2024 FSA Podium and Poster Abstracts
P029: PRETERM PREMATURE RUPTURE OF MEMBRANES IN THE SETTING OF ANTERIOR PLACENTA PREVIA AND PLACENTA PERCRETA IN A SCAR ECTOPIC PREGNANCY: A CASE REPORT OF MINIMIZING BLOOD LOSS
Christopher P Emerson, MD; Alexander W Hall, MD; Paloma Toledo, MD; Division of Obstetric Anesthesiology, Department of Anesthesiology and Perioperative Pain Medicine, University of Miami, Jackson Memorial Hospital
Introduction/Background: Placenta Accreta Spectrum (PAS) is a major source of parturient morbidity and mortality. In the United States, approximately 500-700 deliveries are complicated by PAS. Maternal morbidity from PAS is associated with postpartum hemorrhage and related complications include: coagulopathy, acute kidney injury, anemia, admission to the critical care unit, and death. PAS is a major source of post-partum hemorrhage (PPH) and PAS cesarean section (PAS CS) is a leading cause of peripartum hysterectomy.
Case Description: A 28-year-old female, ASA IV, G7P1234, 185kg (BMI 74), at 18.6 weeks estimated gestational age, with prior cesarean delivery x2, was transferred from outside hospital with preterm premature rupture of membranes (PPROM) for 4 weeks. There was concern for PAS as well as anterior placenta previa on image studies. Patient underwent total abdominal gravid hysterectomy, bilateral salpingectomy, intraoperative REBOA catheter placement, cystoscopy and intraoperative urethral stent placement under general anesthesia. Management of this case was complicated by extreme obesity (BMI 74), anterior placenta previa, and placenta percreta.
Case Summary: Preoperative transvaginal ultrasound showed a nonviable fetus with FHT 141bpm, anhydramnios, anterior placenta previa, and PAS with invasion of left rectus abdominus on MRI. Given diagnosis of non-viability, she initially underwent preoperative embolization of uterine arteries and collaterals, to mitigate hemorrhage during planned hysterectomy. On the day of surgery, patient had an initial hemoglobin of 10.2, platelets of 425, and initial fibrinogen of 449. After induction of general anesthesia, a left radial arterial line, Right IJ Double lumen introducer, and REBOA catheter were placed prior to surgical incision. A midline laparotomy incision was made to enter the peritoneum. The placenta was ballooning out of the lower uterine segment along the anterior and lateral segments with placental invasion through the uterine serosa requiring bladder flap creation. Total abdominal hysterectomy was performed and the patient’s abdominal cavity was closed. Intraoperatively, the patient received 2400cc of crystalloids with minimal blood loss of 250cc and 600cc of UOP. Patient was extubated and transferred to a surgical intensive care unit for post operate monitoring. Follow-up laboratory results showed stable coagulation studies and hematocrit. Remainder of her recovery was uneventful. The patient was discharged home on post operative day 4.
Discussion/Conclusion: This challenging case highlights the importance of interdisciplinary approaches to mitigation of blood loss in a complex obstetric surgical patient. Challenges in the management of this case include (1) scar ectopic pregnancy in the setting of placenta previa and placenta percreta; (2) securing a possible difficult airway in a morbidly obese obstetric patient; (3) anticipation of high likelihood of major obstetric hemorrhage and intra-operative coagulopathy. This case highlights a unique context in which preoperative embolization of uterine arteries and collaterals, in a non-viable fetusprior to a gravid hysterectomy contributed to minimal blood loss and no transfusion of blood products in a very high risk case.