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Management of a Precipitous Vaginal Delivery through a Placenta Previa
Abstract Number: SA-53
Abstract Type: Case Report/Case Series
Cesarean section is the preferred mode of delivery for women with placenta previa. If these patients experience preterm premature rupture of membranes (PPROM), they may require expeditious delivery and are at high risk for major postpartum hemorrhage. We describe the case of a woman who underwent pre-term precipitous vaginal delivery through a placenta previa resulting in massive hemorrhage and hysterectomy.
A 43 year old G8P1 female with a history of one prior cesarean delivery presented to our hospital with PPROM at 18 weeks gestation. She was diagnosed with complete posterior placenta previa by transvaginal ultrasound and admitted for inpatient monitoring. At 25 weeks, the patient experienced a 300cc vaginal bleed. After maternal stabilization, magnesium was initiated for fetal neuroprotection. At 27 weeks, the patient complained of new onset abdominal pain and vaginal bleeding and was transferred to the OR, where she precipitously delivered vaginally. After delivery, she experienced a severe post-partum hemorrhage (>6L blood loss) due to uterine atony and retained placenta. To allow surgical intervention, general anesthesia was induced and an arterial line and large bore peripheral access were placed. Her management was complicated by uterine atony refractory to treatment with misoprostol, oxytocin, carboprost tromethamine, and methylergonovine. Blood loss continued despite dilation & curettage, and placement of a Bakri balloon. To achieve better surgical control of bleeding, a subtotal hysterectomy was performed. A TEE was used intraoperatively to guide fluid resuscitation. The patient received a total of 23 units RBCs, 12 units FFP, 4 pooled platelets, and 3g fibrinogen concentrate. She remained hemodynamically stable throughout. TAP blocks were performed at the end of surgery for post-operative pain relief. The patient was transferred to ICU intubated, without inotropic or vasopressor support. She was extubated 6 hours postoperatively. Her postpartum course was uneventful, and she was discharged home on postpartum day 7. Pathologic examination of the uterus demonstrated placenta accreta.
This case highlights the challenges faced by obstetricians and anesthesiologists when managing patients with unsuspected placenta accreta who experience precipitous delivery. The delivery of the baby through her placenta previa resulted in massive postpartum hemorrhage. Anesthesiologists should be vigilant for placenta accreta in patients with placenta previa with a history of cesarean delivery. Furthermore, major postpartum hemorrhage should be anticipated when managing patients with placenta previa who require expeditious delivery.
1. Obstet Gynecol 2006;107:927–41.
2. J Matern Fetal Neonatal Med. 2015:1-4. (Early Online)