Background: Although there has been a significant reduction in morbidity and mortality of gynecological

patients due to new advancement in medical sciences, post caesarean section hemorrhage is still a major cause of

maternal mortality and the reason for half postpartum deaths.

Case Report: A 37 years old woman, 37 week gestation, with a history of two previous caesarean sections and

two curettages and placenta accrete was being treated for pulmonary embolism. In sonography, placenta accrete

with diffusion to bladder was diagnosed. She was rushed to operation room because of pulmonary hypertension

and underwent caesarean section. Massive hemorrhage happened after the fetus was delivered, so hysterectomy

was performed with bilateral hypogastric artery ligation because of placental penetration into bladder and lateral

side of pelvis and two big-size drains were placed due to diffuse oozing. The infused volume of crystalloid and

blood components to the patient was increased but disseminated intravascular coagulation happened as a

complication of dilution coagulopathy and massive transfusion which was managed with fresh frozen plasma

(FFP) and platelet transfusion. By the end of surgery, the patient underwent cardiac arrest, but was resuscitated

in less than five minutes and the heart rate went back to normal and vital signs became stable. The patient was

transferred to intensive care unit with tracheal tube in-place. One week later, the patient underwent acute

respiratory distress syndrome but her condition improved after two weeks and she was discharged.

Conclusion: Placenta precreta surgery is associated with severe bleeding and high volume of fluid and blood

may be required to stabilize the vital signs. Infusion rate should be reduced afterwards and patient's systolic

pressure be kept between 70 and 100 mm Hg so that possible dilution coagulopathy would not happen as a

complications of this massive transfusion.

I am Dr. Behzad Nazemroaya. I have over 33 years of experience in Medicine with 21 years working as an Anesthesiologist. I am currently an associate professor at the Isfahan University of Medical Sciences. I have a lot of experience in Anesthesia for Obstetrics and most of my papers in anesthesia are related to anesthesia for Electroconvulsive therapy.