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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
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.
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)