A 34-year-old female of 24-week gestation was transferred to this institution with a complaint of painless bleeding per vagina for the last 1 month. A large amount of clotted for 3 days, and she had complained of pain in the abdomen, high-colored urine, pruritus, and constipation for the last 20 days. She had a previous history of two lower segment cesarean sections (LSCSs). She received 11 units of PRBC over the last 1 month along with antibiotic and hepatoprotective drugs. On examination, her pulse was 80 beats/min, blood pressure 110/60 mm Hg, and pallor and icterus were present. Her hemoglobin was 8.6 gm% and INR 1.7. She received 1 unit of packed red blood cell (PRBC) and 3 units of fresh frozen plasma (FFP). Magnetic resonance image (MRI) revealed fetal demise, high-grade complete placenta previa, placenta overlying internal os, and heterogenous placental signal with focal uterine bulge suggestive of placenta percreta (Fig. 1). Her laboratory reports was hemoglobin 10.4gm/dl, total leucocyte count 12,700/cu.mm, platelets 110,000/cu.mm, prothrombin time 14.2 s, INR 1.1, blood urea 56.3 mg/dl, creatinine 1.7 mg/dl, total bilirubin 5.6 mg/dl, and SGOT/SGPT 27.7/7 U/L. She was planned for a hysterectomy after uterine artery embolization. Digital subtraction angiography revealed hypertrophied and tortuous uterine arteries and multiple collaterals from other internal iliac artery branches, the left side being the dominant supplier. More than 90% devascularization was achieved with N-butyl cyanoacrylate, polyvinyl alcohol, and gel foam slurry embolization. Adequate blood and blood product were arranged, informed written consent was obtained.
The patient was shifted to the operative room; monitors were applied, and baseline parameters were recorded. The epidural catheter was placed at L2-3 space, and the test dose was negative. The patient was induced after adequate preoxygenation with fentanyl 2mcg/kg, propofol 2 mg/kg, and succinylcholine 1.5 mg/kg. After confirming adequate ventilation, the trachea was intubated with 7.5 mm internal diameter cuffed tube. Anesthesia was maintained with air, oxygen, and isoflurane and an intermittent bolus of inj. atracurium and fentanyl. Ultrasound-guided right internal jugular vein cannulation and left radial artery were cannulated. Laparotomy was done, and the fetus was delivered by hysterotomy. Hysterectomy was done, and hemostasis was achieved. Placenta had extended towards the bladder, so the bladder had to be dissected carefully from the uterus. The urologist help was taken for separation of the bladder. Bladder separation causes major bleeding, and the total operative time was 3 h and 45 min. Systolic blood pressure falls below 90 mm of Hg during it, so she was started on noradrenaline infusion @5μgm/min and gradually stopped in 2 h. The total amount of blood loss was 1500 ml. Blood loss was replaced with a crystalloid of 3000 ml, 3 units of PRBC, 4 units of FFP, and 4 units of platelets. Intraoperative urine output was 800 ml. The trachea was extubated after adequate reversal from muscle relaxation. She was shifted to the intensive care unit for vital monitoring. Intraoperative arterial blood gas analysis report was normal except the hemoglobin was 8.4gm%. She received 1 unit of PRBC. Post-operative pain was managed with patient-controlled epidural analgesia with 0.125% bupivacaine and fentanyl 2 μgm/ml @5 ml/h with 5 ml demand dose and 15 min lockout interval for 72 h along with paracetamol 1 gm 8 hourly. After 24 h, enoxaparin 40 mg was started for thromboprophylaxis. Her creatinine increased from 1.7 to 2.5 mg/dl on a postoperative day 1 and become normal on the fourth postoperative day. The patient was shifted to the ward on the fifth postoperative day. The patient was discharged from the ward in a stable condition.
