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Transesophageal Echocardiographic Observation of Caval Thrombus Followed by Intraoperative Placement of Inferior Vena Cava Filter for Presumed Pulmonary Embolism During Cesarean Hysterectomy for Placenta Percreta: A Case Report

Nanji, Jalal A. MD, FRCPC*; Ansari, Jessica R. MD*; Yurashevich, Mary MD, MPH; Ismawan, Johanes M. MD*; Lyell, Deirdre J. MD; Karam, Amer K. MD; Hovsepian, David M. MD§; Riley, Edward T. MD*

doi: 10.1213/XAA.0000000000000836
Case Reports

During a cesarean hysterectomy for placenta percreta, transesophageal echocardiography was used to monitor volume status and guide resuscitation. After delivery of the neonate but before massive surgical hemorrhage, a thrombus appeared in the inferior vena cava. Roughly 3 hours later, the patient had hemodynamic changes consistent with an intraoperative pulmonary embolism. Boluses of epinephrine stabilized the patient. An inferior vena cava filter was placed via an in situ internal jugular central venous cannula to prevent further embolic events. We believe transesophageal echocardiography is a useful monitor during surgery for placenta percreta.

From the *Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California

Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina

Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California

§Department of Radiology, Stanford University School of Medicine, Stanford, California.

Accepted for publication May 22, 2018.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Jalal A. Nanji, MD, FRCPC, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Dr, MC: 5640, Stanford, CA 94305. Address e-mail to

Patients who undergo cesarean hysterectomy for placenta percreta are at high risk for life-threatening hemorrhage. Intraoperative transesophageal echocardiography (TEE) is an effective modality to assess intravascular volume and guide therapy but is not routinely used in this setting. In this report, we unexpectedly observed an inferior vena cava (IVC) thrombus using TEE that appeared shortly after delivery. The patient subsequently developed a clinical picture consistent with acute pulmonary embolism (PE). After hemodynamic stabilization, an IVC filter was placed intraoperatively, before intensive care unit transport.

Written consent for publication of this case report was obtained from the patient by the authors.

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A 35-year-old gravida 5 para 3, with an antenatal diagnosis of placenta previa and possible percreta, was admitted to labor and delivery at 27 weeks and 3 days gestation for antepartum bleeding and mild abdominal pain. She had 3 prior cesarean deliveries as well as preeclampsia without severe features in her first pregnancy. Antenatal imaging (2 ultrasounds and an MRI) revealed an anterior placenta previa, placenta accreta, and likely placenta percreta, with possible bladder and cervical invasion.

Due to ongoing significant vaginal bleeding, the decision was made to deliver the patient via cesarean hysterectomy at 28 weeks 1 day gestation. Multidisciplinary planning occurred with specialists from maternal fetal medicine, gynecological oncology, obstetric anesthesiology, trauma surgery, vascular surgery, and neonatology. Interventional radiology (IR) was consulted for possible intravascular balloon occlusion catheter placement.

Because of concerns about the degree and location of placental invasion (including possible cervical and bladder involvement) and risk of massive hemorrhage and hemodynamic instability, general anesthesia (GA) was planned for the entirety of the case with a thoracic epidural placed before the induction for postoperative analgesia. The anesthetic plan also included an arterial line, large-bore peripheral IV access, and central venous access with a large sheath-type catheter (9F Arrow MAC “Multi-lumen Access Catheter,” Teleflex Incorporated, Morrisville, NC) per institutional protocol. Additionally, the cardiac anesthesiology team was consulted for intraoperative TEE probe placement to facilitate ongoing hemodynamic monitoring and to guide anticipated resuscitation. A baseline TEE examination soon after the induction of anesthesia revealed normal biventricular size and function and no hemodynamically significant valve lesions.

Almost immediately after delivery of a live neonate TEE examination showed a previously unseen echogenic filamentous structure in the IVC extending into the right atrium (Figure 1). Its hyperechoic appearance and persistence in the IVC were thought to most likely represent thrombus (versus air or tumor) released from a pelvic vein after decompression of the gravid uterus during delivery. The patient was hemodynamically stable at this juncture. The decision was made to proceed with the hysterectomy and to obtain formal imaging and initiate anticoagulation postoperatively.

Figure 1.

Figure 1.

Hemorrhage occurred later during the hysterectomy and required activation of the massive hemorrhage protocol approximately 3 hours after delivery, well after initial visualization of the thrombus. In total, she received 18 units of packed red blood cells, 12 units of fresh frozen plasma, 3 units of platelets, and 1 unit of cryoprecipitate. TEE guidance was used to aid in decision making regarding the adequacy of volume replacement throughout the resuscitation. Coagulation was guided by laboratory monitoring (ie, prothrombin time/international normalized ratio, activated partial thromboplastin time, fibrinogen concentration) and thromboelastography. She remained fluid-responsive throughout this period and changes in her hemodynamics were consistent with blood loss and subsequent transfusion. Subjective evaluation of left ventricular volume with TEE was consistent with adequate volume status throughout the procedure.

Hemorrhage resulted from hypervascularity of the right pelvic sidewall and placental invasion into the bladder requiring partial cystectomy. Due to ongoing bleeding from the right pelvic sidewall despite attempts at hemostasis, the surgeons applied pressure to the area. Almost immediately the patient developed acute hypoxemia (blood oxygen saturation decreased from 95% to 80%), significant hypotension (mean arterial pressure decreased from 80 to 48), and a decrease in end-tidal carbon dioxide from 34 to 19, felt to most likely represent acute PE of the previously seen IVC thrombus. Arterial blood gas analysis showed marked hypoxemia (decrease in Pao2 to 152 mm Hg from 171 a few minutes earlier despite increase in Fio2 from 0.48 to 1.0). This was reinforced by TEE showing that the thrombus was no longer visible, but several smaller emboli were seen traversing the IVC (Figure 2). The need to simultaneously manage a large-volume resuscitation and a superimposed acute event such as possible PE precluded the acquisition of TEE images at the precise moment that it occurred. She improved hemodynamically with the immediate administration of epinephrine 200 µg intravenously and institution of Fio2 of 1.0. Reassuringly the repeat TEE examination revealed no appreciable ongoing right ventricular dysfunction or failure (Figure 3).

