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Incidental Diagnosis of Inferior Vena Cava Thrombus on Transesophageal Echocardiography in a Patient with Placenta Percreta Undergoing Cesarean Hysterectomy
Abstract Number: S3C-3
Abstract Type: Case Report/Case Series
Introduction: Cesarean hysterectomy (CH) for placenta percreta may result in massive hemorrhage. Transesophageal echocardiography (TEE) can be useful in the management of bleeding parturients (1). Patients with antepartum bleeding may need prolonged hospitalization, placing them at risk for VTE (2). We present the case of a parturient with placenta percreta who was found to have an inferior vena cava (IVC) thrombus on TEE during CH who then developed acute intraoperative pulmonary embolism (PE).
Description: A 35-year-old G5P3 with known anterior placenta previa and placenta percreta with bladder and cervical invasion was admitted at 27+3 weeks gestation for antepartum bleeding, which persisted and necessitated delivery via CH at 28+1 weeks. General anesthesia (GA) was planned with TEE-guidance for management of anticipated hemorrhage. A baseline TEE exam revealed normal biventricular size/function and no hemodynamically significant valve lesions. Soon after delivery a new echogenic filamentous structure was seen in the IVC extending into the right atrium (RA) (Figure 1). The patient was hemodynamically stable, and the rest of the exam was unchanged. The case was later complicated by massive surgical blood loss and TEE was used to guide volume resuscitation during this phase.
3 hours later she developed acute hypoxemia, hypotension, and a decrease in her end-tidal carbon dioxide (ETCO2). She improved with the administration of epinephrine 200 mcg and 100% FiO2. The echogenic mass was now much smaller on TEE (thrombus presumed to have embolized into the pulmonary vasculature), but there was no appreciable RV dysfunction. Anticoagulation was felt to carry significant risk given the hemorrhage and the need to return to the OR for packing removal in 24-48 hours. Interventional radiology was consulted and placed an IVC filter prior to ICU transport via the in situ internal jugular sheath with both fluroscopic guidance using a portable "C-arm" and TEE.
Discussion: TEE is a valuable monitor for volume status, cardiac function, and, in this case, thrombi and embolic events during CH for placenta percreta. We recommend using GA for these cases to allow for its placement. Since anticoagulation often cannot safely be used perioperatively for CH, an IVC filter is a useful tool for patients at high risk for PE.
1. Int J Obstet Anesth. 2015;24:131-6.
2. Semin Thromb Hemost. 2001;27(2):149-53.