Jehovah’s Witness patients presenting with ruptured ectopic pregnancies: two case reports

Design

Case presentation

Only the patient in the second case report received tranexamic acid (TXA).

A 35-year-old Nigerian woman in her second pregnancy presented to the emergency room (ER) with PV spotting, with an ultrasound revealing an empty uterus with free fluid and right adnexal mass. After extensive discussion and declining all blood products, the patient agreed to surgery and was given TXA 1 g IV. The ectopic was of significant size, and 1.5 liters of hemoperitoneum was recorded. Cell salvage was again used to minimize blood loss. Ischemic electrocardiogram changes were noted postoperatively, including ST depression consistent with hypoxic damage. Postoperative hemoglobin was 5.2. The patient was discharged 48 hours later on ferrous fumarate twice daily.

Study Author Conclusions

The authors believe that this case review series emphasizes the importance of appropriate management of Jehovah’s Witnesses in the studied units. In both of the above cases, these women were in potentially life-threatening situations. Advances in hematology and pharmaceutical therapy contributed to their survival.

Management of severe bleeding in a ruptured extrauterine pregnancy: a theragnostic approach

Design

Case presentation

A 37-year-old woman without significant medical history except for implantation of an intrauterine device (IUD) was admitted to the emergency department (ED) with abdominal pain and severe bleeding following a syncopal episode at home. Upon arrival, the patient was hypotensive (75/40 mmHg, 76 bpm) with a hemoglobin (Hb) level of 11.2 g/dL, platelet count of 255 x 10³ /mL, and an international normalized ratio (INR) of 1.09. The patient did not adequately respond to fluid resuscitation. Extrauterine rupture was suspected based on the presence of intra-abdominal free fluid and a positive pregnancy test. 

Emergency laparotomy was initiated and blood samples along with laboratory coagulation tests (extrinsic and intrinsic activation) showed decreased clot strength with maximum clot firmness not reaching 2 mm, indicating hypofibrinogenemia. The patient was immediately administered 4 g fibrinogen concentrate and 1 g tranexamic acid. During surgery, her fibrinogen level decreased to 0.17 g/L; she received a total of 1 U red blood cells and approximately 400 mL from cell salvage. A ROTEM analysis performed immediately postsurgery showed correction of coagulopathy. Patient became hemodynamically stable without further bleeding and coagulation parameters 8 hour post-surgery were back to normal (fibrinogen 2.75 g/L). Without other complications, patient was discharged 5 days after admission. 

Study Author Conclusions

Treatment regimen in this case report included administration of tranexamic acid, despite the absence of overt hyperfibrinolysis at ROTEM analysis. A recent study has shown that low-grade fibrinolysis may not be detected by conventional thromboelastometry; therefore, antifibrinolytic supplementation may be appropriate if, as in this case, there is reasonable cause to suspect hyperfibrinolysis (local rather than systemical).

Tranexamic acid has been shown to be a well-tolerated and effective treatment for the management of hemorrhage during pregnancy and can reduce transfusion requirements and maternal morbidity in postpartum hemorrhage. 

Non-operative treatment of ruptured ectopic pregnancy

Design

Case presentation

A 20-year-old woman presented with vaginal bleeding and abdominal pain but no fever, dysuria, or vaginal discharge. Urine human chorionic gonadotropin was positive, along with tenderness of the abdomen. Ultrasonography revealed a ruptured tubal pregnancy and blood in the abdomen; she was treated non-operatively with close monitoring. The patient received intravenous liquid therapy, nothing by mouth, and intravenous tranexamic acid 1 g four times daily to prevent bleeding. As the patient was hemodynamically stable with no ongoing evidence of bleeding, it was deemed the patient did not need surgery.

Study Author Conclusions

Ruptured ectopic pregnancy with APLA syndrome – a case report

Design

Case presentation

A 32-year-old multigravida patient presented to the emergency department (ED) for sudden onset of severe abdominal pain and drowsiness. The patient was on warfarin 5 mg once daily for the past 9 years. Hypovolemic shock with blood pressure (BP) of 60/45 mmHg lead to a diagnosis of antiphospholipid antibody syndrome. The patient was overdue for 2 weeks and had a history of 5 miscarriages in the past. The patient was sent for emergency laparotomy with a preliminary diagnosis of ruptured ectopic pregnancy. In the perioperative setting, the patient received blood products, volume resuscitation, prophylactic antibiotics, and 1 g of tranexamic acid intravenously. Intraoperative blood loss was approximately 4,100 mL. After postoperative treatment, the patient became stable and was discharged on the post-op day 3.

Study Author Conclusions

To conclude, antiphospholipid syndrome requires a multidisciplinary approach to diagnosis and management. It is an important medical condition manifesting in pregnant women, where use of anticoagulation leads to the dilemma of its perioperative continuation.