A 28-year-old primigravid woman was diagnosed at 7 weeks gestation with MELAS syndrome. Due to earlier stroke-like episodes, the patient was started in the first trimester on aspirin 100 mg daily, which was ceased at 36 weeks. The pregnancy was otherwise uneventful with a planned Caesarean section (CS) due to fetal malpresentation at 38 weeks gestation. The procedure was performed under a combined spinal-epidural anaesthetic. A healthy baby girl was delivered with no intraoperative complications and an estimated blood loss of 300 ml. The patient was transferred to the Adult Special Care Unit (ASCU) for post-operative monitoring and observation. During post-partum observations, the patient was haemodynamically stable with a uterus that was firm, central and not enlarged. However, ongoing moderate per-vagina (PV) loss prompted a blood gas analysis and coagulation profile. The lactate had risen to 2.2 mmol/L from 1.8 mmol/L pre operatively. The fibrinogen was reduced at 1.5 g/L, APTT raised at 41 seconds and platelet count was normal at 187×10⁹/L.

A Rotational thromboelastometry (ROTEM) (TEM International GmBH, Munchen, Germany) performed at this time showed fibrinogen deficiency, and 16 units of cryoprecipitate (CP) were administered. Despite this, bleeding continued and a repeat ROTEM indicated refractory low fibrinogen so a further 8 units of CP was administered. At this stage the uterus was noted to be enlarging and firm. The patient was transferred to the operating theatre for examination under anaesthesia. An 800 ml intrauterine clot was evacuated and a Bakri balloon (Cook Medical Inc., Bloomington, IN, USA) was inserted. Intra-operative investigations showed the patient’s haemoglobin had dropped to 69 g/L (preoperative 121 g/L), platelets now 67×10⁹/L and lactate had risen to 3.6 mmol/L. Further resuscitation with fresh frozen plasma, platelets, packed red blood cells (PRBC), tranexamic acid and calcium chloride was undertaken. An estimated total blood loss at this time was 1500 ml. Due to the post-operative unstable metabolic and haematological picture, the patient remained ventilated and was admitted to the Intensive Care Unit for monitoring. Continuing blood loss occurred with a rise of the lactate to 4.6 mmol/L. Uterine artery embolization was undertaken with subsequent reduction in PV bleeding. Thereafter with supportive care the patient made an uncomplicated course of recovery occurred and the patient was discharged home.

With Regards,
Sara Giselle
Associate Managing Editor
Global  Journal of Digestive Diseases