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Multidisciplinary Management of Cesarean Delivery, Serial Embolizations, and Delayed Hysterectomy for a Parturient with Placenta Percreta into the Cervix
Abstract Number: FCB-278
Abstract Type: Case Report Case Series
A 27 year old G5P3 woman at 23 weeks gestation with suspected placenta percreta was transferred to our institution for delivery planning. She had a history of three previous cesarean deliveries. Ultrasound and MRI showed complete placenta previa with signs of extensive placental invasion of the cervix and focal bladder invasion. The patient was admitted for antenatal observation and monitoring, weekly multidisciplinary meetings and serial MRIs. Due to the extent of the disease and subsequent impossibility to perform a hysterectomy without massive hemorrhage, the surgical plan was cesarean delivery in the Main OR, transfer of the patient to the interventional radiology (IR) suite for embolization, postpartum methotrexate therapy, and then later hysterectomy.
The cesarean delivery was performed at 28 weeks gestation under general anesthesia. Preparations for massive hemorrhage were done in case the placenta began to separate intraoperatively or during embolization. A central line, large bore peripheral IV access and an arterial line were placed. A rapid infuser, cell saver, cardiac anesthesia and trauma surgery were available. Cesarean delivery was performed uneventfully and the placenta remained in situ. The patient was transferred to the IR suite for uterine artery embolization. She was extubated following embolization, transverse abdominis plane blocks were done and she was monitored in ICU. Estimated blood loss was 800 mL. She remained hospitalized for 6 weeks with methotrexate therapy and 2 additional embolizations due to development of collaterals seen on pelvic CTA and MRI. She subsequently had an emergent total hysterectomy, bilateral salpingectomy with complete placental resection due to hemorrhage. Her fibrinogen was 89 mg/dL and INR 1.6. She received 4 units PRBC, 6 units FFP and 1 unit cryoprecipitate to correct coagulopathy. She was extubated at the end of surgery. Postoperative course was uneventful.
Cesarean with planned delayed hysterectomy has shown to reduce total blood loss in patients with severe morbidly adherent placenta (MAP). The optimal timing of delayed hysterectomy has not been established. Several complications such as disseminated intravascular coagulation and sepsis have been reported with retained placenta. This case illustrates a staged cesarean hysterectomy complicated by hemorrhage and coagulopathy. Interval cesarean hysterectomy for severe MAP can be the only feasible approach for complex cases such as this one. Obstetric anesthesiologists should be prepared to manage possible complications at any stage of the course of treatment. Further research is needed to reduce the risks associated with this staged approach.
Gynecol Oncol Res Pract 2017;4:11
BMJ Case Rep. 2018 Jun 11;2018
Obstet Gynecol 2015;126:1016–8