We report a 44 year old nulligravida Jehovah’s Witness with a known fibroid uterus who presented with menorrhagia and life-threatening anemia. Adamant in her refusal of blood products and deemed too unstable for surgical management, the patient was managed conservatively by a multidisciplinary team.
Life-threatening anemia requires a 2-part approach: stabilize the patient by replacing the lost blood volume and control bleeding to prevent further blood loss. This situation becomes complicated when the patient in question declines blood products. Jehovah’s Witness (JW) is a known religion whose literal interpretation of the Bible precludes its practitioners from receiving blood products, even in the face of life-threatening bleeding. Respecting a patient’s religious autonomy and providing optimal care of JW patients can be found in various branches of medical literature.
We report a case of a JW with severe uterine bleeding secondary to a fibroid uterus who presented with life-threatening anemia. The patient, along with her family and church elders, was adamant in her refusal of blood products, stating she would rather die than receive blood or its by-products. With this case report, we hope to create awareness among gynecologists as to the nonsurgical multidisciplinary approaches available to facilitate the management of this challenging scenario while maintaining patient autonomy.
Case Report
A 44 year old nulligravida presented to the Emergency Department (ED) after 3 days of heavy vaginal bleeding. She had a known history of a fibroid uterus and had previously received various hormonal therapies including combined oral contraceptive pills, intramuscular medroxyprogesterone acetate (Depo Provera; Pfizer, New York, NY), and a gonadotropin-releasing hormone agonist (Lupron; Abbott Laboratories, North Chicago, IL). The patient was last seen 12 months prior to admission and had been evaluated for uterine artery embolization, which she declined. She reported no significant past medical or surgical history and she self-discontinued hormonal therapy 7 months prior to presentation because her menses had normalized. She had previously been offered and refused a hysterectomy.
Upon initial evaluation in the ED, although alert and oriented, the patient was pale, diaphoretic, and tachycardic with an initial blood pressure of 92/60 mm Hg. Her physical examination was notable for a mobile 10 cm uterus with a 6 cm posterior fibroid and large clots in the vagina with active bleeding coming from the cervical os. A 16 French Foley catheter with a 30 mL balloon was sterilely placed into the endometrial cavity transvaginally and fully inflated with normal saline to tamponade bleeding.
Admission laboratories were notable for a hemoglobin of 5.1 g/dL and white blood cell count of 16,300. The patient’s coagulation profile showed a slightly prolonged prothrombin time of 17.1 seconds, international normalized ratio of 1.4, and activated partial thromboplastin time of 23.5 seconds. Her electrolyte panel was within normal limits with the exception of hypomagnesemia. An electrocardiogram was significant for sinus tachycardia.
The patient was a JW and carried a blood card stating that she declined all blood products including red blood cells, platelets, and plasma. She was hydrated with intravenous crystalloid and colloid solutions including a 5% solution of albumin every 30 minutes as necessary to maintain her blood pressure greater than 90/60 mm Hg. Three hours after presentation, her hemoglobin and hematocrit decreased to 3.6 g/dL and 10.6%, respectively ( Figure ). There was no evidence of bleeding around the intrauterine Foley catheter.
The patient was admitted to the surgical intensive care unit. The multidisciplinary team deemed the patient’s surgical risk to be excessive therefore an emergent uterine artery embolization was performed by interventional radiology using Contour Endospheres (Contour PVA Embolization; Boston Scientific, Natick, MA). In addition, the patient was started on conjugated estrogen (Premarin; Pfizer) therapy 25 mg intravenously every 6 hours as well as methylergonovine (Novartis Pharmaceuticals Corp, East Hanover, NJ) 0.2 mg intramuscularly every 4 hours for 24 hours.
With this combination of treatments, the patient’s bleeding was successfully controlled. The intravenous conjugated estrogen therapy was discontinued after 48 hours, and the patient was started on a combined 30 μg ethinyl estrogen/0.3 mg norgestimate oral contraceptive pill (Lo/Ovral; Akrimax Pharmaceuticals, Cranford, NJ).
