I was on call at the end of a particularly busy day during my first year of O&G training. I was pretty keen to have something to eat and was contemplating the fact that I might actually get to do some study that night. Unfortunately fate had different plans for me. I was called to the Pregnancy Assessment Clinic at the Royal Hobart Hospital to see a young girl who been brought in at 35 weeks pregnant. She had taken some drugs, was not well and needed to be seen. As the story unfolded it became evident that she had taken some amphetamine, but not in the usual way. She had taken some tablets, crushed them, and then dissolved them in water from a jug on the kitchen table. She had then injected them into a vein. Not the recommended method of ingestion. Why had she done this? – her Uncle had died from an overdose the previous week and she just wanted to “get out of it” for a while.
She was exhibiting all the signs that you would expect from someone who had done this. A little out of it, high pulse rate, but she was okay. And so was her baby – for now. We put in a drip and kept a very close eye on her and the baby.
Half an hour later things seemed to be ticking along just fine. Her pulse was coming down. The blood tests that we had run earlier were normal. And then the baby crashed, it’s pulse rate dropping to dangerously low levels. We whizzed her upstairs to the operating theatres in no time flat and performed a caesarean. The baby came out a bit worse for wear but generally was okay. There was no sign of what had caused the problem. We finished the caesarean and the patient made her way back to the maternity ward. The baby of course went to the neonatal ICU.
Now I had a bit of time to be able to have that dinner I was wanting Afterwards I was enjoying a brief moment of quiet when an urgent page came from the maternity ward. As part of routine post-caesarean care our amphetamine ingesting patient has been discovered to be lying in a very large pool of blood. I rushed down to find what looked to be possibly a scene from a chainsaw massacre. There was blood everywhere – about 2 litres of it. She was shifted over to a critical care bed on the labour ward and I was the bunny who had to figure out what the hell was going on.
None of the blood was from her caesarean scar. All of it was coming from her vagina and there was a lot of it. Every so often she would cry out as she had an afterbirth pain and then SPLOOSH, another gush of bright red blood came pouring out of her vagina.
The main thing that stops women bleeding after they have a baby is the fact that their uterus contracts down HARD and cuts off the blood supply to where their placenta used to be. This girl’s uterus was contracting and every time it did so – another gush poured out. Whatever was going to happen needed to happen fast as she was losing blood at a rate of knots.
You remember how I said that contracting the uterus helped stop the bleeding – well…. We made it contract even harder using some heavy duty medication. This gave more afterbirth pains and that pain combined with the fact that she was not thinking very well due to low blood pressure and low oxygen to the brain made her a slightly uncooperative patient. She was thrashing around all over the place. At one point she thrashed around so much that she pulled out her drip. I thought I might pass out myself when this happened. Thankfully we were able to secure another IV and continue with giving her fluids and blood.
Repeat blood tests came back showing DIC – disseminated intravascular coagulation. Essentially this means that all of her clotting factors had been used up and so she couldn’t clot anymore - she just bled. In the midst of all this I was sent an angel. I rang up the haematologist on call who just happened to be in the hospital. The conversation went something like this, “Uh, Hi Dr Jupe. It’s Warren Kennedy on labour ward. I have someone on labour ward who has had a caesarean tonight and has now developed severe DIC and is currently bleeding to death before my eyes and I need your help.” It may have actually been a bit more garbled than that – I suspect it was. He very calmly told me he would look at her bloods and sort it. About 5 minutes later he appeared on labour ward, took a midwife with him and disappeared to the blood bank. A very short time after that they reappeared with both of them carrying cardboard boxes full of blood products that were duly squeezed into the girl’s veins and ever so slowly her bleeding eased and then stopped. Up until that point of time I had never heard of a “megabag” of platelets. Up until that point in time I didn’t believe in love at first sight until that moment when David Jupe arrived on labour ward with his megabag of platelets.
I really, truly thought that this girl was going to be my first ever maternal mortality (i.e. woman dying from childbirth). Thankfully she wasn’t and I still await for that first ever. I am unsure if I was perceived to be panicked during this crisis. I do know that I probably came very close to soiling my underwear multiple times (that moment when the drip was pulled out was one of them). I distinctly remember in the midst of the crisis one of the midwives fixating me with a look of dread and saying “What do we do next?” and me replying with sagely wisdom “Squeeze the bloody bags harder.”
So what was it due to? In the end it was felt that along with her amphetamine tablets and water she had also given herself a good dose of bacteria and this had caused the DIC. All in all she lost about 4 litres of blood which we calculated was probably about 80% of her total blood volume. It was a LOT of blood. The next day I looked back on what had transpired the night before and shuddered at the thought that for all of that blood she had lost, I had not seen a single clot.
The girl was transferred to ICU. By the next morning she was virtually back to normal. Certainly normal enough that she was able to avail herself of a cigarette outside the front doors of the hospital. She was back in maternity by the afternoon. A couple of days later she was ready to go home and I took the opportunity to tell her that this whole saga might be best looked at as a wakeup call to maybe turn her life around. She nodded and mumbled an obligatory “Yep.”
I have no idea of where she is or what her daughter is doing – she would be 14 now. But…. I hope that it was a wakeup call for her Mum and that she’ll never forget that night from hell. I know I won’t – I still remember her hospital ID number!