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PLACENTA PERCRETA COMPLICATED BY PULMONARY EMBOLISM IN A PREGNANT PATIENT
Abstract Number: F-68
Abstract Type: Case Report/Case Series
Placenta accreta is a potentially life-threatening condition in obstetrics. With the increasing rate of cesarean deliveries, the incidence of placenta accreta is steadily increasing. Here we present a case of a parturient with history of two prior c-sections and placenta percreta with an unexpected course.
25 year old female with complete posterior placenta previa presented at 37 weeks for repeat c-section. MRI revealed placenta percreta with possible bladder involvement. Multidisciplinary meeting was held among obstetrics, anesthesiology, gynecologic oncology, urology, neonatology and interventional radiology. Patient was scheduled for cystoscopy, cesarean hysterectomy, embolization of internal iliac arteries and possible bladder repair.
In the OR, two large bore IVs and a rapid infusion catheter were inserted. Standard ASA monitors and arterial line were placed. Combined spinal-epidural was performed. Cystoscopy and ureteral stents were placed. Bilateral internal iliac artery balloon catheters were placed under fluoroscopy. Epidural catheter was bolused with 2% lidocaine with epinephrine. C-section was initiated via mid-line vertical incision. Immediately after delivery, the patient became unresponsive and profoundly hypotensive. Airway was secured via RSI. Boluses of pressors and chest compressions were started with ROSC in 10-20 seconds. After a few minutes, patient's blood pressure was again not measurable. Second round of chest compression started with ROSC in 10-20 seconds. Massive transfusion protocol initiated. Internal iliac arteries were embolized. Hysterectomy was completed and the bladder dome was repaired. Fibrinogen levels dropped ~40% during this time. Final estimated blood loss ~5L. Patient received a total of 5L of crystalloids, 7 units PRBC, 9 units FFP, 2 units platelets, 4 units cryoprecipitate and 100ml of 25% albumin.
Postoperative CTA showed bibasilar segmental emboli, greater on the right with evidence of right heart strain. Patient was extubated the day after and started on a heparin infusion and transitioned to low molecular weight heparin. Patient was discharged home day 5.
Placenta accreta is associated with significant risk of morbidity and mortality secondary to hemorrhage and is the most common indication for peripartum hysterectomy. Placentation abnormalities account for 1.7% of maternal deaths in the U.S. and 24% of perinatal deaths. A multidisciplinary approach is essential for optimal outcomes. Anesthetic considerations include adequate IV access, invasive hemodynamic monitoring, choice of anesthetic technique as well as preparing for potential massive hemorrhage. In the setting of hemodynamic collapse,embolism must also be high on the differential. There is a five-fold odd of thromboembolic events during pregnancy compared to non-pregnant patients. Thromboembolic events account for ~20% of all maternal deaths. Early recognition, diagnosis and treatment is critical.