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

A Near-Fatal Case of HELLP and Other Peripartum Complications in a Complex Multiple Pregnancy

Abstract Number: RF7A10-89
Abstract Type: Case Report Case Series

Douglas Brack Mulliner DO1 ; Natalie Wong MD2

A 29 yo G4P1021 at 28w6d gestation presented to labor and delivery with elevated blood pressure and peripartum course complicated by prior triplet gestation (baby A ectopic in uterine scar, previously reduced at 12 weeks and baby C spontaneously aborted), with later development of persistent trophoblastic tissue from the uterine scar ectopic and suspected placenta accreta. Patient admitted to L&D with elevated BPs and over course of next week she progressed from preeclampsia without severe features to HELLP syndrome with epigastric pain and elevated LFTs and severe thrombocytopenia. Patient proceeded to cesarean-hysterectomy after placement of fogarty balloons in bilateral iliac arteries. Intraoperative course significant for estimated blood loss of 10 L and transfusion of 11 units PRBCs, 8 units platelets, 8 units FFP, 4 units cryoprecipitate,factor VIIa, 6 L crystalloid, tranexamic acid. Evidence of ongoing DIC so abdomen packed and patient taken to IR for embolization *** where she received another 3 units PRBCs. Magnesium toxicity occurred 12 hours post operatively. She returned to the OR next day for exploratory laparotomy and removal of abdominal packing and was noted to have old clot but no continued bleeding, though another 2 units PRBCs, 2 units platelets, and 2 units FFP were transfused. Post operatively a vaginal cuff bleed was noted and patient taken to IR once again and underwent bilateral internal iliac artery embolization and received another 2 units PRBCs, 2 units platelets, 2 units FFP and 4 units cryoprecipitate. Patient then stable for transfer to major transplant center for availability of liver transplant given ongoing liver dysfunction and DIC. Further hospital course complicated by renal failure necessitating hemodialysis, liver failure due to shock liver and HELLP syndrome recovered, E. Coli peritonitis, multiple pulmonary embolisms necessitating IVC filter, developed HIT while being anticoagulated and ARDS. Patient eventually recovered from all hospital problems, did not need liver transplant, no longer needs hemodialysis, and mom and baby are doing well. Patient did eventually have a hepatocellular adenoma removed and is recovering well. It is imperative for the obstetric anesthesia team to be intimately involved in and understand the specific pathophysiology in the care of these complex parturients due to the emergent nature of placental complications, including; severe preeclampsia, HELLP, trophoblastic disease, placental invasion, DIC and generalized end organ failure. This case stands as a reminder that physiologic changes and disease processes that occur with pregnancy make the parturient unique and the consumptive coagulopathy that can develop with HELLP syndrome must be understood differently and treated more aggressively than that of a typical massive hemorrhage patient.

SOAP 2019