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Please note the delivery note and trauma team notes at the bottom of this summary. Preliminary autopsy is attached as screenshot.
41-year-old female G2P1 with an estimated due date of September 9th of 2023. In April of 2023 and ultrasound revealed the placenta is midline with complete previa. No other abnormal testing to this point.
May of 2023 increased risk of placenta accreta spectrum disorder is noted. Patient is feeling well.
June 29th of 2023 has no abnormalities with the physical exam, however will be transferred to high risk OB due to material age and placenta location.
July 12th of 2023 sees MFM. Evaluation states that PC does have a complete placenta previa with a low probability of accreta. Good fetal movement and no other abnormalities noted. Plan was to do an MRI and follow up in 2 weeks. There are multiple notations stating that if the placenta does not deliver that she is aware of a possible C-section with hysterectomy if necessary.
July 26th, ultrasound still shows placenta the posterior and is complete previa. Placental lakes are noted.
MRI results come back and on July 31st she returns. The MRI shows a suspected placenta accreta. Notation states that despite no history that would indicate accreta was a high suspicion, they elect to admit to delivery hospital on the 10th of August for evaluation and schedule a C-section with possible hysterectomy on the 11th. At this point the PC is complaint-free and they're appear to be no abnormalities or concerns with fetus. No reason for not admitting that day or soon after.
August 6th. PC comes to delivery hospital for vaginal bleeding which started 30 minutes prior to arrival. The large blood clot noted in her underwear but no active bleed. Denied any contractions or fluid leakage. MFM is notified in he requests admission and plans for a C-section of hysterectomy on the 8th (2 days later). A few hours later, the PC begins to develop contractions and begins to actively bleed again. They agree to proceed with the C-section hysterectomy that afternoon. The operative note is unremarkable until after the child is delivered. They say it was a non-traumatic breech fashion, cord was cut and the umbilical cord was ligated and placed into the uterus. Immediately following this, a “massive acute bleed came vaginally estimated at 2000 cc's”. They report that the placenta was not traumatized or manipulated during the delivery. As they begin the hysterectomy, the hemorrhage worsens and Critical
Care surgery jumps in. CPR on progress and begin transfusions.
They attempt a thoracotomy and cardiac massage, internal defibrillation and multiple rounds of meds. After over 30 minutes of resuscitation efforts, they pronounce mother dead at 1513pm.
A preliminary autopsy (PLEASE SEE ATTACHED SCREENSHOT) reveals that there was “a retro placental hematoma associated with decidual necrosis consistent with abruption”. According to the report this “led to significant blood loss and disseminated intravascular coagulopathy”.
We do not have a final autopsy.
We do have all office visit info and U/S imaging available.
DELIVERY NOTE:
Patient was identified and consents reviewed. There was no active vaginal bleeding. Epidural anesthesia was placed without complication. The patient was then placed in the dorsal lithotomy position with a leftward tilt. The abdomen was prepared and draped in a normal sterile fashion. A midline vertical skin incision was made and carried through to the underlying layer of fascia. The fascia was then incised in the midline. The incision was extended inferiorly and superiorly with Bovie cautery. The right lateral aspect of the fascial incision was identified, elevated, and underlying rectus muscles were dissected off with Bovie Cautery. The rectus muscles were then separated in the midline and the peritoneum was identified and entered bluntly. This was extended inferiorly and superiorly with Bovie cautery. The uterus was then gently exteriorized. An area on the fundal aspect of the uterus was identified and marked. Using 2-0 vicryl, 2 stay sutures were placed on the lateral border of the marked lined at the midway point. Using the stay sutures to elevate the uterine wall from the underlying fetus, bovie cautery was used to enter the uterine cavity. The hysterotomy was extended superiorly and inferiorly with bandage scissors. Clear fluid was noted on entry into amniotic sac. Male fetus was delivered in breech fashion atraumatically. After a 30 second delay, the cord was clamped and cut, and the infant was shown to the patient and the father of the pregnancy, and the infant was passed to the waiting pediatric team. Using vicryl free ties, umbilical cord was ligated and placed back into uterus. At this time, it was noted that the patient had a massive acute bleeding from the vagina with approximately 2000cc of blood on the floor and in between her legs. Attention was turned back to the hysterotomy. Placenta was visualized in the posterior aspect of the uterus and was noted to be not bleeding. Placenta was not traumatized or manipulated during delivery. Hysterotomy closed with 0 vicryl in a running locked fashion in one layer and immediately attention was then turned to GYO team who replaced MFM team for attempt at hysterectomy. This report will come in a separate operative note.
