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Background and Aims Placenta percreta is a severe form of placental accretism in which the placenta penetrates the entire uterine wall and attaches to other organs, raising the risk of obstetric haemorrhage, peripartum hysterectomy, along with maternal and fetal mortality. We report a challenging case of a multidisciplinary approach to massive bleeding following a placenta percreta diagnosed during the cesarian section.

Methods A 35-year-old, G2P1 (previous cesarean) and 30 weeks gestation pregnant woman was diagnosed with placenta percreta during an emergent cesarean under spinal anaesthesia due to imminent premature labour. General anaesthesia was performed, and as the caesarean began, a massive haemorrhage survene. The multidisciplinary team and the transfusion protocol were activated and guided by viscoelastic tests. The transfusion therapy included: 5 red blood cell transfusions (5UCE), fibrinogen (4g), tranexamic acid (2g) and crystalloids (4L). Vasopressor support under invasive monitoring (30mcg/min) and, ultimately, the hysterectomy were required to control the bleeding. A total blood loss of 2500mL was estimated.

Results The patient was transferred under invasive mechanical ventilation to an intensive care unit. On the third postoperative day, the patient developed a post-hysterectomy hematoma, and thromboembolism prophylaxis was not started. Two days after, she developed pulmonary thromboembolism and started anticoagulation, receiving hospital discharge on the seventh postoperative day.

Conclusions Placenta percreta is a life-threatening clinical entity where multidisciplinary teamwork and a careful preoperative plan are crucial to success. Our case was handled with a prompt and effective response during an unforeseen event with success.

Attachment Isabel Ramalho (1).pdf