Massive Obstetric Hemorrhage: Placenta Previa Totalis Abruption 

Background:  Placenta previa totalis can cause life-threatening massive postpartum hemorrhage. Massive blood transfusions, coagulopathy and peripartum emergency hysterectomy are documented complications. Association with placental abruption can lead to an emergent catastrophic scenario with severe hemorrhagic shock. Careful anesthetic management is imperative.

Case report: A 37-year-old woman (gravida 4, para 4) with placenta previa totalis was admitted in the emergency department at 33+2 weeks gestation in hypovolemic shock.  Vaginal bleeding was abundant and fetal distress was recognized.
She had been in the hospital 10 hours before for sudden onset abdominal pain and marginal dark blood loss. Fetal wellbeing was confirmed and hospital discharge was requested. Fluid resuscitation and emergent cesarean section were carried out.
At admission to the operating theatre, her vital signs were HR 100/min and BP 90/43 mmHg. She was drowsy but arousable to verbal command and extremely pale.  An ASA 4(E) was assigned. Massive transfusion protocol (MTP) was activated. Volume resuscitation with warm fluids was performed until the arrival of blood products.
Due to hypovolemia and need of emergent obstetric and fetal care, a general anesthetic technique was selected. RSI was carried out with propofol and succinylcholine. Anterior placenta section to access the fetus caused important blood loss and an episode of bradicardia. A live-born infant was delivered. Anesthesia was maintained with sevoflurane and rocuronium and was supplemented with fentanyl after fetal extraction. Hypothermia was prevented.
First laboratory evaluation showed a hemoglobin of 5,7 g/dL.
Intraoperative blood loss was unpredictable and urine output was vestigial. Total amount of infused crystalloid and colloid was 2000 ml and 1000 ml, respectively. ORh+ Packed Red Blood Cells (PRBCs) and Fibrinogen were administered.
The total operation time was 60 minutes. 
Patient was transferred to ICU mechanically ventilated, still with evident abundant vaginal hemorrhage.  Aggressive resuscitation care took place in this setting. PRBCs, Fresh Frozen Plasma, Platelets, Fibrinogen and Tranexamic Acid were transfused. Recovery was uneventful and she was discharged on day 5 postoperative.

Discussion: Peripartum hemorrhage remains a major cause of maternal morbidity and mortality. 
Placenta previa totalis renders a serious concern for the anesthesiologist. The existence of abnormal placentation (in particular, placenta accreta), placental abruption and transplacental approach during cesarean section frequently cause massive hemorrhage with higher rates of blood transfusion and hysterectomy might be required to avoid fatal outcome.
Efforts should be made to avoid the vicious cycle of hypothermia, acidosis and coagulopathy in the massive transfusion patient.
In emergency cases, the anesthesiologist must activate MTP. 

Learning points: A multidisciplinary approach and planning improves management in critical situations.

Multidisciplinary approach in obstetric life threating emergency: placental abruption in a pregnant woman with an anterior placenta praevia