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Cesarean delivery due to massive hematemesis
Abstract Number: 241
Abstract Type: Case Report/Case Series
Introduction: Hematemesis during pregnancy is a rare complication. Massive bleeding may need to urgent surgery, caused by hypovolemic shock, nonreassuring fetal status.
Case Presentation: A 32-year-old G1P0 woman at 25 4/7 weeks gestation was admitted because of massive hematemesis, anemia, and hypovolemic shock. An emergency endoscope and thoracic computed tomography was performed, and esophageal rupture was suspected. Blood pressure was 100/72 mmHg, heart rate was 142 beats/min, saturation was 95% on 3L O2 via nasal cannula. Fetal heart rate was decreased with late decelerations. The patient was transferred to the operating room for urgent surgery with cesarean delivery and transthoracic esophagectomy. Awake intubation was performed and the patient underwent ventilation with 100% oxygen. General anesthesia was given, and the baby was delivered within the next 6 minutes, with Apgar scores of 4/6. She was found to have a grossly dilated esophagus and was thought to have achalasia. The endoscope examination was performed again, and the appearance of the esophagus was consistent with copious bleeding and submucosal hematoma. Cardioplasty was performed. After surgery, she was brought to the ICU and extubated within 8 hours. The patient was transferred to the ward after 2 nights, and discharged from the hospital 15 days later in good health.
Discussion: Achalasia is a rare cause of bleeding in the esophagus. The few cases reported in pregnancy were associated with hematemesis, and no massive hematemesis were remarked. In this case, nonreassuring fetal status with late decelerations was attributed to a hypovolemic shock. In addition, the esophageal bleeding remained brisk. Failed intubation or aspiration after induction of general anesthesia for cesarean delivery remains the major contributing factor to anesthesia-related maternal complications. Awake intubation seems to offer the best chance to prevent Menderson syndrome from a massive hematemesis so that surgical repair can be performed.
In summary, we reported the successful delivery and operation of a gravida with a previously undiagnosed hematemesis.