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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 5, September/October 2018
292
AFRICA
required evacuation of retained products of conception six days
post normal vaginal delivery. This procedure led to postpartum
haemorrhage of two litres, massive blood transfusion, bilateral
uterine artery embolisation and vaginal packing to control
bleeding. There were two cases of wound haematomas requiring
evacuation in theatre.
In patients delivering before 20 weeks’ gestation, two
major haemorrhages occurred. The first patient underwent a
hysterotomy at 19 weeks. She required a second laparotomy
for post-operative intraperitoneal bleeding of more than one
litre. The lowest documented haemoglobin was 3.9 g/dl and she
received a massive transfusion.
One episode of serious haemorrhage occurred following
a first-trimester termination of pregnancy, performed as the
patient did not wish to continue with a high-risk pregnancy.
Following evacuation of the products of conception, this patient
bled to a haemoglobin of 3g/dl and required fluid resuscitation.
Eight patients received blood transfusions. In five cases, blood
products were given after bleeding. In three cases blood and/or
fresh frozen plasma was given to increase a low haemoglobin
level or to avoid bleeding prior to a procedure.
Minor bleeding was common. One episode of haematemesis
following assault occurred, eight patients experienced epistaxis
on one or more occasion, four patients experienced gum
bleeding, one patient had a drip-site haematoma and another
had problematic bleeding at a drip site.
Nine (45%) of 20 term pregnancies were delivered by
caesarean section. There was an additional hysterotomy carried
out to deliver a previable infant. The hysterotomy was performed
as the mother had had two previous caesarean sections. HIV
infection was more likely to be associated with surgical delivery
(
p
=
0.0017).
Eleven pregnancies had episodes of arrhythmia, most
commonly atrial fibrillation. However, in seven cases, the
arrhythmia had been documented prior to pregnancy. Nine
pregnancies were associated with worsening of New York Heart
Association functional class, with three patients developing
pulmonary oedema.
The average hospital stay was 41.0 days. Five (17.2%) patients
spent 60 or more nights in hospital. The average number of
admissions per patient was 3.0. Fourteen (48%) patients had four
or more admissions.
Four or more admissions refused hospital treatment. There
were 57 admissions between weeks 12 and 36, the period in
which admission was not mandated, equating to an additional
two admissions per patient, most commonly for sub-therapeutic
INR requiring ‘heparin cover’. In one case this occurred
on five separate occasions, when the patient was repeatedly
found to be sub-therapeutic on warfarin at antenatal visits
and offered in-patient intravenous heparin. Additionally, two
patients absconded.
Three spontaneous first-trimester miscarriages and three
second-trimester miscarriages occurred (Table 5). Three
pregnancies were terminated, one in the first trimester because
the patient did not wish to continue a high-risk pregnancy. There
were two terminations for foetal malformations not attributed to
warfarin (Table 6). One of these had confirmed Dandy–Walker
syndrome and was delivered by hysterotomy at 19 weeks. The
other delivered vaginally at 22 weeks because of suspected
anomalies based upon the presence of echogenic bowel.
One infant was born alive with multiple anomalies, including
features consistent with warfarin embryopathy, together with
other abnormalities. This patient had been taking 5 mg of
warfarin daily. Antenatal ultrasound showed an absent nose
and abnormal face with close-set eyes, low-set ears and a bossed
forehead. Brain abnormalities were also noted and included
dilated anterior horns of the lateral ventricle fusing in the
midline and a dilated fourth ventricle. This patient refused early
termination of pregnancy and the baby, born alive by caesarean
section, died on day five of life.
Discussion
In this study, a high rate of serious adverse events was observed
in maternal and foetal outcomes (Table 5). Maternal morbidity
included major haemorrhage, cardiac failure and sepsis, as well
as ischaemic stroke. There were three instances of pulmonary
oedema, an approximately 20% risk of major haemorrhage,
three ischaemic strokes and one case of infective endocarditis.
Both deaths occurred post-partum. One was in a patient with
significant vascular disease caused by Takaysu’s arteritis, further
complicated by HIV infection.
Adverse perinatal outcome was evident as a high rate of
miscarriage in the first and second trimesters, two cases of
Table 4. Details of major haemorrhage
Patient
No.
Timing of
bleeding Delivery
Gestation
(weeks) Details
Transfusion
Drop in Hb
pre- and post-
delivery (g/dl)
1
Peripartum C/S
37 1 100 ml lost during C/S. Wound continued to bleed. Day 5 post C/S
had relook laparotomy but only required cauterisation of fat
2 units RBCs
3.4
2
Peripartum C/S
37 Required repeat laparotomy for evacuation of haematoma and TAH
and BSO. Patient was septic
2 RBCs, 4 FFPs
Not available
3
Peripartum C/S
34 Wound haematoma, required return to theatre for evacuation
No
1.6
4
Peripartum NVD +
forceps
35 On day 6 post-delivery required evacuation of RPOC in theatre. Post
evacuation found in shock requiring resuscitation and massive transfu-
sion. Bilateral uterine artery embolisation attempted. This failed and
patient had further surgery to pack vaginal bleeders. Patient was septic
3 units in pregnancy. Peri-
partum 11 RBCs + other
products
6.6
5
Peripartum Medical
termination
11 Patient had termination of pregnancy. Later found in shock with Hb
of 3 g/dl
2 units RBCs
7.0
6
Peripartum Hystero-
tomy
19 1 litre intraperitoneal bleed post hysterotomy. Lowest Hb 3.9 g/dl.
Required repeat laparotomy 2 days post hysterotomy.
Massive transfusion. 7 units
RBCs, 6 units FFPs, cryo-
precipitate and haemo-solvex
7.1
Hb: haemoglobin, RBCs: red blood cells, FFPs: fresh frozen plasma, C/S: caeserean section, TAH: total abdominal hysterectomy, BSO: bilateral salpingo-oophorecto-
my, RPOC: retained products of conception.