https://scholarlycommons.henryford.com/merf2020caserpt/1001/thumbnail.jp

Ahuja, Sanchit

Attali, Ami

Isley, Michael

Tolson, Jane N

Younger, Joshua

English

Henry Ford Health System Scholarly Commons

Henry Ford Health System Henry Ford Health System Scholarly Commons Case Reports Medical Education Research Forum 2020 5-2020 Placenta Percreta: A Report On Surviving Death From The Bleeding Disaster! Jane N. Tolson Henry Ford Health System, jtolson1@hfhs.org Sanchit Ahuja Henry Ford Health System, sahuja2@hfhs.org Michael Isley Henry Ford Health System, MISLEY1@hfhs.org Ami Attali Henry Ford Health System, aattali1@hfhs.org Joshua Younger Henry Ford Health System, jyounge1@hfhs.org Follow this and additional works at: https://scholarlycommons.henryford.com/merf2020caserpt Recommended Citation 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. 133. https://scholarlycommons.henryford.com/merf2020caserpt/133 This Poster is brought to you for free and open access by the Medical Education Research Forum 2020 at Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Case Reports by an authorized administrator of Henry Ford Health System Scholarly Commons. IntroductionDiscussion• Abnormal placentation is one of the important causes of obstetric hemorrhage.• The term “morbidly adherent placenta” describes a spectrum of disordersincluding placenta accreta, increta and percreta with increasing degrees ofinvasion of the uterus by placenta respectively with/without invasion intoadjacent structures.(1)• The rapidity of blood loss in these cases can become rapidly overwhelminggiving no time for an organised approach.• There is necessity for multi disciplinary planning for the safe peri-partummanagement of the mother and baby.• Here we describe the case of a multigravid woman with placenta previapercreta who bled massively leading to intraoperative cardiac arrest despiteadequate preparation in terms of personnel, planning and available resources.• We would like to further discuss the questions and dilemma that arose regardinganesthetic plan and perioperative management of this patient with emphasis onthe lack of dedicated obstetric resuscitation guidelines in the face of acutemassive hemorrhage, which is not very uncommon in this population even in acompletely elective setting as above.Preop IR guided procedures have been described and may decrease blood loss duringCH. However, reported complications including catheter migration and arterialaneurysms leading to limb ischemia limit their use. Currently there is not enoughevidence to make this a routine practice. (3).There is a recent shift towards conservative management with an aim to preservefertility and decreasing morbidity. In 2016, Konishi Y et al described conservativelymanaging a patient with placenta praevia where after baby delivery and clamping ofplacenta, uterine artery embolization and uterine closure was performed in a hybridOR suite (4). However an Australian retrospective study reported over 40 % ofwomen managed conservatively required emergent or elective hysterectomy and 42%experienced major morbidity (5).Trauma transfusion guidelines i.e., 1:1:1 ratio is not as validated for obstetrichemorrhage(6). At present there are no transfusion guidelines for obstetrichemorrhage management. Blood and blood product transfusion was managedintraoperatively with the use of thromboelastogram (TEG) and lab based coagulationprofile. Volume resuscitation and electrolyte correction was monitored with serialABGs.With no way to reliably predict which of these patients will bleed massively, it isreasonable to approach these patients with invasive lines and monitoring and a rapidinfusor ready to go from the start with blood available. There may be a subset ofpatients with percreta that would benefit from the conservative approach with all itsrisks. Being able to predict severity of bleed may help risk stratify and guide inplanning peripartum management of these patients.Team work and strong communication cannot be over emphasized in any crisismanagement. Point of care testing and additional personnel support are indispensableand may add to cost.Learning Objectives1. Highlight the need for recommendations regarding anesthetic technique inpatients with abnormal placentation2. Contemplate the appropriateness of an epidural in patients prone tocoagulopathy from hemorrhage3. Emphasize that guidelines are needed to help direct transfusion duringobstetrical hemorrhage and to underscore that point of care testing such asthromboelastogram (TEG) based blood component transfusion requiresvalidation in obstetric hemorrhageCase ReportBibliographyReferences:1. Booker W., Moroz L. Abnormal placentation. Semin Perinatol 2019 Feb;43(1):51-592. Lim G, Horowitz JM, et al. Correlation of probability scores of placenta accreta on magnetic resonance imaging with hemorrhagic morbidity. J ClinAnesth 2016;34:261-93. Bishop S et al. Multiple complications following the use of prophylactic internal iliac artery balloon catheterisation in a patient with placentapercreta.Int J. Obstet Anesth 2011 Jan; 20 (1): 70-34. Konishi Y et al. A novel and multidisciplinary strategy for cesarean delivery with placenta percreta:Intraoperative Embolization in a hybrid suite. A ACase Rep. 2016 Sep 155. Pather S. et al. Maternal outcome after conservative management of placenta percreta at cesarean section: a report of three cases and a review ofliterature. Aust, N.Z. J. Obstet Gynaecol. 2014 Feb6. Reitman E ey al. Case scenario: Perioperative management of a multigravida at 34-week gestation diagnosed with abnormal placentation.Anesthesiology 2011; 115: 852–7Placenta Percreta; A Report On Surviving Death From The Bleeding Disaster !Jane Nithya Tolson, Sanchit Ahuja, Michael Isley, Ami Attali, Joshua YoungerDepartment of Anesthesiology and Critical care, Henry Ford Hospital, Detroit, MichiganPatient received combined spinal and epidural (not activated) for the ureteric stentingwith an aim to use the epidural for post-operative analgesia followed by generalanesthesia 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, patientcontinued to bleed from multiple intraabdominal sites. While surgical hemostasisremained a challenge, patient developed PEA arrest. CPR was started with return ofspontaneous circulation(ROSC) after chest compression for 2 minutes and 1mg ofepinephrine. Following this, abdomen was packed with a decision to close secondarilyafter interventional radiology(IR) assisted intervention if necessary and hemodynamicstabilization. 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 withan estimated blood loss of 25L. Tranexamic acid and prothrombin complex concentratewas given. Thromboelastogram(TEG) and lab based coagulation profile was usedintraoperatively to guide blood component transfusion. Serial blood gas analysesguided volume and electrolyte correction. In the ICU patient improved with noneurological insult or DIC. On postop day 1 IR found no active extravasations andsurgical abdominal closure was performed. Epidural catheter was used forpostoperative pain control and was removed on day 4. Patient was discharged on post-op day 10.Obstetric hemorrhage from abnormal placentation can be massive. MRI of theabdomen may show invasion but imaging has no predictive value for hemorrhageanticipation(2).A 34 year old G6P5 diagnosed with placenta previa percreta (fig 1) in her 2ndtrimester was reviewed by a multidisciplinary team. Baby delivery was planned at 34weeks gestation by cesarean hysterectomy(CH) immediately preceded by bilateralureteral stents for anticipated surgical complexity. Fig 1: USG image of the patient showing placenta covering the cervical os with fetal head in vertex presentation. 

Placenta Percreta: A Report On Surviving Death From The Bleeding Disaster!

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Placenta Percreta: A Report On Surviving Death From The Bleeding Disaster!

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