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Massive Hemorrhage in Placenta Increta
Abstract Number: F2C-7
Abstract Type: Case Report/Case Series
Background: placenta accreta is a morbid adhesion of placenta to myometrium that increases risk of massive hemorrhage during delivery. Prior uterine surgery (e.g., C-section) is a major risk factor.
A 23-year-old G5P3A1 with 3 prior C-sections with suspected placenta percreta was scheduled for C-section of 37-week infant followed by hysterectomy. PIV access was deemed insufficient (left 18G and right 22G) given the expected coagulopathy, but multiple attempts at additional IVs were unsuccessful. Consequently, a pre-induction RIJ was placed with single needle pass, ultrasound guidance, and manometry confirmation.
Sudden, significant bleeding was noted 30 minutes after uncomplicated delivery. Transfusion was initiated using pressure bags on both RIJ and PIV. 45 minutes later the A-line (right radial) waveform was lost suddenly, followed shortly by loss of pulse oximeter signal. Carotid pulses were not palpable. Significant neck hematoma was noted, and RIJ use was abandoned. Surgeon reported no aortic pulse, despite stable ETCO2 of 30. CPR was initiated. Epinephrine 100 μg was given. A-line tracing was reacquired with elevated BP (~140/105). Surgeon reported aortic pulse. Total CPR time was approximately 1 minute.
Vascular surgeon was consulted to explore the right neck; RIJ tip was in proper position except with sideports partially outside the vessel. No other damage was noted. The case continued with femoral central line and brachial A-line (both left). There was continued need for vasopressors and blood products. Long discussion was had about closing the abdomen and transferring to SICU. After two ultrasound exams, however, free fluid eventually became evident. Obstetricians re-opened abdomen, finding 5 liters of blood as well as multiple liver lacerations. Trauma surgeons were notified. Argon beam, bilateral hypogastric artery ligations, manual compression, and packing were applied to tamponade the bleeding.
Patient’s abdomen was left open with a wound vac in place. Over 80 units of blood products had been given by the end of the case. Abdomen was closed on POD1, extubated in SICU (POD1), transferred to floor on POD2, and discharged on POD11. Pathology report showed placenta increta.
Conclusion: Placenta accreta variants can be lead to massive hemorrhage. Patient has the best chance with thorough preparation, good communication among multidisciplinary team, rapid identification of problems, and availability and rapid delivery of blood products.
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2. Ammirati C, Maizel J, Slama M. Is chest X-ray still necessary after central venous catheter insertion? Crit Care Med 2010; 38:715.
3. Gladwin MT, Slonim A, Landucci DL, et al. Cannulation of the internal jugular vein: is postprocedural chest radiography always necessary? Crit Care Med 1999; 27:1819.