# Case Illustration

A 35-year-old multigravida (G4P3A0) Indonesian female referred to the Emergency Room (ER) by local midwifery and about giving birth to her twin pregnancy. The first baby was born spontaneously in her house one hour before admission. She had massive and continued bleeding during delayed the second child labor. The patient was observed to be lethargic during the ER examination and had blood pressure (BP) 100/60 mmHg, heart rate 100 beats per minute, respiratory rate of 24 breaths per minute, and oxygen saturation of 95%. Hemoglobin from complete blood count shows 10.5 g/dL. The gynecology examination was found uterine portio rupture and active bleeding with three tampons attached. The second child was born in hospital. She lost 750 ml of blood during labor and still had active bleeding because of uterine atony and Disseminated Intravascular Coagulation (DIC). The blood pressure decrease to 90/50 mmHg, a pulse rate of 144 beats per minute, and the patient became agitated. She was given 3000 ml of ringer lactate, four bags of whole blood transfusion, and 1000 cc of HES solution. After the initial fluid resuscitation, there was no sign of shortness of breath; however, the patient was still agitated and disoriented. The patient was then scheduled for a histerectomy right away.
During the hysterectomy, there was ongoing massive bleeding. She had a transfusion of 750 ml of whole blood and 1000 ml of normal saline. After the hysterectomy, the bleeding from vagina and drain was still active (900 ml). Hemoglobin count showed 8 g/dL. The obstetrician decided to reopen 3 hours after. After surgery, in the Intensive care unit (ICU), the patient got five bags of fresh frozen plasma transfusion and five bags of thrombocyte concentrate. The patient was noted to have DIC with Prothrombin time (PT) 16.3 s (10-13 s), International Normalized Ratio (INR) 1.22, Activated Partial Thromboplastin Time (aPTT) 35.5 s (25-35 s), Fibrinogen 319 g/L, D Dimer 7,777 ng/ml FEU. She was then observed in ICU for 6 days and general ward for 9 days and then discharged with no complaint.
Ten days after discharge from the hospital, the patient came to the ER with shortness of breath, fever, and chest pain during cough for five days and worsened in the last two days. The increased short of breathness was associated with physical activity, and orthopnea was noted.
On the ER examination, the patient was observed to be febrile and had a normal BP (120/80mmHg), tachycardia (112 beats per minute), dyspnea (27 breaths per minute), and an oxygen saturation of 95% while receiving oxygen through 3 lpm nasal cannula. Her lungs were noted symmetrically on inspection, dim on percussion in basal inferior, and bilateral rales were found. Her heart rate was regular, without S3 gallop or murmur. Her extremities were non-edematous. Compete blood count shows Hb 9.1 g/dL, White blood cells 19,530 / μL, Thrombocyte 439,000 / μL. Blood gas analysis showed partially compensated respiratory acidosis. An electrocardiogram showed sinus tachycardia with a heart rate of 113 beats per minute with normal frontal axis and clockwise rotation on horizontal axis (figure 1). Chest radiographs showed bilateral pleural effusion, right paracardial infiltrate, and early lung edema (figure 2).