Primary Cesarean Delivery in a Parturient with a Large Uterine Arteriovenous Malformation (AVM)
Abstract Number: S-55
Abstract Type: Case Report/Case Series
Introduction: Uterine AVM is a rare underreported condition and is often diagnosed after postpartum hemorrhage and hysterectomy.(1) In the following case, we had the benefit of early antepartum diagnosis allowing multidisciplinary planning.
Case Report: A 29-year-old G3,P0020 female, at 33 4/7 weeks presented to L&D with PPROM. A 1st trimester US revealed an extensive uterine AVM. MRI showed dilated uterine/periuterine veins communicating with the internal iliac veins, and enlarged uterine and internal iliac arteries. PMH was significant for a molar pregnancy (D&E, chemotherapy) in 2000, and a 1st trimester SAB in 2004. A cesarean delivery (C/S) at 34 weeks was planned prior to PPROM, because the AVM involved the entire anterior lower uterine segment (LUS) and for fetal breech presentation. The interdisciplinary team for this complicated delivery included OB, Gyn-Onc, Vascular surgery, Anesthesia, Urology, Neonatology, and CVIR. On admission, vital signs were stable; she was 5’4” tall and weighed 82 kg, Hgb was 12.4 g/dL. A growth scan showed a 1683 gm fetus. Two doses of betamethasone were given and the C/S proceeded.
Our patient was first taken to CVIR for insertion of B/L internal iliac artery occlusion balloons. Two large bore IVs were started and 30 mL sodium citrate was given. 4 units of PRBCs were prepared, a Belmont® Rapid infusion system was ready, and the vascular surgeon was available. A slow careful C/S under GA was intended; standard monitors and a BIS were placed. After preoxygenation, a RSI was initiated (fentanyl, propofol, succinylcholine) and she was intubated with a 7.5 ETT; maintenance included sevoflurane until delivery. Following intubation, radial arterial and internal jugular catheters were inserted.
B/L ureteral stents were placed and a midline abdominal incision was made. Dilated arterial vessels were noted in the right LUS involving the right uterine artery. Using intraoperative US, the placental margins were delineated and a uterine incision was made. The fetal head was brought through the incision without pressing on the LUS; the remaining fetal parts were delivered atraumatically. Neonatal APGAR scores were 2, 2, 5. With gentle uterine massage and cord traction, the placenta was removed, the anesthetic converted to TIVA (remifentanil, propofol), and oxytocin (80 unit/L) was started. There was no bleeding from the LUS AVM so the uterus and abdomen were closed, the internal iliac catheters were removed and the patient was awakened and extubated. EBL 600 mL, IVF 3700 mL, U.O. 600 mL. The patient was discharged on POD #4; the infant, 24 days later.
Discussion: The extensive multidisciplinary approach to this case with a well executed plan helped achieve a positive outcome. Through clear goals, open communication and careful management, a case that frequently ends in massive blood loss and possible embolization or hysterectomy, ended favorably.
References: 1.JUM 2004;23:1101-4