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Concurrent Intraoperative Uterine Rupture and Placenta Accreta. Do Concurrent intraoperative uterine rupture and placenta accreta Romanian Journal of Anaesthesia and Intensive Care 2018 Vol 25 No 1, 83-85 CASE REPORT DOI: http://dx.doi.org/10.21454/rjaic.7518.251.acc Concurrent intraoperative uterine rupture and placenta accreta. Do preoperative chronic hypertension, preterm premature rupture of membranes, chorioamnionitis, and placental abruption provide warning to this rare occurrence? M. Anthony Cometa, Scott M. Wasilko, Adam L. Wendling Department of Anesthesiology, Division of Obstetric Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA Abstract Uterine and placental pathology can be a major cause of morbidity and mortality in the parturient and infant. When presenting alone, placental abruption, uterine rupture, or placenta accreta can result in significant peripartum hemorrhage, requiring aggressive surgical and anesthetic management; however, the presence of multiple concurrent uterine and placental pathologies can result in significant morbidity and mortality. We present the anesthetic management of a parturient who underwent an urgent cesarean delivery for non- reassuring fetal tracing in the setting of chronic hypertension, preterm premature rupture of membranes, and chorioamnionitis who was subsequently found to have placental abruption, uterine rupture, and placenta accreta. Keywords: preterm premature rupture of membranes (PPROM), chorioamnionitis, placental abruption, uterine rupture, placenta accrete, cesarean-hysterectomy Received: 14 March 2018 / Accepted: 30 March 2018 Rom J Anaesth Intensive Care 2018; 25: 83-85 operative bleeding that requires aggressive fluid and blood product management and resuscitation [5]. At present, the literature does not reference the Introduction presentation and anesthetic management of these aforementioned conditions being concurrently present Various placental and uterine pathologies can result in one parturient. We present one such patient. in significant peripartum obstetric hemorrhage. Chorioamnionitis, an inflammation of the placenta and Case maternal decidua, can precipitate placental abruption and lead to post-partum uterine atony [1, 2]. Placental A 33-year-old Gravida 5 Para 1213 with chronic abruption, a disruption between the union of the hypertension presented to the labor and delivery unit placenta and endometrium, can have effects that result with a 2-day history of preterm premature rupture of in hemorrhagic hypovolemia and disseminated intra- membranes (PPROM), now at concern for chorio- vascular coagulation [3]. In uterine rupture, there is a amnionitis and actively contracting at 33 weeks and 6 breach in the wall of the myometrium that can have days gestation. Sterile speculum examination revealed fatal consequences to the fetus and hemorrhagic se- vaginal bleeding. A recent ultrasound performed 1 quelae to the mother [4]. A morbidly adherent placenta week prior showed no evidence of abnormal placen- such as placenta accreta often results in massive intra- tation, and the obstetrical team proceeded with careful continuous fetal monitoring with expectant vaginal Address for correspondence: M. Anthony Cometa, MD delivery management. Department of Anesthesiology The anesthesiology service was consulted for labor University of Florida analgesia management. There were no contraindica- College of Medicine 1600 SW Archer Road tions to neuraxial anesthesia, and a labor epidural was Gainesville, FL 32610, USA placed uneventfully; satisfactory labor analgesia was E-mail: [email protected] obtained. During continuous electronic fetal monitoring, 84 Cometa et al. repeated variable and late decelerations were observed hysterectomy, continuing to utilize the patient’s labor on fetal tracing. Additionally, the parturient was epidural for surgical anesthesia. An additional pre- experiencing increased vaginal bleeding and the servative-free 2% lidocaine with a 1:200,000 dilution decision was made to proceed to the operating room of epinephrine was introduced into the epidural catheter, for urgent cesarean delivery due to non-reassuring fetal requiring a total of 12 mL for the duration of the ce- tracings in the setting of suspected evolving placental sarean-hysterectomy. Mild sedation was provided to abruption. the patient with midazolam and fentanyl during the case. Upon entering the operating room, American The rest of the surgery concluded with no other Society of Anesthesiologists monitors were applied, untoward events, and the patient was transferred to which included a non-invasive blood pressure cuff, an the labor and delivery post-anesthesia care unit in electrocardiogram, and pulse oximetry. Initial vital signs hemodynamically stable condition at conclusion of the were