Successful resuscitation of a patient with pernicious placenta previa and placenta accreta who had massive life-threatening bleeding during cesarean section

Abstract

Rationale: Pernicious placenta accrete (PPP) is an obstetrical complication associated with severe life-threatening hemorrhage, which is one of the leading causes of maternal mortality worldwide. Caesarean hysterectomy is the effective method to control intraoperative bleeding for this unscheduled high-risk patient. But a challenge for clinicians in this case is to determine the optimal timing of hysterectomy, because it will directly determine maternal outcome. Patient concerns: We here report a case diagnosed with PPP who suffered from a severe life-threatening hemorrhage during cesarean section but was successfully resuscitated and subsequently discharged from hospital after a smooth recovery. Diagnoses: Although binding the lower uterine segment with a tourniquet markedly reduced bleeding in the surgical field after delivery, massive concealed vaginal life-threatening bleeding occurred immediately, and the amount of vaginal blood loss within 10 minutes was as much as 3000 mL. Interventions: An experienced multidisciplinary team was immediately established, and an unscheduled caesarean hysterectomy was performed immediately, and cell salvage was used. Outcome: The patient was successfully resuscitated and both the parturient and neonate were well and discharged. Lesson: If binding the lower uterine segment with a tourniquet markedly reduces bleeding in the surgical field after cesarean delivery in high-risk patients with PPP, and persistence of hypotension after active resuscitation of the circulation is detected, anesthesiologist should be vigilant enough to detect the possibility of concealed vaginal life-threatening bleeding. If this is confirmed, it should be quickly identified whether bleeding can be quickly controlled within a short period of time. If not, the preferred strategy is that the earlier the unscheduled hysterectomy, the better the outcome. A well-established multidisciplinary team and autologous blood recovery and transfusion techniques are also important in ensuring successful resuscitation of patients.

The Risk of Postpartum Hemorrhage Following Prior Prelabor Cesarean Delivery Stratified by Abnormal Placentation: A Multicenter Historical Cohort Study

“…Alternatively, an explanation might be related to the differences in the proportion of normally remodeled blood vessels ( 25 ). Therefore, to meet the local oxygen demands and metabolic requirements, the area and depth of the trophoblast invading the myometrium might increase ( 26 ), predisposing these women to severe bleeding and additional intrauterine intraoperative procedures ( 27 ).…”

Effect of previous placenta previa on outcome of next pregnancy: a 10-year retrospective cohort study

“…Jauniaux et al reported that the complication of placenta previa was present in more than 90% of patients with placenta accreta [12,21]. A placenta located in the lower segment of the uterus influences the contraction of the uterus and its ability to compress the blood vessels, leading to bleeding and more intrauterine intraoperative procedures [22], which in turn result in uterine scar formation and pelvic adhesions. The area of scarring will exhibit poor vascularization, deficient tissue oxygenation, and inflammation, which may inhibit reepithelialization and decidualization, leading to abnormal placental anchoring villi and invasion of trophoblasts [23].…”

Enhancing postpartum hemorrhage prediction in pernicious placenta previa: a comparative study of magnetic resonance imaging and ultrasound nomogram

“…All patients were suspected of having PPP due to routine ultrasound examination during pregnancy and received MRI scoring of PPP in the second trimester and ultrasound examination and scoring before delivery. The exclusion criteria were ( Chattopadhyay et al, 1993 ): gestational age of delivery < 28 weeks; ( Zhu et al, 2021 ): non-delivery in our hospital ( Jiang et al, 2019 ); multiple pregnancies ( Chen et al, 2016 ); vaginal delivery ( Yu et al, 2016 ); perioperative procedures that significantly affect blood loss, such as abdominal aortic balloon occlusion and total hysterectomy; and ( Hou et al, 2020 ) the evidence of other hemorrhage factors, such as coagulopathy and uterine contraction weakness, among others. Figure 1 shows the flow chart of patient selection criteria.…”

“…Due to the revision of the family planning policy in China, cesarean section, induced abortion, and other intrauterine surgery are increasing. Consequently, the number of patients with PPP and the incidence of PAS are gradually increasing and have become one of the important causes of maternal death ( Chen et al, 2016 ; Jiang et al, 2019 ). According to a study, the risk of placenta accreta in women with a previous cesarean section is 35 times higher than that in those without ( Yu et al, 2016 ).…”