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Major placenta previa in a cystic fibrosis patient: A challenging case
Abstract Number: SU-08
Abstract Type: Case Report/Case Series
Cystic fibrosis (CF) is a multisystem disorder with significant respiratory implications. Placentia previa is one of the major complications that can lead to catastrophic bleeding. We describe a challenging case of Primigravida (PG) who had CF and insulin dependent diabetes (IDDM) that presented with bleeding placenta previa requiring urgent Caesarean section (LSCS).
A 24 year old PG, 35+2 weeks, BMI 20 had diagnosed CF and IDDM with FEV1 of 1.1L, VC 2L, PEFR 150-200ml/min (around 50 % of predicted values). She was on long-term antibiotics for repeated chest infection, enzyme supplements and low dose heparin. On routine ultrasound scan, she was found to have placenta previa. Multi disciplinary (MDT) in put was sorted at 10 +6 weeks. Follow up plan was formulated. Patient had recurrent vaginal bleeding. In view of her repeated bleeding, Grade 3 LSCS at 35+2 weeks. Full anaesthetic assessment and detailed discussion with obstetric team was carried out. ICU team was informed and HDU bed was available on labour ward for post op recovery. Cell saver was used peroperatively. Anaesthetic and obstetrics consultant were present during the LSCS. Spinal with 2.5 mls of heavy bupivacaine + 300 micrograms of Diamorphine was used. LSCS was performed and healthy baby 2.4kg was delivered. Intrauterine balloon was placed due to excess bleeding of around 800-1000mls. Syntocinon infusion was started and patient transferred to HDU. Intrauterine balloon was removed next day and patient was transferred at day 2 with uneventful recovery.
Incidence of CF is 9.8/100,000 deliveries and CF is 5.2/1000 pregnancies. CF increases risk of respiratory complications, infections and mortality during pregnancy. CF patients also suffer from diabetes and enzyme deficiencies. Placenta previa mostly presents with painless bleeding that could be catastrophic. LSCS, uterine artery embolization, re exploration, hysterectomy etc. may be required as preventative or curative procedures. Anaesthetic management could be particularly challenging, as avoidance of General anaesthesia is desirable but patients may not be able to lie flat awake after regional, for extended periods. Strict Intrapartum diabetic control is required. DVT prophylaxis could be challenging, as timing of antithrombotic agents could be a contraindication for regional anaestheisa; increased risk of bleeding and prompt need to restart anti thrombotic therapy post delivery. Regular physiotherapy, continuation of long-term antibiotics and low threshold for ICU/HDU care is recommended. Anxiety could be a challenging issue. Various anaesthetic options are available. We chose spinal with Diamorphine as patient was quite keen on regional and in case of prolonged surgery or heavy bleeding, we had low threshold to proceed to GA. MDT approach and clear planning helped us to resolve issues that arose during the course of this high-risk eventful pregnancy.