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Survival of a Percreta Patient
Abstract Number: 207
Abstract Type: Case Report/Case Series
A 34 year old G3 P2 presented to an outside hospital at 16 weeks gestation with brownish spotting was told she had a low-lying placenta. She had two previous uneventful cesarean sections. At 31 weeks, MRI suggested a large anterior placenta previa with possible bladder and parametrium involvement. One week later, after a third significant bleed, the patient was transferred to our facility for cesarean hysterectomy with ureteral stents.
The patient was stable on transfer and surgery was planned for the next day. According to our obstetrical hemorrhage protocol, 10 units of PRBCs, FFP, platelets and cryoprecipitate were prepared. The patient was taken to operating room where standard ASA monitors were placed, spinal anesthesia with bupivicaine 7.5 mg, fentanyl 20 mcg, and morphine 300 mcg was placed. General anesthesia was then administered with a rapid sequence intubation. An arterial line and Right IJ cordis were placed using ultrasound guidance. Urology placed ureteral stents and delivery of a female infant with Apgars of 4 and 8 occurred one hour and forty five minutes after general anesthesia was initiated. Pitocin and a propofol infusion were started with withdrawal of the volatile anesthetic after delivery to favor contraction of the uterus during clamping of the uterine vessels. Shortly thereafter, a hysterectomy was performed with intact placenta, when the surgeons noted uncontrolled bleeding. Packed red blood cells and plasma were transfused in a one to one ratio at maximal rate (up to 500 ml/minute) with the hematocrit remaining stable at 22. One hour after delivery the patient suddenly became asystolic and advanced cardiac life support was initiated. At this time the potassium concentration was noted to be 6.4 mEq and the ionized calcium was 0.41mmol/L. The patient was treated with calcium, dextrose, and insulin in addition to cardiac massage. A transesophageal echocardiogram probe was placed which identified a flaccid myocardium and ruled out a large pulmonary embolus. A BIS monitor, which was used during surgery showed a value of around 30 throughout the resuscitation. The patient was placed on cardiopulmonary bypass 56 minutes after asystole occurred. After the first attempt to wean from bypass, oxygenation was marginal, and extracorporeal membrane oxygenation (ECMO) circuit placed to limit anticoagulation and address bleeding. Because of intractable surgical bleeding, the patient was weaned from ECMO and her coagulopathy was reversed with Factor VIIa in addition to the fresh frozen plasma, platelets and cryoprecipitate. The patient was transfused over 70 liters in the operating room. She was transferred to the cardiothoracic intensive care unit with norepinephrine and epinephrine infusions. The patient was discharged six weeks later with no recall of the event and no neurological deficits other than a lumbosacral plexopathy that was thought to be surgical in origin.