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Balanced transfusion in the setting of massive placenta percreta hemorrhage
Abstract Number: T-13
Abstract Type: Case Report/Case Series
Placenta percreta presents a unique challenge to the obstetric team. We present a case of massive hemorrhage due to percreta with successful transfusion of an approximate 6:6:6:1 ratio of pRBCs, FFP, platelets and cryoprecipitate. (1)
A 32 year-old G5P2 presented at 31 weeks gestational age with known placenta percreta for Cesarean/hysterectomy. She had 2 previous Caesarean deliveries. Her history and physical exam were unremarkable. At 24 weeks in the current pregnancy she developed vaginal bleeding and was diagnosed with placenta accreta. She was admitted for prolonged bed rest, remained stable for seven weeks, but a placenta percreta was confirmed. In the 24 hours prior to surgery her bleeding worsened. Preoperative planning included a multidisciplinary collaboration between obstetrics, urology, gyn/onc, anesthesiology, blood bank and interventional radiology. Concurrent with the patient's wishes the anesthetic plan was to begin with neuraxial anesthesia with likely conversion to general after delivery.
Pre-operatively, 2 16-gauge IVs were placed, and a radial arterial line inserted. A CSE was admistered. While the surgical team prepped, a long 20 gauge antecubital IV was placed. Cystoscopy prior to Cesarean incision was normal. Prophylactic bilateral ureteral stents were placed.
After delivery of a 1.7 kg male (APGARs 8/9), hemorrhage occurred and the obstetricians proceeded to hysterectomy. We converted to general anesthesia and began resuscitation with pRBC's, FFP and a phenylephrine infusion. Her 20 gauge IV catheter was changed to a 7 Fr. rapid infusion catheter. Placental vessels had invaded deep into the retroperitoneum and the bleeding was very difficult to control. Trauma and vascular surgery were called but blood loss persisted for hours, at times as rapidly as 1 liter/minute.
The anesthesia team was divided into roles - one assigned to each of the three IV's, one charted and sent labs every 30 minutes, one checked and distributed blood products and one communicated with the OB team, administered miscellaneous medications (calcium, antibiotics, muscle relaxant, narcotics, anti-fibrinolytics). A dedicated nurse made trips to the blood bank with coolers.
After approximately 7 hours the bleeding was controlled enough with packing and ligation to travel to interventional radiology and branches of the left internal iliac and inferior epigastric arteries were embolized.
Labs upon arrival in the ICU showed a pH of 7.53, a normal ionized Ca++ (nadir was 0.26), lactate was 3 mmol/L (peak = 8.3), Hct was 25% (nadir was 21%). Coagulation profile demonstrated an INR of 1.3 (peak = 1.5), fibrinogen of 203 and platelets of 79,000 (nadir 62 K).
Final totals included EBL > 60 liters, transfusion of 73 units of pRBC's, 72 units of FFP, 66 units of platelets, 12 units of cryoprecipitate, ten liters of crystalloid and a liter of cell saver.
1) Lal DS, Shaz BH. Massive transfusion: blood component ratios. Curr Opin Hematol. 2013 Nov;20(6):521-5.