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Previously Undiagnosed Intraoperative Placenta Increta in a Patient With Atypical Von Willebrand Disease
Abstract Number: RF5AH-99
Abstract Type: Case Report Case Series
Introduction: Morbidly adherent placentation is associated with maternal morbidity including massive blood loss, intraoperative hysterectomy, and prolonged hospitalizations. Risk factors include placenta previa, prior cesarean deliveries, advanced maternal age, and uterine surgeries. When diagnosed antenatally, these cases typically require additional resources and preparation including large bore intravenous access for massive transfusion, additional personnel, cell savage, and various other resources.
Case Report: An obese 40 year old G9P5 female at 34w6d with history of Von Willebrand disease, 4 previous c-sections, and type 2 diabetes mellitus presented for repeat cesarean in setting of worsening diabetes and polyhydramnios. She was given one dose of DDAVP preoperatively, a combined spinal/epidural anesthetic was placed, and appropriate T4 level was achieved. Soon after incision, the surgeons unexpectedly found a previously undiagnosed placenta increta. A brief intra-op huddle was conducted, additional help was called and the appropriate resources were procured.
During the 30 minutes that it took Gyn-Onc to arrive, the baby was monitored in sterile fashion via trans-uteral ultrasound, an awake right internal jugular introducer was inserted, a radial arterial line was placed, a rapid infuser was brought in and assembled, and 2 units of PRBCs were pre-emptively administered. Induction of general anesthesia occurred just prior to hysterotomy, and the baby was promptly delivered. Massive blood loss was encountered necessitating activation of the massive transfusion protocol. Uterotonics were administered without much improvement and Tranexamic acid was given. Hematology was consulted intraoperatively who recommended Antihemophilic Factor / VWF Complex be given. Total EBL was 10 liters and a total of 43 units of blood products were transfused through the newly placed lines. At the end of the case, the abdomen was packed due to swelling and the patient was transported to the STICU intubated but off vasopressors. She went back for surgical closure 2 days later and was extubated shortly after.
Discussion: With the rate of cesareans increasing nationwide, we are seeing an increase in rates of morbidly adherent placentation. This increases the challenge on the obstetricians and anesthesiologists taking care of these patients while also increasing the rate of patient morbidity and mortality. Diagnosis prior to hysterotomy can provide time to obtain adequate access and obtain additional personnel and blood products.
Conclusion: Clinicians should remain vigilant to the possibility of morbidly adherent placentation when patients have risk factors, even in the setting of negative ultrasound findings and should be able to formulate a new plan intraoperatively should the diagnosis be made then.