TRAUMA TEAM NOTE:
Trauma Assisted The Primary Operative Team (OB/GYN) With Continued Exploratory Laparotomy. The Bowel Was Eviscerated To The Patients Right And A Mattox Maneuver Was Performed Exposing The Aorta. The Aorta Was Clamped With A Satinsky Clamp. Supraceliac Aortic Control Was Then Obtained And Direct Pressure Was Held On The Aorta. A Left Resuscitative Anterolateral Thoracotomy Incision Was Made @ The Level Of The 4TH-5TH Intercostal Space And Carried Through The Subcutaneous Tissues To The Level Of The Intercostal Muscles. The Thoracic Cavity Was Entered Bluntly And Mayo Scissors Were Used To Extend The Incision By Dividing The Intercostal Muscles. A Finochietto Retractor Was Placed And Opened To Spread The Chest. Upon Entry, There Was No Active Bleeding Or No Gross Blood. There Was No Obvious Pulmonary Injury. The Pericardium Was Not Bulging / Tense. The Pericardium Was Opened Longitudinally To Avoid The Phrenic Nerve. There Was No Cardiac Injury. The Thoracic Aorta Was Clamped At The Level Of The Diaphragm With Care To Take Down The Left Inferior Pulmonary Ligament And Without Clamping The Esophagus Which Was Palpated With An OGT. Cardiac Massage Was Performed And Continued. MTP Transfusions Was Continued. ATLS Protocols Were Performed With Administration Of Epi x 1 Intra-Cardiac. Internal Cardiac De-Fib x3 2/2 VFib. At This Time, The Heart Was Full From Blood Transfusions But Stiff With No Cardiac Activity Despite x1 Intra Cardiac Epi, Defibrillation And Cardiac Massage. Decision Was Made To Pronounce The Patient After > 30 Minutes Of Active CPR/Resuscitation And Attempts At Hemorrhage Control.
Files:
Q: Did the physician choose to wait 2 days for planned CS after admission to administer late steroids?
A: YES, that is correct. Once she began to bleed again, they elected to not wait.
Q: Were coagulation studies performed on admission i.e. PT/PTT, fibrinogen?
A: Yes. In triage. PT was 13.3 and INR was 1.0
Do you believe there might have been medical error?
ACOG CO #831 gives room for delivery of suspected accreta cases at 34w0d to 35w6d. Where one lands in that time frame depends on stability of the maternal status balanced with the fetal EGA. In patient who was completely stable with an unremarkable maternal or fetal course - no contractions, bleeding etc, the original plan of 35w6d is acceptable. However at the point where the patient presented symptomatic with a significant amount size clot as described, in context of the EGA at 35w 1d it would have been reasonable to deliver while the patient was hemodynamically stable with or without late antenatal steroids given or completed. In my opinion it would have been preferable to deliver right away given 35w1d. Moreover, given suspicion of accreta on MRI done at 34+ weeks, knowing delivery was to occur preterm, was there a plan for late antenatal steroids prior to planned delivery? If not this is also a potential medical error. If the case of steroids, if the physician was trying to complete a late course after admission, this might have made waiting somewhat acceptable.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The summary of the case provided describes "a few hours later'" after admission, contraction and bleeding began again. As such, the patient was delivered while a second episode of an acute abruption was occurring (the first being the initial presentation). Given the EGA of 35w1d, as described above, immediate delivery could have been justified on presentation even if late antenatal steroids were awaiting completion. In this way, a more controlled delivery could have taken place and it stands to reason that the picture of, and level of, consumptive coagulopathy could have been prevented if delivery took place earlier in the process than when it actually occurred. Or, the coagulopathy described might have been on a lesser scale whereby blood product resuscitation might have been more effective, Regarding planning for delivery at the end of the time frame recommended by ACOG - I find that risky past 34w0d when MRI suspected accreta is suggested. It adds cumulative maternal risk while trying to optimize the fetal/neonatal outcome. I would hope that a shared decision making discussion was had between the patient and the delivering physicians. If the team was aiming to perform scheduled delivery 2d after admission for the purpose of steroid completion, it might have been a more controlled plan that, when accreta was suspected on MRI at 34+ weeks, administer steroids then or one week prior to planned delivery.
What makes you a good expert for this case?
I come from a strong academic general OBGYN residency and MFM fellowship training where I was exposed to many cases such as the one described. My career as an attending MFM Physician also gave me experience of managing such cases. These situations have helped hone my sense of the grey zones of perinatology.
How often do you encounter cases similar to this one in your practice?
I often serve as consultant to the general ob/gyn's in our health system. On average, we see a number of patients with accreta risk factors and about 2/month with utrasound findings of concern. Individualizing their delivery timing and antenatal followup plan is essential.
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