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Placental Abruption, Uterine Rupture, Placenta Percreta and Emergent Cesarean Hysterectomy with Massive Transfusion Protocol in a Preterm Obstetric Patient with Tricuspid Valve Infective Endocarditis
Abstract Number: F2C-3
Abstract Type: Case Report/Case Series
A 30-year-old G3P2 at 31w1d with PMH 2 prior cesareans, IVDA, Hepatitis C, MRSA endocarditis, pulmonary emboli, and recent admission for debridement of septic sacroiliitis from which she left AMA from outside hospital, presented with dyspnea and angina. She had known tricuspid valve infective endocarditis and echo from OSH showed LVEF 60%, normal RV systolic function with tricuspid valve anterior leaflet vegetation 2x1cm and moderate TR. Initially admitted to antepartum for monitoring, patient reported abdominal cramping and passage of blood clots. Hemoglobin noted to drop from 9 to 7 g/dL. As patient was undergoing bedside ultrasound for assessment of placenta previa, an ongoing uterine rupture was identified. She was taken emergently to OR. Placental abruption, uterine rupture and percreta were identified and she underwent cesarean hysterectomy, left uterolysis, and repair of cystotomy. EBL was 8L; she required massive transfusion protocol and received 12 pRBC, 10 FFP, 2 cryoprecipitate, and 1 pool platelets. Postop, she had worsening RV volume overload and torrential TR. She required aggressive diuresis with IV furosemide and paracentesis with 4L of fluid removed. She was treated with an 8 week course of ceftaroline for endocarditis and repeat echo revealed LVEF 45% with interventricular septal flattening consistent with RV volume overload and severe TR. Cardiac surgery performed tissue TVR with postop course complicated by 3rd degree AV block, which resolved. She was recovering well but decided to leave AMA once again and has not followed up.
Discussion: Infective endocarditis in pregnancy is rare, about 6:100,000. Right-sided lesions usually involve the tricuspid valve and are due to IVDA or preexisting valvular abnormalities (1).
Hemorrhage in obstetric patients (PPH) is a leading cause of maternal mortality (2,3,4). Risk factors include uterine rupture, abnormal placentation, and previous cesareans (4). Structured team approach for management with implantation of safety bundles and checklists has shown to reduce mortality (3).
Early identification is essential, however few studies highlight optimal management and clinical outcomes of massive transfusion in obstetrics (2,3). New data suggests that tranexamic acid may reduce postpartum blood loss; however, the risk of thrombotic events may preclude its routine use (4).
The successful resuscitation of an abruption, rupture and percreta patient for cesarean hysterectomy highlights the importance of obstetric emergency and PPH preparedness and multidisciplinary collaboration. The complicating factor of TV endocarditis leading to subsequent right heart failure would not have been relevant if protocols and resources for rapid massive resuscitation were not in place to see her through cesarean hysterectomy.
1. Obstet Med. 2010 Jun; 3(2):78-80
2. BJOG. 2010 Dec; 123(13):2164-2170
3. Am J Obstet Gynecol. 2017 Mar; 216(3):298.e1-11
4. Obstet Gynecol. 2017 Oct; 130(4):765-769