Figure 2.

Figure 2.

Figure 3.

Figure 3.

Given the acute hemodynamic event, the significant surgical hemorrhage, and ongoing bleeding that prompted the surgical team to pack the pelvis and return to the operating room (OR) for exploration and removal of packing 24–48 hours later, the institution of therapeutic anticoagulation was felt to carry significant risk. Instead, the decision was made to place an IVC filter, given the concern of ongoing embolization. The interventional radiologist present during the operation used the in situ MAC cannula in the right internal jugular vein to successfully place a Gunther Tulip IVC filter using both fluoroscopic (portable C-arm) and TEE guidance in the infrarenal IVC, before intensive care unit transport.

Postoperatively, the patient was started on therapeutic anticoagulation after interval removal of packs and abdominal closure. She had lower extremity Doppler ultrasound, which did not show evidence of deep vein thrombosis. She also had transthoracic echocardiography and computed tomography of the chest with contrast (CT Angio). Right ventricular function was in the low-to-normal range on transthoracic echocardiography. CT Angio did not reveal obvious PE to the segmental level but the images were severely limited by respiration artifact.

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Although the obstetric, surgical, and anesthetic management of abnormally invasive placenta (ie, placenta accreta, increta, or percreta) have been well described,1,2 this case highlights 3 unique aspects of care.

TEE is now an indispensable tool in the management of cardiac surgical patients,3 but is becoming more widely used outside the cardiac OR (eg, in orthotopic liver transplantation, trauma, and in unstable obstetric patients).4 One important obstacle to more widespread use in obstetrics is the need for sedation or GA to allow the patient to tolerate the probe.5 Although, in this case, TEE fortuitously identified an unexpected complication (IVC thrombus and presumed PE), its principal value was in helping to guide resuscitation in the setting of anticipated massive obstetric hemorrhage. Eleven percent of patients with abnormally invasive placenta will require more than 20 units of packed red blood cells during cesarean delivery.6 Previous case reports have described the use of TEE in the management of obstetric patients with PE,7,8 but, in these cases, TEE was used only after hemodynamic instability or collapse had occurred. Our anesthetic plans for cesarean hysterectomy for placenta percreta involve GA for at least part, that is, delivery of the neonate onward, if not all of the procedure. We feel that TEE is a valuable additional monitoring tool during GA in appropriately selected patients for both anticipated and unanticipated hemodynamic instability before such events occur.

Second, TEE examination also revealed the presence of a new, probable thrombus in the IVC soon after delivery, enabling the OR teams to be particularly vigilant for a potentially impactful PE. We were able to ensure that epinephrine and other vasoactive medications were available, to consult our IR colleagues for management advice, and to respond immediately when intraoperative events suggested that PE may have occurred. Intraoperative PE has also been reported in a patient under GA with relatively unimpressive TEE findings at the time (ie, visible thrombus in the right atrium and isolated elevation of PA pressures).9 Additionally, up to 60% of PE may arise from sites other than the deep veins of the lower extremities when examined at autopsy.10 Other embolic phenomena such as amniotic fluid embolism11 or venous air embolism (incidence 10%–97%)12 have also been diagnosed by intraoperative TEE specifically during cesarean delivery. To our knowledge, this is the first reported case in the literature of an incidentally found IVC thrombus by intraoperative TEE in a pregnant patient. The combination of avoidance of thromboprophylaxis due to the risk of antepartum hemorrhage, prolonged inpatient hospital admission, prolonged surgery, and the hypercoagulable state of pregnancy may increase the risk of thromboembolism in patients with abnormally invasive placenta.

Third, we often utilize the services of IR as part of the management of patients with placenta percreta, who often place internal iliac balloon occlusion catheters preoperatively in the IR suite before transport to the main OR for the remainder of the case.13 In this case, IR also assisted intraoperatively with the placement of the IVC filter. Previous reports have described the placement of IVC filters before cesarean delivery in 1 patient at high risk of venous thromboembolism14 and in another who developed PE after postpartum hemorrhage,15 but, to our knowledge, this is the first report of it being placed intraoperatively during cesarean delivery. Close communication among the teams of caregivers regarding risks, benefits, and facilitation of treatment in a timely manner allowed for this patient to recover fully.

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Name: Jalal A. Nanji, MD, FRCPC.

Contribution: This author helped care for the patient, and contribute to and review the manuscript.

Name: Jessica R. Ansari, MD.

Contribution: This author helped care for the patient, and contribute to and review the manuscript.

Name: Mary Yurashevich, MD, MPH.

Contribution: This author helped care for the patient, and contribute to and review the manuscript.

Name: Johanes M. Ismawan, MD.

Contribution: This author helped care for the patient, and contribute to and review the manuscript.

Name: Deirdre J. Lyell, MD.

Contribution: This author helped care for the patient, and contribute to and review the manuscript.

Name: Amer K. Karam, MD.

Contribution: This author helped care for the patient, and contribute to and review the manuscript.

Name: David M. Hovsepian, MD.

Contribution: This author helped care for the patient, and contribute to and review the manuscript.

Name: Edward T. Riley, MD.

Contribution: This author helped care for the patient, and contribute to and review the manuscript.

This manuscript was handled by: Kent H. Rehfeldt, MD.

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