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Emergent Peripartum Hysterectomy with Massive Transfusion and Coagulopathy
Abstract Number: T-73
Abstract Type: Case Report/Case Series
In obstetric anesthesia few cases are as challenging as an emergent peripartum hysterectomy due to hemorrhage. At term the gravid uterus receives greater than 15% of cardiac output (~700ml/min) and exsanguination can occur in a matter of minutes if bleeding is not promptly controlled. While abnormal placentation and uterine atony are by far the most common causes of severe uterine hemorrhage, other less common causes include uterine rupture and laceration of uterine vessels. In these cases, peripartum hysterectomy is indicated when conservative measures fail to control the hemorrhage. While conservative measures may be able to avoid the sterilization due to hysterectomy, they have been shown to lead to greater transfusion requirements and higher maternal morbidity overall.
In our case, a G7P2042 @ 34 5/7 weeks presented for repeat cesarean delivery. Her past medical history was significant for two prior cesarean sections, two prior D&Cs, morbid obesity, smoking, hepatitis C, asthma, GERD, and gestational diabetes mellitus. Ultrasound on admission revealed placenta previa with suspicion for placenta accreta. While the incidence of placenta accreta is only 1:22,150 in the absence of placenta previa and without uterine scar, this incidence is >33% when placenta previa is present with a history of 2 or more prior cesarean sections as was the case for our patient. Preoperatively, 2 IVs were places and a type and crossmatch was completed in addition to preparation for invasive lines.
A spinal was performed which was converted to general anesthesia secondary to partial failure. Shortly after delivery the placenta did not appear adhered to the uterine wall and was removed without excessive force per the obstetric team. However, massive hemorrhage ensued immediately. The patient quickly became hemodynamically unstable and both arterial line and central venous access was established. Massive transfusion protocol was activated while conservative surgical measures to stop the hemorrhage including intrauterine balloon placement ultimately failed. Over the next five hours the patient was multi vasopressor dependent receiving in total 28 units PRBCs, 25 units of FFP, and 6 units of platelets in addition 9000mcg of Factor VIIa and 24mcg Desmopressin. EBL for the surgery was estimated at 8000 ml. Amazingly, the patient was extubated on POD1 and discharged home on POD5. She was noted to have only a foley catheter for ureteral injury and right femoral nerve injury likely secondary to retraction at discharge.
Bodelon C, Bernabe-Ortiz A, Schiff MA, Reed SD. Factors associated with peripartum hysterectomy. Obstet Gynecol 2009; 114:115.
Knight M, UKOSS. Peripartum hysterectomy in the UK: management and outcomes of the associated haemorrhage. BJOG 2007; 114:1380.
Palmer, C.M. (2011) Obstetric Anesthesia. New York, New York: Oxford University Press.