///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Placenta Percreta- How to Effectively and Efficiently Manage a Massive Hemorrhage of 40 liters

Abstract Number: RF5BH-477
Abstract Type: Case Report Case Series

Advaita Punjala-Patel MD1 ; Lauren Griswold MD2; Efrain Riveros MD3; Linda Street MD4; Paul Browne MD5; Bunja Rungruang MD6

Background: The placenta accreta spectrum is a complex obstetric complication associated with abnormal placentation and is becoming a common occurrence as the cesarean delivery rate increases. Given the increased morbidity and mortality associated with this condition, it is important for institutions to put forth multidisciplinary protocols to manage these patients in a controlled manner. Here we present a case of placenta accreta complicated by massive hemorrhage that was successfully managed by an interdisciplinary team of OBGYN, anesthesia, critical care, general surgery, vascular surgery, and interventional radiology (IR).

Case Presentation:

37 yo patient G6P4115 with a history of four prior cesarean sections presented for planned cesarean hysterectomy secondary to complete placenta previa with possible percreta documented by antepartum MRI. In preparation for the OR, bilateral hypogastric artery balloons were placed by IR and ureteral stents were attempted without success by urology due to possible anatomic distortion secondary to placental erosion into the bladder. Intraoperatively, it was noted that the placenta invaded the entire posterior bladder with excessive collateral vessels feeding the placenta from the bladder, pelvic sidewalls and vagina, demonstrating a placenta percreta with massive hemorrhage. To control the bleeding, the uterus had to be amputated at the cervicouterine junction with a cystotomy to remove portions of the placenta. Her operation was further complicated by DIC with bleeding from the left common iliac artery that needed intervention from vascular surgery. The patient was taken to IR for embolization of the hypogastric vessels. During this course, patient’s blood loss was estimated to be 40 liters, wherein a massive transfusion protocol was called. She received 118 units pRBC, 61 units FFP, 2 units of cryoprecipitate and 3000 mL of cell saver volume. On POD 1, in the SICU, the patient required a reintervention for fascial release due to abdominal compartment syndrome. Her postoperative course was further complicated by Clostridium infection leading to micro-perforations in the rectosigmoid requiring diverting loop colostomy. Patient was successfully extubated and discharged from the hospital on POD 28 with minimal additional complications.

Conclusion:

The importance of multidisciplinary collaboration in placenta accreta spectrum is highlighted by the successful resuscitation of the patient presented above.



SOAP 2019