Post-Termination Hemorrhage

: Audience: This case scenario is appropriate for emergency medicine residents of all levels and senior medical students. Discussion: Overall, this simulation is an effective method of introducing important concepts in the evaluation and management of a patient with post-termination hemorrhage and allows for assessment of learners in the acute resuscitation of these patients.


Linked objectives and methods:
Simulation is an appropriate method to meet these goals and objectives because it safely allows learners to identify a patient who is in shock (objective 1), actively resuscitate a patient with hemorrhage and hemorrhagic shock, allow them to consider the broad differential diagnosis of vaginal bleeding, and discuss the treatment options for hemorrhagic shock (objectives 2 and 3). Learners will also have to appropriately transfuse the patient, ideally utilizing a massive transfusion protocol (objective 4). Simulation can be speeded up to increase the difficulty for more experienced learners or slowed down to allow more junior learners to talk through the case and discuss their medical decision making. The subsequent debriefing can focus on either diagnosis and management of hemorrhage/hemorrhagic shock including massive transfusions (objective 4) or post-termination complications, or both.

Recommended pre-reading for instructor:
We recommend that instructors review literature regarding post abortion hemorrhage and massive transfusions, including: • Their institution's massive transfusion protocol.

Learner responsible content:
While there is no specific learner responsible content, should learners wish to review literature regarding post abortion hemorrhage and massive transfusions, we recommend: • Their institution's massive transfusion protocol.

Results and tips for successful implementation:
This case can be run using a low, medium, or high-fidelity simulator, or used as an oral boards case. Depending on the level of learner, the case can be speeded up so that the patient decompensates faster, thus inducing more stress for the learners and forcing them to commit to decisions more quickly. Alternatively, it can be slowed down allowing more novice learners time to talk through the management.
To demonstrate active hemorrhage instructors could utilize a birthing manikin that can simulate hemorrhage. If a birthing manikin is unavailable, one could set up a water pump under the gurney with red water and attach it to tubing that could be placed between the manikin's legs to simulate vaginal bleeding during the case. For a simpler, but less realistic option, instructors can simply saturate sheets or a bed pad (chuck) with red dye to simulate active bleeding and verbally explain what is seen within the vault of the simulator manikin.
This simulation was initially implemented at an emergency medicine residency program simulation conference with approximately 15 residents and medical students. We opted to verbally explain the pelvic exam to the learners. Overall response was positive and learners felt the case was a unique

Objectives:
By the end of this simulation session, the learner will be able to: 1. Recognize post-termination hemorrhage and hemorrhagic shock 2. Demonstrate appropriate acute resuscitation for a patient with hemorrhagic shock 3. Review the differential diagnosis for a patient with post-termination hemorrhage 4. Identify the indications for massive transfusion protocol Background and brief information: Ms. Johnson is a 21-year-old female brought in by her boyfriend for heavy vaginal bleeding and syncope at home after a medically induced abortion.
Initial presentation: Patient presents to the emergency department with complaints of vaginal bleeding and syncope at home. She reports lightheadedness, and when sitting down to be triaged, she has another syncope episode and is immediately brought back to an emergency department (ED) bed.

How the scenario unfolds:
The patient is brought to a resuscitation bay after her syncope in triage. Participants should begin an immediate resuscitation, including airway, breathing and circulation (ABCs). They should request vital signs, which will show tachycardia and hypotension. Two large-bore intravenous (IV) lines and fluids should be started. Bedside glucose will be within normal limits, and initial point-of-care hemoglobin will be 8.2g/dL. Participants should take a brief history and complete a physical exam including pelvic exam, which will reveal active heavy vaginal bleeding. Appropriate labs, including blood type and cross, should be ordered, and bedside ultrasound should be performed. Participants should repeat point-of-care hemoglobin which will show down-trending hemoglobin, and should activate massive transfusion protocol. The patient will remain persistently tachycardic and hypotensive and will require multiple fluid boluses and blood transfusions. Participants should recognize the patient is hemorrhaging from her medically induced abortion, and should call Ob/gyn for definitive management such as emergent dilation and curettage (D&C) or uterine artery embolization. • Medical management If participants order methylergonovine maleate (methergine), misoprostol, oxytocin or another uterotonic, pharmacy will state that it will need to come from labor and delivery and will likely take 5 to 10 minutes to obtain. The product will be available later in the case.

4:00
Participants should order IV fluids and request blood products for transfusion [preferably starting with packed red blood cells (pRBCs)].
If participants do not order blood/massive transfusion at this time, typed blood will not be available until it is ordered. However, O-blood will be available if requested. Once ordered, nurse will notify learners it will be available in a couple minutes.
If patient not given fluids her blood pressure will decrease and she will become more tachycardic If patient given fluid her blood pressure will increase slightly and heart rate decrease Ultrasound shows clot and blood in uterus, concern for retained products. If medical management ordered, it will now be available for administration.
If blood products are given, patients' blood pressure will improve and heart rate will improve after the 3 rd unit of pRBCs. However, patient will continue to have extensive vaginal bleeding.
If medical management with methylergonovine maleate, misoprostol, or oxytocin are given, the patient's bleeding will slightly improve but she will continue to have active bleeding. If the participants provide an appropriate sign out and consult with appropriate concern, Ob/gyn will state that they are coming right now.

Post-termination Hemorrhage
History: • Since abortion was legalized in 1973, morbidity and mortality from abortion has dramatically decreased. Minor complications occur in 8 out of every 1000 abortions, major complications in 0.7 out of 1000 abortions, and death in 0.7 in 100,000 abortions. • 1st Trimester abortion mortality is typically caused by infection (33%) and hemorrhage (14%). • 2nd trimester abortion mortality is typically caused by hemorrhage (33%-40%).
• However, hemorrhage after abortion is rare, occurring in <1% of all abortions, but when it does occur, it is often life threatening. • There are varying definitions of post-termination hemorrhage, ranging from 250cc of blood loss to 500cc of blood loss to patients requiring hospitalization or requiring transfusion. § If primary treatment has not improved the bleeding or the patient remains unstable, then the physician should place 2 large bore IVs, begin fluid resuscitation, order blood work: complete blood count, coagulation studies, type and cross for blood transfusion and consider a disseminated intravascular coagulation panel. § Physicians can attempt uterine packing or tamponade with a foley or uterine tamponade device such as the Bakri balloon which can be left in place for 12 to 24 hours.
• Foley: Off label use. Foley is inserted through the cervix, and once it is proximal to the cervix, the balloon is inflated to 30-80cc with normal saline (do not use air as rupture can cause an air embolus). • Bakri balloon: specifically designed for uterine tamponade in the setting of post-partum hemorrhage, it is inserted through the cervix, and once it is proximal to the cervix, the balloon can be inflated with 500cc of normal saline, although in the case of post-termination hemorrhage, inflation to <250cc has been demonstrated to be successful. § Blood transfusion: • Physicians should be familiar with massive transfusion protocols as well as with their specific institution's protocol. • Typically massive transfusions are defined as replacement of greater than 1 blood volume in a 24 hour period or 50% of blood volume in 4 hours. • Physician should be able to recognize acute blood loss, hemorrhagic shock, abnormal vital signs, decreased tissue perfusion and oxygenation.