A 28-year-old woman with sickle cell disease undergoes an induction of labor and has a spontaneous vaginal delivery. After delivery of the placenta, the patient begins to have heavy vaginal bleeding and passage of large, fist-sized clots. She is administered a high-dose oxytocin infusion and multiple uterotonic agents but continues to bleed heavily. Ten minutes later, the patient suddenly develops shortness of breath and chest pain. Blood pressure is 70/40 mm Hg, pulse is 118/min, and respirations are 28/min. Cardiac examination shows sinus tachycardia. Respiratory examination reveals tachypnea but clear lung bases. The uterus is soft and distended above the umbilicus, and the patient continues to have profuse vaginal bleeding. Laboratory results are as follows: Which of the following is the most likely cause of this patient's acute decompensation?

Question

A 28-year-old woman with sickle cell disease undergoes an induction of labor and has a spontaneous vaginal delivery.  After delivery of the placenta, the patient begins to have heavy vaginal bleeding and passage of large, fist-sized clots.  She is administered a high-dose oxytocin infusion and multiple uterotonic agents but continues to bleed heavily.  Ten minutes later, the patient suddenly develops shortness of breath and chest pain.  Blood pressure is 70/40 mm Hg, pulse is 118/min, and respirations are 28/min.  Cardiac examination shows sinus tachycardia.  Respiratory examination reveals tachypnea but clear lung bases.  The uterus is soft and distended above the umbilicus, and the patient continues to have profuse vaginal bleeding.  Laboratory results are as follows:  Which of the following is the most likely cause of this patient's acute decompensation?

Quizplus · Accepted Answer

11ec25c8_da67_69fa_bc81_0ba4753d1312_MD0003_00 This acutely decompensating patient has most likely developed disseminated intravascular coagulation (DIC). Obstetric complications (eg, postpartum hemorrhage, placental abruption) are a major cause of DIC due to the large volume of bleeding associated with these conditions. Significant bleeding can cause release of tissue factor (thromboplastin), which leads to uncontrolled activation of the coagulation cascade and a consumptive coagulopathy. This leads to the formation of fibrin- and platelet-rich thrombi, which consume platelets (ie, thrombocytopenia), coagulation factors (evidenced by prolonged PT/INR and PTT), and fibrinogen. Fibrinolysis is then triggered to degrade the clots, which elevates D-dimer (a fibrin degradation product) and depletes antithrombin and proteins C and S. This results in a paradoxical thrombosis, as in this patient who has developed symptoms of pulmonary embolus (eg, dyspnea, chest pain, tachypnea). The thrombi in the vasculature also often shear red blood cells, leading to a microangiopathic hemolytic anemia (evidenced by elevated total bilirubin levels). Patients with DIC require emergency supportive care, including treatment of the underlying etiology (eg, uterine atony causing postpartum hemorrhage) and resuscitation with blood products (eg, packed red blood cells, fresh frozen plasma). (Choice B) Although patients with sickle cell disease may require chronic opioids to manage painful vasoocclusive episodes, opioid withdrawal typically presents with mydriasis, piloerection, and yawning, not thrombocytopenia or abnormal coagulation studies. (Choice C) Oxytocin toxicity can occur in patients with prolonged or high-dose oxytocin administration (eg, induction of labor, postpartum hemorrhage). However, these patients have severe hyponatremia and related neurologic symptoms (eg, headache, seizure), not thrombocytopenia or abnormal coagulation studies. (Choice D) Splenic sequestration crisis, a life-threatening complication of sickle cell disease, can cause acute anemia, thrombocytopenia, and hypovolemic shock due to splenic pooling of RBCs and platelets. However, this condition mainly affects children because adults with sickle cell disease are functionally asplenic due to recurrent splenic infarction. (Choice E) Thrombotic thrombocytopenic purpura causes microangiopathic hemolytic anemia and thrombocytopenia that can result in shortness of breathing and bleeding. However, it does not typically cause a consumptive coagulopathy; therefore, patients typically have normal coagulation studies. Educational objective: Significant obstetric bleeding (eg, postpartum hemorrhage) can cause disseminated intravascular coagulation. This condition typically presents with bleeding and/or thrombosis (eg, acute pulmonary embolus), thrombocytopenia, and prolonged PT and PTT. References: Disseminated intravascular coagulation syndromes in obstetrics. (http://www.ncbi.nlm.nih.gov/pubmed/26444122) Disseminated intravascular coagulation in pregnancy: insights in pathophysiology, diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/25840271)

A 28-Year-Old Woman with Sickle Cell Disease Undergoes an Induction