PLACENTA PERCRETA: A TWO CASE SERIES – Lessons in Management, Communication and Planning
Abstract Number: F-21
Abstract Type: Case Report/Case Series
INTRODUCTION: Placenta accreta is a leading cause of severe post-partum hemorrhage. With an increasing cesarean section (C/S) rate, the incidence of accreta has risen to 1 in 533 pregnancies from 1 in 2510.(1) Average blood loss at delivery with accreta is 3-5 L.(2) We report two cases of placenta percreta (PP), within one month of each other, managed differently based on the preoperative information.
CASE 1: A 32 y/o old G2 P1 with a known placenta increta (per MRI), presented at 34 weeks for a scheduled C/S. After a discussion with OB, Anesthesia, and Radiology, the diagnosis of PP was unlikely and prophylactic iliac artery stents were deemed unnecessary. The anesthetic plan was to begin under spinal in order to minimize exposure of the preterm fetus to anesthetics, and convert to GA after delivery for the intended cesarean hysterectomy. She was 5’4”, 57 kg, and had a good airway. Two 16G IVs and an arterial catheter were inserted and surgery started. Ureteral stents were placed, followed by cesarean delivery of a viable baby, RSI of GA, and hysterectomy.
During hysterectomy, massive hemorrhage ensued and the placenta was noted to be invading the bladder. Hypotension required fluids and pressors, while our massive transfusion protocol was initiated. A right IJ catheter was placed and the Gyn Onc and Trauma services were consulted. EBL was 17L, requiring 23 units (U) PRBCs, 12 U FFP, 30 U platelets and 10 U cryoprecipitate. The abdomen was packed, vital signs stabilized and the patient was taken to CVIR for uterine artery embolization. POD#1, the abdomen was closed, she was extubated, and discharged on POD#5.
CASE 2: A 37 year old G5 P4 parturient presented at 36 weeks with a known PP by MRI. This delivery plan included placement of B/L iliac artery balloon catheters pre-operatively, ureteral stents, and cesarean hysterectomy under GA because of the potential for massive uncontrolled bleeding. In addition to 2 large bore IVs and an arterial catheter, we inserted a right IJ catheter during ureteral stenting. This patient also hemorrhaged after delivery; the balloon catheters were inflated and she stabilized with 5 U PRBCs, 4 U FFP, 5 U cryoprecipitate, and 10 U platelets; EBL was 4.5L. She was transferred to the ICU, extubated on POD#1, and discharged home on POD#5.
DISCUSSION: Cesarean hysterectomy for placenta percreta involves a multidisciplinary approach including the OB, Anesthesia, Urology, Surgery (trauma, gyn-onc), Interventional Radiology, and Neonatology services. A delivery plan including preparation for massive blood loss must be in place. With the diagnosis of placenta increta, percreta should be entertained as well. The literature lacks a clear advantage of regional over GA;(3) a careful case by case plan must evolve. Advanced planning and preparation is mandatory.
1. Am J Obstet Gynecol 2005;192:1458-61
2. Obstet Gynecol Surv 1998;53:509-17
3. Cochrane Database of Systematic Reviews 2006, Issue 4