bilirubin (mg/dL)	0.2
Aspartate aminotransferase (IU/L)	8
Alanine aminotransferase (IU/L)	3
Alkaline phosphatase (IU/L)	31
γ-glutamyltransferase (IU/L)	6
Lactate dehydrogenase (IU/L)	106
Amylase (IU/L)	39
Blood urea nitrogen (mg/dL)	7.9
Creatinine (mg/dL)	1.26
Creatine kinase (IU/L)	55
Glucose (mg/dL)	565
HbA1C (%)	5.8
Sodium (mEq/L)	137
Potassium (mEq/L)	4.8
Chloride (mEq/L)	102
Calcium (mg/dL)	6.6
Phosphate (mg/dL)	10.0
C-reactive protein (mg/dL)	0.16
Prothrombin time (s)	28.7 (12.0)
Activated partial thromboplastin time (s)	>150 (27.3)
Fibrinogen (mg/dL)	62
Fibrinogen degradation products (μg/mL)	109.2

HbA1C: Hemoglobin A1c

The first key point influencing the survival outcome might be our adherence to the postpartum hemorrhaging care bundle, including rapid team management.[4] The second key point influencing the favorable neurological outcome might have been the accidental and subsequent induced hypothermic therapy for hypoxic encephalopathy.[5] The further accumulation of cases is necessary to evaluate the efficacy of this approach to managing patients with cardiac arrest due to massive postpartum hemorrhaging and the final cerebral performance category.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Nil.

Conflicts of interest

There are no conflicts of interest.