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Cesarean Delivery in a Parturient with Massive Uterine Fibroids
Abstract Number: S-62
Abstract Type: Case Report/Case Series
Introduction: The prevalence of fibroids in pregnancy is 0.9%-3.9%. They are more common in African American and older women and are associated with an increased rate of cesarean section (C/S) and fetal malpresentation.(1) Most pregnancies are unaffected by fibroids; however large submucosal and retro-placental fibroids may impart greater risk.(2) One study found that the presence of multiple fibroids was predictive of massive peripartum hemorrhage.(3) We present a case of a C/S in a patient with multiple unusually large fibroids complicated by massive hemorrhage requiring uterine artery embolization.
Case Report: A 29 y/o G5 P1031 female presented at 37 weeks gestation for elective C/S due to extremely large fibroids and fetal transverse lie. The fibroids measured 12x9x11cm in the lower uterine segment and 31x21x24cm in the fundus. Past medical history included childhood asthma, chronic HTN, and a family h/o masseter muscle spasm during anesthesia. Our Apollo anesthesia machine was appropriately prepared for possible MH and Dantrolene was readily available. Blood was typed and crossmatched. We inserted 2 large IV’s, a radial artery catheter, and placed a CSE in the OR. Following delivery of the infant, maternal BP dropped precipitously to 35/15, requiring resuscitation with fluid, ephedrine, phenylephrine, and epinephrine. The surgeon noted massive bleeding. A RSI and intubation was performed using propofol and rocuronium; a cordis introducer was placed in the right internal jugular vein. Massive hemorrhage protocol was initiated and the patient required 14 units PRBCs and 9 units FFP. A Bakri Balloon was inserted into the uterine cavity to tamponade the bleeding. The abdomen was closed and we transported the patient to interventional radiology for uterine artery embolization. EBL was 5000 mL. POD #1 the Bakri balloon was removed with no further bleeding and the patient was extubated. She developed persistent fevers due to necrotic fibroids and was finally discharged POD #15.
Discussion: The decision to use regional anesthesia for a C/S with possible massive hemorrhage is not clear-cut. Most techniques for planned C/S utilize regional anesthesia to avoid the potential difficult maternal airway and to minimize fetal exposure to anesthetic agents. However, a systematic cochrane data review for maternal and neonatal outcomes did not find regional to be more advantageous than GA(4). In our case the interval from incision to delivery was expected to be prolonged. More importantly, we were hoping to avoid GA in a patient with family history of masseter muscle spasm during anesthesia. Our case report illustrates the need to prepare and promptly carry out a back-up plan.
References: 1. Obstet Gynecol Clin N Am 33 (2006) 153-169 2. Obstetrics & Gynecology Feb 2007; 410-414 3. Ultrasound Obstet Gynecol 2009; 34:322-325 4. Cochrane Database of Systematic Reviews 2006, Issue 4