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Elective Cesarean Section Complicated by Post Partum Hemorrhage
Abstract Number: F2C-8
Abstract Type: Case Report/Case Series
Introduction: PPH is a major cause of morbidity and mortality accounting for 25-30% of maternal deaths worldwide. The most common cause is uterine atony.
Case Presentation: 26-year-old F G4P2012 presented for elective repeat C-section at 39w2d. Prior history of 2 C-sections.
An uncomplicated CSE was performed and delivery of a viable infant was achieved. Extensive adhesive disease was noted intra-op and EBL was 1600. She remained stable intra-op with fluid resuscitation, and uterotonics. In PACU, she became hemodynamically unstable, which was initially attributed to under-resuscitation of intraop blood loss. She was a transient responder to resuscitation with crystalloids and 2 units PRBC. CBC revealed a fall in Hgb to 6.9 from 11.
The initial plan was for Bakri balloon placement. However, a combination of mental status decline and worsening abdominal exam led to decision for ex lap. RSI was performed after placing a pre-induction arterial line.
Hemoperitoneum was found but the source was not identifiable. She was transferred to IR where active extravasation from the left uterine artery was identified & embolized. Coagulation studies were reflective of DIC: fibrinogen<60, INR 2.6, PT 28.2 with improvement to 278, 1.3 & 16 respectively. TEG showed prolonged K 4.2, decreased MA: 46.3 & decreased R 4.6. Replacements included an additional 5PRBCs, 20 units of cryoprecipitate, 9 units FFP and 2 platelet packs. Resuscitation was continued in the ICU. She was extubated on POD 1 and downgraded from ICU on POD 2.
Discussion: Defining PPH is challenging, as blood loss is often underestimated or difficult to determine. While 500 or 1000ml of blood loss for vaginal and cesarean deliveries, respectively or a 10% drop in Hct, are generally used as parameters for PPH, may patients will tolerate this degree of blood loss. A more useful definition is an amount of blood loss that results in hemodynamic compromise in the individual patient.
Uterine artery embolization preserves fertility unlike hysterectomy. The first reported case of uterine artery embolization to treat postpartum hemorrhage was in 1979. A review of 138 cases reported a success rate of 94.9%. 7 cases required hysterectomy due to failed embolization.
1: World Health Organization, The World Health Report 2005: Make Every Mother and Child Count. 2005Geneva, SwitzerlandWHO Presspg.62
2: M. Walfish, A. Neuman, D. Wlody; Maternal haemorrhage, BJA: British Journal of Anaesthesia, Volume 103, Issue suppl_1,1 December 2009, Pages i47–i56, https://doi.org/10.1093/bja/aep303
3: Badaway SZA, Etman A, Singh M, Murphy K, Mayelli T, Philadelphia M. Uterine artery embolization: The role in obstetrics and gynecology. J Clin Imag 2001;25: 288–95
4: Heaston DK, Mineau DE, Brown BJ, Miller FJ. Transcatheter arterial embolization for control of persistent massive puerperal hemorrhage after bilateral surgical hypogastric artery ligation. Am J Roentgenol 1979;133:152–4.