Once the patient’s blood loss was controlled, attention was turned to stimulating erythropoiesis. On hospital day 2, with a hemoglobin of 3.5 g/dL, the patient was started on an erythropoiesis stimulating agent, Darbepoetin alfa (Aranesp; Amgen, Thousand Oaks, CA) 200 μg intravenously once a week and intravenous ferric gluconate complex (Ferrlecit; Watson Pharmaceuticals, Corona, CA) 125 mg in 100 mL normal saline intravenously over 60 minutes every day for 5 days ( Table ). The patient also received supplemental oxygen as well as intravenous multivitamin supplementation once a day until she was able to tolerate an oral multivitamin and oral vitamin K 10 mg every day.
| Objective | Procedure | Projected length of onset | Potential side effects/Comments |
|---|---|---|---|
| Legal issues | Determine what products are acceptable (if any) to patient Ask whether patient has signed Durable Power of Attorney for Health Care (OPTIONAL: or an Advance Medical Directive card.) If not, contact Hospital Information Services for Jehovah’s Witnesses at 718-560-4300 (United States). | Should be established upon admission | |
| Control acute bleeding | Endometrial tamponade a. 30 cc Foley catheter b. Bakri balloon (Cook Women’s Health) | Immediate | Infection |
| Uterine artery embolization | Rapid | Pain, infection, infertility, failure, need for hysterectomy | |
| External radiation therapy | Rapid | Consult radiation oncology | |
| Hormonal supplementation | |||
| a. Conjugated estrogen 25 mg IV q 6 h (Premarin; Pfizer, New York, NY) | Rapid | Thromboembolic events | |
| b. Medroxyprogesterone acetate 20 mg PO tid × 7 d, then 20 mg qd × 30 d | 3 d | Nausea, cramping, bloating | |
| c. OCP taper: 35 μg ethinyl estradiol/1 mg norethindrone 1 tab tid × 7 d, then 1 tab qd × 30 d | 3 d | Nausea, cramping, bloating | |
| Uterotonic agents | |||
| a. Methylergonovine 0.2 mg IM/PO q 4 h × 24 h | Rapid | Contraindicated in HTN | |
| Minimize blood draws | Use pediatric tubes | ||
| Maximum oxygen delivery/decrease oxygen demands | Maintain oxygen saturation 98% or greater | ||
| a. Oxygen delivered by nonrebreather face mask | Immediate | ||
| b. Neuromuscular blockade, sedation with ventilatory support | Immediate | Consult critical care specialists | |
| c. Mild hypothermia, 30-32°C 2 | Immediate | Consult critical care specialists | |
| Correct coaguloapthy | Vitamin K supplementation for prolonged prothrombin time | ||
| a. Vitamin K (phytonadione) 10 mg slow IV push q 12 hours until normalization of INR | 4-8 h | Severe anaphylaxis in rare cases | |
| b. Vitamin K 10 mg PO | 24-48 h | ||
| c. Cryoprecipitate (if allowed) | Rapid | ||
| d. Avoid anticoagulation/antiplatelet medications in particular, aspirin, NSAIDS, other platelet inhibitors, heparin, vitamin K antagonists | Rapid | ||
| Stimulate erythropoiesis | Recombinant erythropoietin Regular and high doses available, consult hematology for specific dosing | Varies, depending on dosage | Increased cardiovascular/thromboembolic events, stroke |
| Darbepoetin Regular and high doses available, consult hematology for specific dosing | Varies, depending on dosage | ||
| Iron supplementation | Days | ||
| a. Iron dextran: Dose (mL) = 0.0442(desired Hgb in g/dL – observed Hgb in g/dL) × LBW in kg = (0.26 × LBW in kg) 11,12 | Hypersensitivity reaction (epinephrine should be available) | ||
| b. Ferric gluconate complex: 125 mg undiluted slow IV push at 12.5 mg/min or diluted in 100 mL isotonic saline infused over 30-60 min × 5 d | Drug allergy | ||
| c. Ferric carboxymaltose: single doses up to 1000 mg of elemental iron over 15 min | Drug allergy | ||
| d. Iron sulfate 325 mg PO bid-tid | Constipation | ||
| Multivitamin, B12, and folate where appropriate | Days |
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