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Utility of ROTEM results in a patient with biphasic bleeding during Cesarean hysterectomy for placenta perceta
Abstract Number: RF6AI-108
Abstract Type: Case Report Case Series
A 31-year-old G4P3 woman 3 prior cesarean deliveries and imagining suggestive of placenta percreta presented at 32 weeks’ gestational age for cesarean section. In preparation for delivery, a combined spinal epidural, central venous line, and an arterial line were placed. An Interventional Radiology team placed inflatable catheters in the internal iliac arteries and a Urology team placed ureteral stents. With exposure of the uterus, the surgical team noted extensive placenta percreta, involving both broad ligaments, with strong suspicion of left sided pelvic sidewall involvement. Delivery was uncomplicated, but immediately after, large volume of blood loss occured. The patient was dosed with tranexamic acid and the internal iliac artery balloons were inflated. She was placed on high dose vasopressor infusions and rapid transfusion was initiated expeditiously.
After 37 minutes, 6 units of RBCs and FFP were transfused, surgical hemostasis appeared to be achieved, and pressor requirements decreased. However, more bleeding was expected; the hysterectomy had not been completed, and the site of the most significant placental invasion remained in situ. In standard massive transfusion protocol, a 6-pack of platelets was administered. A simultaneous ROTEM performed suggested normal clotting parameters (Figure 1). Indeed, with complete resection of the uterus, the patient experienced a second instance of postpartum hemorrhage. Transfusions and vasopressors were reinitiated to good effect. The patient received 2 units more of FFP and RBCs. At the conclusion of the case, she was transferred to the SICU. She was discharged home on POD#6.
Placenta percreta patients are at risk for hemorrhage, the etiology of which may evolve during the course of the surgery leading to multiple phases of bleeding (1, 2). Multi-phasic bleeding can be from arterial bleeding, venous oozing, or consumptive coagulopathy among other etiologies. Times of decreased hemorrhage should cue evaluation of the adequacy of transfusion. In this case, ROTEM results between times of profuse bleeding helped guide resuscitation and assure our readiness for an expected repeat bleed. In cases where significant bleeding is encountered, the option to evaluate the efficacy of transfusion efforts via ROTEM is a useful tool clinicians have at their disposal(3).
(1) Am J Obstet Gynecol. 2018 Dec;219(6):B2-B16
(2) J Matern Fetal Neonatal Med, 29 (2016), pp. 1077-1082
(3) J Clin Anesth. 2018 Feb;44:50-5