Massive hemorrhage in a previously undiagnosed abdominal pregnancy presenting for elective Cesarean delivery

To report a case of previously undiagnosed abdominal pregnancy diagnosed at the time of Cesarean section for persistent oblique lie. Delivery of the fetus was followed by near catastrophic hemorrhage. The management of massive hemorrhage in the context of the obstetric patient is discussed.

A 32-yr-old, ASA 1 primigravida was scheduled for elective Cesarean delivery at 38 weeks gestation under general anesthesia for a persistent oblique lie. On opening the abdomen, the extra-uterine position of the fetus became obvious. Delivery of the fetus was accompanied by torrential hemorrhage. A portion of the placenta was non-resectable and, following surgery, the patient was sent to the intensive care unit. The patient continued to lose blood and was returned to the operating room soon after. The abdomen was packed with large swabs and the wound left open. The hemorrhage continued and the application of military anti-shock trousers (MAST suit) helped stem the loss. A total of 36 U of red cells, 20 U of fresh frozen plasma, 7 U of platelets and 10 U of cryoprecipitate were transfused perioperatively. Both the baby and the mother survived.

Massive hemorrhage in obstetric patients is a major test for the anesthetic and obstetric teams. As our experience shows, a multidisciplinary team based approach helped manage this crisis. Obstetric patients are often young and have great physiological reserve. In this case we feel that the MAST suit significantly contributed to the positive outcome.