Ante partum Haemorrhage case presentationJ.Parthasarathy SHO

Day 138 yrs Multigravida 27/40 weeks

Fit & well previously

Adm to Labour ward with h/osudden onset abdominal painfeeling faintcollapsed at home onto bathroom floor

On admission

Very pale Cold & clammy

Pulse 90sBP - 85/42

Spo2 99%FH - 142 regular

Impression : ? Placental Abruption

Emergency LSCS was planned

Anaesthetic assessment Prev GAs + 2 X LSCSAbdominal pain / Hypotension / AnaemiaNo Foetal distressHb = 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 consultants 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.roomRSI Thio/suxaMaintenance 02/N20/Isoflurane/atracuriumCentral 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 blood8 units of FFP1.5 L of Voluven1.0 L of Volplex500 mls normal saline

No O neg blood was given

HbPre-op intra-op immed.post op

89 g%62 g%90 g%

ITU Day 1

Haemodynamically unstableHypotensiveTachycardic 130 140 /minUrine output 40mls/hr8 more units of blood transfused

Abdomen appeared distended ? BleedResponded to fluid loading Not requiring inotropesOn 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 precipitates4 FFP4 units blood2 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 stayDay 6

Day 7 Discharged to Labour ward

Day 9 Discharged Home