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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Navigating the Perfect Storm: Placenta Membranacea with placenta/vasa previa & percreta for repeat c/s

Abstract Number: F2D-1
Abstract Type: Case Report/Case Series

Michael R Barnes MD1 ; Laurie Sutherland MD2

A 34 yo G2P0100 woman with history of 2016 emergent c/s for 10 cm uterine rupture, IUFD & placenta accreta with hemorrhage requiring transfusion was admitted to our facility in 2017 for monitoring at 28 weeks following MFM ultrasound diagnosis of placenta membranacea, vasa/placenta previa & accreta. After 6 weeks of inpatient monitoring, she was scheduled for repeat c/s & possible hysterectomy under GA. Extensive interdisciplinary preoperative collaboration between our team of obstetricians, anesthesiologists & neonatologists designed a care plan that avoided blood transfusion in this high risk surgery.

Our approach included preemptive activation of the massive transfusion protocol, 4 units of cross-matched pRBC in the OR, 2 large bore IVs, an arterial line available, NICU team present & cell saver technology in place prior to induction for RSI with McGrath video laryngoscopy. Upon entry into the peritoneal cavity, several areas of placenta increta/percreta were noted & the decision to proceed with cesarean hysterectomy was made prior to uterine incision. Approximately 1700 mL of blood loss was noted before uterine artery clamping & ligation. Tachycardia into the 110's & hypotension requiring moderate pressor support ensued, however the patient’s hemodynamics normalized quickly with return of 613 mL cell saver autotransfusion from a final EBL of 2L. Mom was discharged home on POD4 & a healthy baby girl continues grow each day.

Placenta membranacea is a rare placental disorder in which fetal membranes are completely or partially covered by directly attached chorionic villi. Incidence is extremely rare, occurring 1 in 20,000-40,000 pregnancies. As described, this condition can be associated with other placental abnormalities like vasa previa & accreta as well as perinatal complications including antepartum bleeding, preterm delivery, IUGR, placental retention, PPH & neonatal death.

(PMID: 7782592)

While we did not choose to employ prophylactic TXA antifibrinolytic therapy, we did consider how the WOMAN trial's demonstration of decreased PPH blood loss & without more thrombotic events makes the potential transfusion sparing effect a promising prophylactic therapeutic option in high risk cases anticipating severe PPH. Indeed, the MFMUN’s ongoing RCT comparing prophylactic TXA v placebo in the setting of known placental invasion may provide the evidence to support such an addition to our care plan we felt did not yet exist.

(APSF Newsletter 10.2017)

SOAP 2018