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It will only take a few minutes - it is just a simple dilation and evacuation
Abstract Number: F3D-2
Abstract Type: Case Report/Case Series
A 46yo G5P2022 with two prior cesarean sections (C/S), presented with vaginal bleeding and was found to have a 15-week fetal demise on ultrasound (US) on a Sunday. Antibiotics were given for infection, and a dilation and evacuation procedure scheduled. For over a month, she had reported on-going dark red vaginal bleeding, that increased recently. With the bleeding, she noted increased crampy left sided pain. Two weeks before this admission she had a transabdominal US that showed a viable 13-week fetus but revealed an abnormal appearing placenta previa. US findings included multiple vascular lacunae, an indistinct myometrial interface with unclear location of the placenta, and was read as questionable for an accreta or a partial molar pregnancy, with a suspected retro-membranous hematoma. Repeat transvaginal US on current admission revealed the anhydraminios, the placenta previa, absent fetal cardiac activity, but no evidence of accreta, molar pregnancy or hematoma.
She was taken to operating room for an US guided dilation and evacuation under intravenous sedation with a paracervical local anesthetic block. However, upon initial dilation, patient briskly hemorrhaged. After removal of fetus and partial removal of placenta, the surgeon realized with US that a portion of placenta was contained within the C/S scar and could not be removed. An intrauterine Bakri balloon was inserted and inflated with 70cc sterile water for tamponade and an urgent gynecologic oncology consultation was called by the original surgical team. The blood bank was notified of activation of the massive transfusion protocol, the anesthesia team induced general anesthesia with endotracheal intubation, placed additional intravenous access, and organized the institution of cell salvage. The patient was prepared for laparotomy and underwent an urgent total abdominal hysterectomy and repair of incidental cystotomy. Total blood loss from the surgery was 5200cc and she received resuscitation with 6200cc LR, 2000cc NS, 500cc albumin, 500cc colloid, 486cc cell saver, 1U cryoprecipitate, 2 packs platelets, 7U PRBCs, 2U FFP. She recovered while intubated in the ICU with immediate postoperative course complicated by DIC and hemorrhagic shock. Extubation and hemodynamic/coagulation stability occurred by postoperative day 1.
She recovered and was discharged home in good condition in a week. This case exemplifies the importance of an organized and rapid systemic response to obstetric hemorrhage. Also, that careful review of ultrasound findings in early pregnancies (even by the anesthesia team) is advisable.
1.Stirnemann, J.J. et al. Screening for placenta accreta at 11-14 weeks of gestation. American Journal of Obstetrics & Gynecology, Volume 205, Issue 6 , 547.e1 - 547.e6
2. Orlando B., et al. When Should a Patient Undergoing Dilation and Evacuation of Products of Gestation Be Intubated? .Scher C., et al (eds) You’re Wrong, I’m Right. Springer 2017