Ante partum Haemorrhage

case presentation

J.Parthasarathy
SHO
 Day 1

• 38 yrs Multigravida 27/40 weeks

• Fit & well previously

• Adm to Labour ward with h/o

sudden onset abdominal pain
feeling faint
collapsed at home onto bathroom floor
On admission

Very pale Cold & clammy

Pulse – 90’s BP - 85/42

Spo2 – 99% FH - 142 regular

Impression : ? Placental Abruption

Emergency LSCS was planned

Anaesthetic assessment
Prev GA’s + 2 X LSCS
Abdominal pain / Hypotension / Anaemia
No Foetal distress
Hb = 8.9 Plt = 284

PLAN : Inform consultant

2 x 14G IV Access
6 units Xmatched and ready
art line in anaesthetic room
2L fluid + 1 unit blood transfusion pre induction
central venous line intraop
RSI + GA
Obstetric consultant’s assessment:

USG : Normal lying placenta

no retro placental clot
“ free fluid in the abdomen”

Impression : ? Scar Dehiscence

? Vascular rupture
Perioperative Events:

• Art line in anesth.room

• RSI – Thio/suxa
• Maintenance – 02/N20/Isoflurane/atracurium
• Central venous line in theatre

Laparotomy findings:

Placenta accreta – perforating through uterine wall

Heavy intra abdominal bleeding
• Two more surgeons called in (vascular & general)

• Hysterectomy + Ligation of External iliac vessels done

• Abdomen packed for removal after 24 hrs

• Transferred to ITU ventilated and sedated for Post op care

Blood Loss : 13,000 mls approx

She received : 12 units of blood

8 units of FFP
1.5 L of Voluven
1.0 L of Volplex
500 mls normal saline

No O neg blood was given

Hb
Pre-op intra-op immed.post op

89 g% 62 g% 90 g%
 ITU – Day 1

• Haemodynamically unstable
• Hypotensive
• Tachycardic 130 –140 /min
• Urine output 40mls/hr
• 8 more units of blood transfused

• Abdomen appeared distended ? Bleed

• Responded to fluid loading
• Not requiring inotropes
• On minimal respiratory support
Plan Exploratory Laparotomy +
to give recombinant activated Factor V11

Findings : small vascular bleeders

vascular pedicles resutured

Blood loss : 4000 mls approx

Received intra op: 10 cryo precipitates

4 FFP
4 units blood
2 units platelets
 Day 2

Haemodynamically stable

No evidence of ongoing blood loss

Hb - 85 g%
Plt - 57
 Day 3

To Theatre : For removal of abdominal pack+Closure

Transferred back to ITU

Extubated that evening

Day 4
Day 5 Uneventful ITU stay
Day 6
Day 7
Discharged to Labour ward

Day 9
Discharged Home