///2009 Abstract Details
2009 Abstract Details2019-08-03T15:55:31-06:00

The Use of a Massive Transfusion Protocol for an Emergency Cesarean Hysterectomy due to a Previously Undiagnosed Placenta Percreta

Abstract Number: 213
Abstract Type: Case Report/Case Series

Jeffrey Wright MD1 ; Sachin H Mehta MD2

Introduction: Massive Transfusion Protocols (MTP) have been implemented in many trauma centers for the resuscitation of acutely exsanguinating trauma victims. We present a case in which our institutions MTP was applied to treat life-threatening hemorrhage resulting from a previously undiagnosed placenta percreta.

Case: A healthy 33 year old G6P1 at 30 weeks gestation presented for urgent repeat cesarean delivery for breech and preterm labor. Spinal anesthesia was administered with hyperbaric bupivacaine to obtain a T3 level, and the procedure progressed to delivery of the child. At this point, profuse bleeding occurred, and the placenta was noted to be adherent to the uterus. The patient became hypotensive and tachycardic, and additional large bore IV access and aggressive volume resuscitation were begun.

Simultaneously, the emergency operator was called and was asked to initiate the MTP for our patient. After initially resisting because the MTP as written required a trauma attending for activation, the operator relented. Upon MTP activation, blood product coolers were automatically brought by a runner from the blood bank (2nd floor) to the obstetric OR (8th floor) at set intervals (figure 1). Emergent hysterectomy and bladder repair were performed under general anesthesia. During the case, chest compressions and epinephrine were required on two occasions for pulseless electrical activity. Ultimately, the patient received 29 units of PRBCs, 24 units FFP, 4 six-packs of platelets, 3 eight-packs of cryoprecipitate, and 8mg of activated-factor VII.

Once all visible bleeding was controlled, the patients abdomen was packed and the she was transferred to the surgical ICU on a vasopressin infusion for further stabilization. The patients perioperative INR peaked at 1.5, and the PTT and fibrinogen remained within normal limits throughout. Her postoperative course was complicated by necrotizing fasciitis, but she was discharged home in stable condition several weeks later with a healthy neonate.

Discussion: We believe that aggressive resuscitation and the early use of coagulation products per the MTP helped our patient avoid a dilutional coagulopathy and associated morbidity. With the automatic delivery of blood products in fixed ratios, critical time was not lost in ordering products and arranging transportation. Since this event, obstetric hemorrhage has officially been incorporated into our institutions criteria for MTP activation.

SOAP 2009