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Urgent peripartum hysterectomy @ 16 weeks for twin pregnancy with placenta previa percreta complicated by massive hemorrhage and DIC
Abstract Number: S-81
Abstract Type: Case Report/Case Series
Background: Abnormal placentation and peripartum hysterectomy are known risk factors for peripartum hemorrhage (PMID:24373590). We present the case of an urgent peripartum hysterectomy for a 16 week nonviable twin gestation with placenta previa percreta, complicated by massive hemorrhage.
Clinical Features: A 34 yo G8P4125 presented with di-di twin pregnancy at 16 wks GA following PPROM for fetus A. Fetus A was noted to have placenta previa and accrete on ultrasound and MRI. Urgent peripartum hysterectomy was recommended by the Maternal Fetal Medicine service. Gyn-Oncology was consulted, and after review, deferred to General Gynecology; Gyn-Oncology, Trauma and Vascular Surgery were all on standby for intraoperative consultation if needed. The opinion of the obstetric and surgical teams was that the likelihood of massive hemorrhage was relatively low, due to relatively reduced vascularity of the uterus secondary to early gestational age; the plan was for hysterectomy only since the fetuses were nonviable. Nevertheless, we adhered to our abnormal placentation protocol. Large bore IV access and invasive monitoring were obtained; along with multiple units of verified blood products in the OR prior to induction and blood bank notification for possible massive transfusion. Hysterectomy proceeded uneventfully until oozing was noted from the right pelvic sidewall. The pelvis was packed and Gyn-Oncology was consulted. EBL was minimal and the patient remained stable. Upon inspection by Gyn-Oncology, placenta percreta was noted with extensive invasion into the bladder and cervix. Once the pelvic packing was removed, EBL increased dramatically. Both trauma and vascular surgery were called when further dissection resulted in ongoing rapid blood loss (EBL of 30 liters), necessitating aortic cross clamping. Massive transfusion and resuscitation maintained SBP above 80mmHg; the abdomen was packed, and the patient was stabilized for transfer to SICU. Exploratory laparotomy, cecal repair and cystorrhaphy were performed on POD#1. The patient was extubated on POD#2 and transferred to postpartum on POD#3.
Conclusions: Although reassuring obstetric factors may be present, abnormal placentation presents a risk for massive hemorrhage. Multidisciplinary consultation, blood bank notification and preparation for massive transfusion are key feature in reducing mortality and morbidity