Atypical presentation of hemorrhagic shock in pregnancy: a case highlighting the developing field of emergency medicine in Israel

Abstract

Background: Occult hemorrhagic shock secondary to uterine rupture represents a true obstetric emergency and can result in significant morbidity and mortality for both the patient and the fetus. Multiparity and prior cesarean sections are known risk factors. Typically, these patients present late in gestation, often secondary to the physiologic stresses on the uterus related to contractions. This pathology is less common earlier in pregnancy and can often be overlooked in the acute setting. Case presentation: We present the case of a 31-year-old female with three prior gestations, two parities and two prior cesarean sections, resulting in three live births, who presented to the Emergency Department (ED) 22-weeks pregnant with acute onset dyspnea and an episode of syncope. Due to her altered mental status there was concern for occult shock, despite normal vital signs. Large amounts of free fluid in the abdomen were noted on bedside ultrasonography with a high suspicion for uterine pathology. She was resuscitated with blood and taken immediately to the operating room for surgical management where she was found to have had a uterine rupture. Conclusion: This case highlights a rare presentation of a well-known obstetric emergency, due to the patient's development of uterine rupture early in gestation. Consequently, emergency physicians should consider atraumatic hypovolemic shock, secondary to this obstetric catastrophe, even at a stage that far precedes its expected presentation. In addition, we make note of how this case validated our department's integrated emergency medicine model, the first in the State of Israel.

A team approach to peripartum hemorrhage control incorporating resuscitative endovascular balloon occlusion of the aorta

“…Trauma surgeons can support obstetric providers with expertise in management of hemorrhagic shock, resuscitation, and definitive hemostasis. This aligns with increasing reports citing the benefits of resuscitative balloon occlusion of the aorta (REBOA) for obstetric patients with noncompressible hemorrhage 2–6 . Our hospital is a regionalized center for the care of women at high risk of peripartum hemorrhage, including those with placenta accreta spectrum (PAS).…”

“…This aligns with increasing reports citing the benefits of resuscitative balloon occlusion of the aorta (REBOA) for obstetric patients with noncompressible hemorrhage. [2][3][4][5][6] Our hospital is a regionalized center for the care of women at high risk of peripartum hemorrhage, including those with placenta accreta spectrum (PAS). As such, a multidisciplinary team was convened to develop a strategy for high-risk obstetric surgeries in accordance with the American College of Obstetricians and Gynecologists-Society for Maternal Fetal Medicine Obstetric Care Consensus for PAS.…”

Aortic balloon occlusion in distal zone 3 reduces blood loss from obstetric hemorrhage in placenta accreta spectrum

“…3 Several groups have reported superior outcomes with resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to hemorrhage control during cesarean hysterectomy for PAS. [4][5][6][7][8][9][10][11][12] A meta-analysis of 731 PAS patients who underwent cesarean deliveries in which a REBOA catheter was used to occlude the infrarenal aorta, termed zone 3, found that these women experienced significantly less blood loss, received fewer transfusions, and achieved a higher rate of uterine preservation compared with other hemorrhage control strategies. 9 However, in the 11 studies pooled to generate this metaanalysis, there was no specific standard location of occlusion within zone 3 of the aorta.…”

“…There are several approaches available to decrease surgical blood loss during cesarean hysterectomy, including multivessel surgical ligation, temporary aortic clamping, multivessel embolization, and balloon occlusion of the aorta or iliac arteries 3 . Several groups have reported superior outcomes with resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to hemorrhage control during cesarean hysterectomy for PAS 4–12 . A meta-analysis of 731 PAS patients who underwent cesarean deliveries in which a REBOA catheter was used to occlude the infrarenal aorta, termed zone 3 , found that these women experienced significantly less blood loss, received fewer transfusions, and achieved a higher rate of uterine preservation compared with other hemorrhage control strategies 9 .…”

Spontaneous Antepartum Posterior Wall Uterine Rupture in an Unknown Pregnancy

“…Spontaneous rupture has been reported after uterine artery embolization or in unscarred uterus as well. Maternal age has also been associated with increased risk(6)(7)(8)(9)(10).…”