reassuring, with repeated blood pressures noted surgery. There was no need for intraoperative blood to be approximately 120/80 mmHg and maternal heart product transfusion or aggressive intraoperative vaso- rate ranging between 115 and 120 bpm. The patient’s pressor use; however, the patient did require a blood existing 18-guage intravenous line was noted to be transfusion on the first postoperative day for postope- patent and functioning well. The anesthesiology team rative anemia. The remainder of the patient’s hospital was confident that the existing labor epidural would course was uneventful, and she was discharged on be effective for surgical anesthesia, as the patient en- the fifth postoperative day. dorsed sensory changes to ice at T10 bilaterally. An initial 5 mL of preservative-free 2% lidocaine with a Discussion 1:200,000 dilution of epinephrine was provided via the labor epidural to obtain surgical anesthesia and a Proceeding to the operating room to perform an bilateral T4 dermatome analgesic level was obtained urgent cesarean delivery is a common occurrence on swiftly. The patient’s vital signs continued to remain labor and delivery units. Anesthetic management for stable, and the obstetrical team proceeded with these situations is dependent on the severity of the cesarean delivery. clinical presentation of the mother and baby. The Approach to cesarean delivery was through a presence of concurrent chorioamnionitis, placental Pfannensteil incision. As the surgical team entered the abruption, uterine rupture, and placenta accreta is a lower uterine segment, a large amount of very foul very rare occurrence and presents significant anes- smelling blood was immediately expelled. The infant thetic concerns. Our particular patient had a 2-day was delivered and given to the neonatal team for history of PPROM that predisposed her to chorio- evaluation; the infant’s APGAR scores at minutes 1 amnionitis [1]. In addition, her chorioamnionitis in and 5 were 7 and 9, respectively. During exteriorization, conjunction with her chronic hypertension increased the uterus was noted to have ruptured in the lower her risk for placental abruption [1]. Our particular uterine segment inferior to the level of hysterotomy. patient’s risk factors for uterine rupture were almost Additionally, during attempted delivery of the placenta, non-existent. The classic risk factors for uterine rupture increased hemorrhage was noted during extraction and can include prior uterine surgery, trauma, uterine it was immediately apparent that the patient had a con- hyperstimulation via pharmacologic induction of labor, current placenta accreta. and uterine over-distension, of which our patient had A massive transfusion protocol was ordered imme- none [4]. When evaluated alone, the overall risk of diately and the anesthesiology team placed additional uterine rupture in an unscarred uterus is estimated to intravenous access lines and began invasive monitoring. be just over 1 of 20,000 [6]. Even in the presence of a Aggressive intravenous fluid replacement was initiated previous uterine scar, the incidence is still less than and a right radial 20-guage arterial line was placed. A 1% [7]; however, it has been reported in the literature one-time dose of ephedrine 10 mg IV push was that uterine rupture has occurred in previously provided for a brief moment of hypotension. During unscarred uteri in parturients with increased parity and this time, the obstetrical team had informed the in women with placental abruption [6,10]. As such, anesthesiology team that the uterine vessels had been the clinical presentation of a multiparous parturient with identified and controlled. The patient remained hemo- chronic hypertension and placental abruption may have dynamically stable and mentally alert. precipitated a uterine rupture – despite the patient After proximal control of the bleeding had been having an unscarred uterus. established by the obstetrics surgical team, the patient’s The major risk factors for placenta accreta are clinical status remained stable. Her hemoglobin as ob- related to previous uterine surgery and concurrent tained by arterial blood gas was noted to be 8.2 g/dL. placenta previa [5] – neither of which this patient had. The decision was made to proceed with a supracervical The risk of placenta accreta without concurrent previa Concurrent intraoperative uterine rupture and placenta accreta 85 is 0.2%, 0.3%, 0.6%, 2.1%, 2.3%, and 7.7% for partu- References rients undergoing their first through sixth cesarean delivery, respectively [8]. For this particular patient 1. Nath CA, Ananth CV, Smulian JC, Shen-Schwarz S, Kaminsky L; New Jersey-Placental Abruption Study Investigators. Histologic presenting with both uterine rupture and placenta evidence of inflammation
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