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Morbidly adherent placenta of twin A in a surrogate gestational carrier with dichorionic-diamniotic twins
Abstract Number: SU-79
Abstract Type: Case Report/Case Series
A 28 year old G4 P2103 presented at 29 weeks gestation as a surrogate gestational carrier of an in vitro fertilization pregnancy with findings of complete posterior placenta previa and increta of twin A on ultrasound. Follow up magnetic resonance imaging was concerning for placenta percreta. She had a history of one previous cesarean delivery. After a multidisciplinary meeting, an elective cesarean hysterectomy at 32 weeks was scheduled to maximize the fetuses’ gestational ages while being precautious of the maternal risks associated with preterm labor and/or antepartum hemorrhage and the subsequent need for emergency cesarean delivery by prolonging the pregnancy.
On the day of surgery, our massive transfusion protocol was on standby, as well as both trauma and vascular surgeons. Cell salvage and a rapid infuser were available. Prior to induction and intubation, a radial arterial line and a peripheral 7 French rapid infusion catheter were placed. Interventional radiology placed bilateral occlusion balloons in the internal iliac arteries. After rapid sequence induction and intubation, a 9 French double-lumen central venous catheter was placed in the right internal jugular vein. The twin fetuses were delivered by cesarean and the hysterotomy was closed with the placentas in situ. After delivery, hemorrhage was suspected, and although a source was not readily apparent, blood transfusion was started as the surgeons began the hysterectomy. Bleeding from the vagina finally became evident, likely due to the placenta previa. Bilateral occlusion balloons were inflated, and the dissection proceeded quickly. At the end of surgery, estimated blood loss was 4 liters and transfusion included 10 units packed red blood cells, 8 units fresh frozen plasma, 1 adult dose of platelets, and 125 milliliters of blood from cell salvage. Laboratory analyses was satisfactory, vital signs were stable, thus she was extubated and taken to recovery.
Discussion: The incidence of twin gestation has increased due to increasing advanced maternal age and assisted reproductive technology. Twin pregnancies are associated with increased risks of placental abnormalities, including a 40% higher incidence of placenta previa compared to singleton pregnancies. Data is limited surrounding the diagnosis and management of morbidly adherent placenta in twin pregnancies, but most cases report uterine rupture and emergency hysterectomy in the second trimester. The surgical management in our case was for elective preterm cesarean delivery followed by closure of the hysterotomy with both placentas in situ and then hysterectomy. This case was complicated by significant bleeding requiring transfusion, mostly from the vagina, and likely due to partial separation of the adherent placenta.
Hubinont et al. Am J Obstet Gynecol 2015;213:S91-102.