Gestating woman aged 33 years G4P2002Ab100 gestational age 30–32 weeks canceled going to RSUD dr. Saiful Anwar Malang with complaints of bleeding from the birth canal for the past 1 month. Stosel came out a lot for 5 days before hospital admission and the patient complained of abdominal pain, reddish urine color, and constipation for 3 weeks. The patient had a history of caesarean section in the lower segment. In the last 1 month, the patient has received a total of 6 RRC bags with antibiotics. While in the hospital room dr. Saiful Anwar Malang, physical examination revealed heart rate 92x/minute, blood pressure 100/75 mmHg. The patient looks clinically pale and had hematuria condition.
Caesarean section (SC) to be performed due to the abnormal estimation of placental implantation from ultrasonography and gross hematuria. The patient was consulted for anesthesia 7 days before the scheduled SC. The procedure has been done three times for the patient so far, and the patient also had a history of curettage once. Two previous CSs were performed under spinal anesthetic management. From the fetomaternal ultrasound, the placenta implanted anteriorly extends to cover the internal uterine orifice with grade II-III maturation, bridging veins are found, and myometrium is 0.2 cm thick. Calculation of the Placenta Accreta Index (PAI) score obtained a total score of 5 (Former SC 2x: 3, Pathological Lacuna: 0, Myometrial thickness: 0.5, Placenta anterior: 1, Bridging vein: 0.5) with a probability of 69%. The patient underwent a Magnetic Resonance Imaging examination and found placenta previa type III (partial placenta previa) accompanied by placenta percreta, the impression of infiltrating the superoposterior wall of the urinary bladder (shown in Fig. 1).
Preoperative management is carried out by involving a multidisciplinary team. We consulted the patient to the Radiology Department for transarterial ballon Catheter (temporary) as interventional radiology since it was estimated that there would be massive bleeding during the operation. Interventional radiology was carried out 3 hours before the SC procedure. We also contacted the Urology Department to evaluate gross hematuria due to implantation of the placenta into the bladder. While in the patient's room, a total of 4 bags of PRC transfusion were given in 3 days due to anemia condition (Hb 6.4), active flux, and gross hematuria. Evaluation of CXR post installation of central access in the dextra Jugular Vein guiding USG found cardiomegaly with pulmonary edema. Patient’s hemodynamic found stable while in the room. Preoperative transfusion preparation was carried out by ordering 4 PRC bags, 4 WB bags, 600 cc TC, and 600 cc FFP. On D-1 before the action we attach an epidural catheter by insertion at L3-L4 and catheter tip at T9-T10.
On the scheduled day, the patient underwent a Transarterial Ballon Catheter (temporary) in the interventional radiology room with a 9mm x 60mm balloon inserted up to the right internal iliac artery – right common iliac artery. Then the patient was escorted to the operating room carrying 2 WB bags and 2 PRC bags. We installed EKG, SpO2, and invasive blood pressure monitors on the Left Radial Artery. The patient underwent epidural anesthesia management by being given local anesthetic Ropivacaine 0.75% + sufentanyl 5mcg total volume 14cc targeting T4-L2 block. The patient was fully sedated 10 minutes after the epidural regimen was injected. Water warmers were given to prevent hypothermia.
The incision was made midline above the umbilicus and was done layer by layer of the abdomen. Visual inspection was performed on the uterus, bilateral adnexa, lower uterine segment, and bladder. After the baby was born, the interventional radiology team inflated the left and right catheter balloons with a pressure of 2atm (left internal iliac artery) and 3atm (right internal iliac artery) for 3–5 minutes and deflated for 1 minute.
During the duration of the operation, the patient's hemodynamics were closely monitored. Urine production is recorded hourly in terms of quality and quantity. When the bleeding is 2000 cc and not controlled, the anesthetic action is changed to general anesthesia with endotracheal intubation. Midazolam 2mg IV, ketamine 60mg IV, and rocuronium 50mg IV were administered for induction followed by laryngoscope and intubation with a 7.0 mm endotracheal tube. Maintenance anesthesia with oxygen + sevoflurane. Estimated total bleeding 4000cc with blood transfusion during surgery 700cc whole blood, 750cc PRC, and 600cc FFP. Ca gluconate 10% 10cc IV given slowly as bolus over 10 minutes. During the operation, the patient was hypotensive when the bleeding was not controlled, but only temporarily. After hemodynamic resuscitation the patient was stable and there were no crackles until the end of the operation. The total urine output mixed with blood during the operation was 740cc.
Consideration that due to massive bleeding, the patient was sent to the ICU for intense observation while still intubated. In ICU, hemodynamics and urine output were monitored. Blood samples were taken for postoperative laboratory evaluation, namely complete blood, serum electrolytes, blood gas analysis, lactate, hemostatic physiology, and albumin. The patient underwent rapid ventilator weaning and then a spontaneous awake trial (SAT) 4 hours postoperatively. SAT was successful with GCS 4x6 and stable hemodynamics (shown in Table 1.), the patient underwent a spontaneous breathing trial for 2 hours after which the patient was extubated. 1 hour post extubation the patient was hemodynamically stable without respiratory distress with 98% oxygen saturation using NRBM 10 lpm.
Table 1
Preoperative and Postoperative Laboratorial Test Results
| Preoperative | Postoperative |
Hemoglobin | 9,3 mg/dL | 9,5 mg/dL |
Leukocyte | 9.320 mg/dL | 4.240 mg/dL |
Hematocrite | 28,2% | 31,2% |
Trombosit | 136.000 | 254.000 |
PPT | 9,4 | 10,9 |
INR | 0,9 | 1,05 |
APTT | 24,8 | 25,1 |
Ureum | 11,7 | 81,2 |
Creatinin | 0,58 | 1,66 |
Albumin | 3,52 | 3,52 |
RBS | 101 | - |
D-dimer | - | 2,22 |
Table 2
During Procedure and Postoperative Laboratorial Test Results
| During Procedure | Postoperative |
Hemoglobin | 9,3 | 4,7 | 9,5 mg/dL |
Leukocyte | 18.900 | 8600 | 4.240 mg/dL |
Hematocrite | 28,4% | 13,8% | 31,2% |
Trombosit | 99000 | 132000 | 254.000 |
PPT | 11,6 | - | 10,9 |
INR | 1,12 | - | 1,05 |
APTT | 33,2 | - | 25,1 |
Lactate Acid | 1,4 | - | 1,2 |
Blood Gas Analysis |
pH | 7,34 | 7,37 |
pCO2 | 36,3 | 30,3 |
pO2 | 208,2 | 148,6 |
HCO3 | 16,4 | 21,3 |
BE | -9,7 | -4,2 |
SpO2 | 98,5% | 98,5% |
Postoperative pain management with epidural analgesia dose Ropivacaine 0.25% adjuvant morphine 1mg total volume 10cc, given every 12 hours. NRS while in the ICU ranged from 1–2. The patient was transferred to the normal room after 24 hours postoperatively. On observation in the room, there is still gross hematuria with a hemoglobin level of 4.7. Transfused 500cc PRC. cystoscopy procedure with fulguration and evacuation of the H + 3 post op SC then planned by the urology department. Our patient returns with epidural anesthesia management. The operation lasted for 2 hours with the patient's hemodynamic found stable during and post-surgery (shown in Table 2.). The patient was declared able to leave the hospital on the sixth day post SCTP.