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Resident PGY 3
Henry Ford Hospital
A 34 year old G6P5 diagnosed with placenta previa percreta (fig 1) in her 2nd trimester was reviewed by a multidisciplinary team. Baby delivery was planned at 34 weeks gestation by cesarean hysterectomy(CH) immediately preceded by bilateral ureteral stents for anticipated surgical complexity. Patient received combined spinal and epidural (not activated) for the ureteric stenting with an aim to use the epidural for post-operative analgesia followed by general anesthesia and establishment of invasive lines and monitoring prior to start of CH. Soon after baby delivery, patient became hypotensive from severe hemorrhage. Massive transfusion protocol was instituted. After completion of hysterectomy, patient continued to bleed from multiple intraabdominal sites. While surgical hemostasis remained a challenge, patient developed PEA arrest. CPR was started with return of spontaneous circulation (ROSC) after chest compression for 2 minutes and 1mg of epinephrine. Following this, abdomen was packed with a decision to close secondarily after interventional radiology (IR) assisted intervention if necessary and hemodynamic stabilization. Intraoperatively, patient received a total of 29pRBCs, 22FFP, 4platelet & 3Cryo units with 21 L of crystalloids, 3.25 L of 5% albumin and 1.8L of cell saver with an estimated blood loss of 25L. Tranexamic acid and prothrombin complex concentrate was given. Thromboelastogram (TEG) and lab based coagulation profile was used intraoperatively to guide blood component transfusion. Serial blood gas analyses guided volume and electrolyte correction. In the ICU patient improved with no neurological insult or DIC. On postop day 1 IR found no active extravasations and surgical abdominal closure was performed. Epidural catheter was used for postoperative pain control and was removed on day 4. Patient was discharged on postop day 10.
Tolson, Jane N.; Ahuja, Sanchit; Isley, Michael; Attali, Ami; and Younger, Joshua, "Placenta Percreta; A Report On Surviving Death From The Bleeding Disaster!" (2020). Case Reports. 10.