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Exploratory Laparotomy on POD 1 after Planned Cesarean Hysterectomy for Placenta Accreta. What's the Big Deal?
Abstract Number: F2D-4
Abstract Type: Case Report/Case Series
Introduction: Abnormal placentation (previa/accreta) is a leading cause of postpartum hemorrhage (PPH). In the United States, approximately 1 per 1000 deliveries is complicated by peripartum hysterectomies and only 5% of these will be complicated by postoperative bleeding requiring laparotomy.1 Despite large intraoperative EBLs, planned peripartum hysterectomies are often managed with conservative blood component resuscitation due to baseline hypercoagulation and increased circulating volume. Optimization with fluid administration prior to hysterectomy may decrease need for transfusion. In the rare case where patients who experience bleeding after C-hyst, much more aggressive transfusion strategies may be necessary. We present our experience with such a case.
Case: Patient is a 37yo G4P3 at 36+1 GA who presents for placenta accreta (3 prior CD with complete previa) with planned cesarean delivery and hysterectomy. Intraoperatively, her resuscitation was managed with rapid TEGs, CBCs, and coagulation profiles to guide transfusion resulting in a conservative approach of 3 units pRBCs, 11 L crystalloid, 350 cc cell saver, and 500 ml 5% albumin. Estimated total EBL of 3900cc. Pt was taken to ICU in stable condition with a normal coagulation profile.
On POD 1, the patient experienced worsening abdominal pain, distention and hypotension requiring vasopressors. She was emergently taken to OR for exploratory laparotomy where 1.5L of blood was in the peritoneum originating from the right infundibulopelvic (IP) ligament housing the ovarian artery. Aggressive transfusion was initiated in OR. In total, 4.5L of crystalloids, 1 L of 5% albumin, 4u PRBCs, 150cc cell saver, 4u FFP, 1u cryoprecipitate, and 1u platelets were given. Initial laboratory values indicated DIC. Total EBL was 2L. Recovery was uncomplicated and she was discharged in stable condition POD 6.
Discussion: Resuscitation strategies related to a planned delivery and hysterectomy secondary to abnormal placentation are well defined. Lab guided conservative management in regards to transfusion can allow for less overall blood component utilization. However, providers should be aware that in the rare event that patients who have significant surgical bleeding following hysterectomy may have less coagulation reserve and require a much more aggressive blood and factor resuscitation strategy. Therapy should be initiated in unstable patients prior to laboratory verification.
Dulu, Alina, et al. Critical Care Eds. John M. Oropello, et al. New York, NY: McGraw-Hill
Van Den Akker, Thomas et al. Obstetrics and Gynecology. Vol. 128, no. 6, Dec. 2016, pp. 1281–1293.
Pre CD -TAH Labs
Post CD- TAH Labs
Pre Ex Lap
TEG Activated Time