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Severe complications during dilation and evacuation at 20 weeks: massive hemorrhage from unanticipated placenta percreta and venous thromboembolism
Abstract Number: RF6AI-523
Abstract Type: Case Report Case Series
Second trimester abortions are generally considered safe procedures with rates of severe complications estimated at 0.4% . Even in women with placenta previa, second trimester dilation and evacuation (D&E) is not contraindicated. However, placenta previa increases the risk of transfusion (3% versus 1%) . We present a case of a woman at 20-week gestation with placenta previa whose D&E was complicated by massive hemorrhage due to unanticipated placenta percreta, as well as inferior vena cava (IVC) thrombus necessitating intraoperative filter placement.
30-year G9P5 at 20w3d with one prior cesarean delivery, newly diagnosed lethal fetal anomalies and complete placenta previa presented for D&E. Ultrasound 3 days prior showed no evidence of placenta accreta. During the D&E, after cervical dilator removal, the procedure was rapidly converted to an exploratory laparotomy due to massive hemorrhage and inability to extract the placenta. The patient was found to have placenta percreta with extension into the urinary bladder. She underwent hysterectomy, bladder repair, and right ureteral stent placement. Estimated blood loss was 10L, and she received 6L crystalloid, 17u pRBCs, 8u FFP, 3 packs platelets, 2g fibrinogen concentrate, and 2g tranexamic acid. During resuscitation, a transthoracic echocardiogram (TEE) exam was performed to guide transfusion, which revealed a large mobile IVC thrombus (Figure). Given the risk of pulmonary embolus and inability to anticoagulate, interventional radiology performed intraoperative IVC filter placement guided by TEE through the neck 9Fr introducer sheath (inserted during resuscitation). Postoperatively, the patient was transferred to the ICU intubated and ventilated. She was extubated the next day, started on anticoagulation at 48 hours, and discharged home on day 8.
Second trimester D&E is generally considered safe, however major life-threatening hemorrhage may occur. The immediate availability of a massive transfusion protocol and intraoperative TEE allowed for rapid resuscitation, as well as diagnosis and prevention of a thromboembolic event. The case highlights the potential for hemorrhage from abnormal placentation in high risk D&Es, and suggests these cases should be performed in settings that can manage these unanticipated life-threatening conditions.
1 Curr Opin Obstet Gynecol. 2016;28(6): 510-516
2 Aust N Z J Obstet Gynaecol. 2017;57(1):99-104