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Massive Hemorrhage and Pulmonary Embolus in a Parturient with Placenta Accreta
Abstract Number: S-36
Abstract Type: Case Report/Case Series
Purpose: We present the anesthetic management of a patient with placenta accreta who experienced a pulmonary embolus (PE) during a massive postpartum hemorrhage, and subsequently required an intraaortic balloon pump (IABP).
Clinical features: A 36-yr G5P2 was scheduled for cesarean delivery and possible hysterectomy at 34 weeks due to a known placenta previa and suspected focal placenta accreta. Her BMI was 29 and she had a reassuring airway. Anesthesia was provided with a CSE technique and an infant with a known prenatal diagnosis of truncus arteriosus was safely delivered. The placenta separated easily, however the lower uterine segment myometrium appeared attenuated with only a serosal layer remaining and a hysterectomy was planned. There was significant bleeding from her left ovarian vein, and the anesthetic was converted to general. During volume resuscitation, her end-tidal CO2 suddenly declined and pulseless electrical activity requiring cardiopulmonary resuscitation ensued. After return to spontaneous circulation, a PE was observed with intraoperative transesophageal echocardiography (TEE); a large clot was seen moving out of the right ventricle into the pulmonary circulation. She was started on an epinephrine infusion to maintain blood pressure and inhaled nitric oxide for right ventricular enlargement seen on TTE. The patient continued to bleed from the surgical site and a liver laceration sustained during the chest compressions, and a 10.5 L estimated blood loss was recorded. She received 48u PRBC, 40u FFP, 13u platelets, 8u cryoprecipitate, 8L crystalloid, 7g factor VII, 2g human fibrinogen intraoperatively. She received further PRBC, FFP and platelets in ICU for ongoing bleeding from her sacral venous plexus. She was taken back to the operating room for abdominal washout and re-packing. Her PaO2 continued to remain in the low 40s. An IABP placed due to severe cardiac dysfunction resulted in dramatic improvements of her hemodynamics and oxygenation. The IABP was removed post-operative day 3 after she stabilized hemodynamically, she was extubated on day 7, and started on therapeutic anticoagulation. She was discharged from hospital on day 35, without significant morbidity or neurological injury.
Conclusion: This case presents a therapeutic dilemma of PE in the setting of massive postpartum hemorrhage during a surgical procedure. Prolonged bed rest (4 weeks) prior to the surgery may have contributed to her PE, however prophylactic or therapeutic anticoagulant use in a setting of potential and actual catastrophic hemorrhage is problematic. The IABP for this case was likely a lifesaving intervention, that improved her oxygenation and contributed to preservation of neurological function.1 Early recognition of decompensation and interventional measures are key after a catastrophic event during abnormal placentation cesarean delivery.2
1. Int J Obstet Anesth. 2008; 262-6
2. Clin Cardiol. 1985:599-602