Sunday, January 11, 2009

Twins! And DIC/Couvelaire's Uterus.

To the midwives in my life who've been quietly praying for twins and breech babies this trip - THANK YOU! Today those requests paid off when the supervising midwife thrust a chart at me to admit. I wandered into the admitting room, greeted the mama, introduced myself and opened her very abbreviated antenatal chart. My eyes skimmed the data, and stopped dead on the ultrasound report which, like all ultrasound reports here consist of a hand drawn sketch of baby's lie, and are otherwise completely illegible. Big difference with this particular report: there were two stick figures drawn. Sure enough after some further investigation I realized I had a mama in active labor with two babies. Twin A was easily palpable as a vertex, Twin B was much more ambiguous but as supervising MW and Doc said - we'll deliver them vaginally regardless.

After a little kerfuffle about whether they were 35 weeks or later, some steriods and a little nifedipine to try to slow the labor down (didn't work) later she was shortly complete and asking to push. A short while later she pushed her first 2.8kilo baby boy into my hands. I quickly clamped and cut his cord, and we auscultated twin B who was sounding very happy. MW asked me to feel for a presenting part - I reached up and felt what felt like tiny toes inside the second bag of waters. Several minutes tick past as we waited for her contractions to pick up again, and for that presenting part (no one was overly convinced we had either a breech or a vertex presenting). To my inexperienced hands, it seemed like it could have been a head, or perhaps a compound presentation (a hand?) to engage in the pelvis. A couple of contractions later, as baby sank further down into the pelvis, the bag was broken, and in a rush of fluid and fresh meconium, a footling breech babe slid out. Another boy, about 700gms smaller than his brother. Both babies were howling at each other within minutes, as her giant placenta was born. I expect both babies will hang out here till Twin B makes 2.500kg.

Too much fun. :)

The twins were actually babies 2 and 3 of the day for me, and were followed shortly by babies 4 and 5. All NSVD's with no complications. The last one though (a G1P0) pushed out a substantial baby and tore pretty spectacularly down both posterior sulcus'. I took a good look at the tears (which actually started as baby was descending) and decided that the senior MW on the floor should do that repair. So I assisted, with both med students looking on. I used some of my BYO lidocaine and am now officially convinced that it works much better than the lidocaine we have available to us here.

The day though, started with a helluva complication, as a mother who delivered in the night bled torrentially. I immediately asked the Doc to check her first thing during rounds. Swiftly the decision was made to move her to the theater for exploration. Some small lacerations were repaired while they were there, but the blood loss was clearly originating from her uterus. Some very small fragments were removed, by this time it was estimated that she had lost some 2500cc's of blood and her uterus was still not behaving. Medications were administered, both into the myometrium directly, as well as sublingually and IM. An hour later, suspecting DIC (faucet-like, watery bleeding), an emergency hysterectomy was performed when the doc discovered a Couvelaire uterus, which was bleeding through the myometrium into her peritoneum, her uterus was simply incapable of contracting at all. TEBL at the end of the day >5000ml/cc's. She's had 7 units of blood when I left for home this afternoon and her pulse was still in the 130's. Two of the med students (one a universal donor, and the other compatible)parted with two units of their own blood before we had to send them home, dizzy. Hanging nice warm bags of 'doesn't get any fresher' whole blood is definitely something I'll remember.

She is the first woman I've worked with who literally might not survive the experience of delivering her baby who was, incidentally, born healthy and happy (no abruptio placentae which is usually responsible for a Couvelaire's uterus). Little babe has an auntie who's breastfeeding her tonight.

Thoughts tonight toward the pacific if you will, for a swift recovery for this mama.


Aimee said...

As I've had little time to sit and enjoy blogs, I just read three or four of these and my head is spinning! I can't imagine doing this while pregnant! As I am, not gestating at all, I am fighting back tears after reading about a tiny green bundle that was left to die and a mama who has had her entire inventory of blood replaced. Now I am waiting on the edge of my seat to learn what fate has in store for her. Will she ever be reunited with her newborn?

S said...

oh Louisa!! How do you process all of this??? Do you have any ideas what caused this complication?? Is this common?


S said...

And* that's pretty awesome about the twins!!

Morag said...

S. What caused this? It's not 100% clear but probably a combination of factors. The fact that she had some retained fragments probably started it, but its also possible that she has a clotting factor issue as well which predisposed her to the disseminated intravascular coagulation - which makes EVERYTHING bleed. Bottom line, had the staff had better meds to treat her hemorrhage, she'd bled heavily during the day, rather than the middle of the night (when there's OR staff around), and she'd been able to be treated more aggressively sooner, then she may still have her uterus.

It's my understanding that fortunately, in more high resource settings (like the States) DIC and Couvelaire's Uterus is very rare indeed in the absence of serious underlying pathology (like a clotting factor issue).

Today, after her kidney's looked dodgy for a bit (DIC often causes kidney failure) she improved rapidly. Turns out she had been breastfeeding her baby throughout this, with relatives helping the baby latch and nurse on demand, even when she was unconscious. They all look set to be ok.

S said...


Betsy said...

Oh wow. We're finally moved into our house (in SC, incidentally - the right rental was just over the GA border!) and I'm just now reading your new blog! It sounds as though you're extremely busy and that things are very intense. I'm so glad you got some twins and a breech! I'll send you some full-term singleton breech vibes as well :) I'm guessing you've gotten used to the heat and humidity a bit more by now too!

Much love to you <3


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