Open abdomen negative pressure wound therapy for intractable hemorrhage in advanced abdominal pregnancy: a case report

Abstract

Advanced abdominal pregnancies are rare in obstetrics. They have the potential for implantation of the placenta on highly vascular intra-abdominal structures leading to morbidity and mortality. This report presents the case of a 32-year-old woman who underwent delivery at 31 weeks of gestation of a heterotopic twin pregnancy (intrauterine and intra-abdominal). Delivery was complicated by life-threatening hemorrhage of the placental bed, which was managed with abdominal packing and open abdomen negative pressure wound therapy for temporary abdominal closure. She subsequently underwent primary abdominal closure with the placenta left in situ and serum beta human chorionic gonadotropin levels trended to zero. Temporary abdominal closure with negative pressure wound therapy is an effective mechanism to minimize surgical morbidity with avoidance of abdominal compartment syndrome and postoperative wound complications in cases of uncontrollable intra-abdominal hemorrhage associated with abdominal placentation.

Highlights

• •Abdominal pregnancy can involve critical maternal anatomy.
• •Open abdomen provides a temporizing measure to correct coagulopathy.
• •Open abdomen negative pressure wound therapy reduces wound complications.

1. Introduction

Morbidity and mortality from abdominal pregnancy is most commonly due to implantation of the placenta on highly vascular intra-abdominal structures [1], as demonstrated in the case reported here. Management of the placenta includes removal at the time of delivery versus leaving it in situ, with the latter having the benefit of avoiding catastrophic hemorrhage, but the risks include superimposed infection, secondary hemorrhage, coagulopathy, ileus, reoperation, and prolonged hospitalization [1].

The term “open abdomen” refers to intentionally leaving an abdominal incision open at the conclusion of intra-abdominal surgery when there is concern for development of abdominal compartment syndrome, such as nontraumatic intraperitoneal hemorrhage [2]. Temporary abdominal closure (TAC) is a method used in conjunction with open abdomen to protect the abdominal contents, and techniques include patch closure, negative pressure wound therapy (NPWT), and silo closure [2], [3]. NPWT allows for fluid removal and opposes lateral retraction of the abdominal musculature and fascia, increasing the likelihood of subsequent primary closure and is therefore the World Society of Emergency Surgery's preferred method of TAC (grade 2B evidence) [2], [3].

2. Case Presentation

A 32-year-old woman (gravida 4, para 3) presented at 31 2/7 weeks of gestation with a heterotopic twin pregnancy with one viable intrauterine gestation and an extrauterine fetal demise in the posterior cul-de-sac. She presented for care with the current pregnancy at 12 weeks of gestation; her body mass index at that time was 38.5 kg/m². Her preceding pregnancy was 8 months prior and resulted in a term cesarean section for multiple gestation and malpresentation.

On ultrasound at 13 weeks of gestation, there was suspicion for bicornuate uterus due to a thick dividing septum between the two pregnancies. At her subsequent 20-week anatomy ultrasound, there was increasing suspicion of abnormal implantation of one gestation, with the differential being ectopic abdominal pregnancy versus ruptured cornual ectopic versus implantation in a rudimentary uterine horn. It was then that hospital admission was recommended for further evaluation, including magnetic resonance imaging, which the patient declined. Despite many contact attempts, she was subsequently lost to follow-up.

She presented to labor and delivery triage with severe abdominal pain and vomiting at 31 2/7 weeks of gestation. Ultrasound revealed a viable intrauterine pregnancy and fetal demise of the suspected extrauterine gestation with free fluid in the abdomen. The exact location of the demised twin and its placenta was difficult to determine due to fetal size and the patient's body habitus. Vital signs were within normal limits (pulse 97, blood pressure 117/69, afebrile) but the patient was exquisitely tender to palpation of the abdomen with point-of-care ultrasound revealing intra-abdominal free fluid. The viable twin's heart rate was 140 beats per minute, but continuous fetal heart rate monitoring was not possible due to the patient's abdominal pain and movement. Due to concern for intra-abdominal bleeding and its imminent risk to the health of the patient and viable fetus, she was taken to the operating room emergently for exploratory laparotomy by maternal fetal medicine and gynecologic oncology.

A midline laparotomy was performed with scant hemoperitoneum appreciated. The uterus was exteriorized and the extrauterine pregnancy was visualized within its amniotic cavity. The extrauterine placental bed was posterior to the uterus and appeared to be morbidly adherent to the posterior cul-de-sac, including the sigmoid colon and its mesentery, the posterior uterus, and the broad ligaments (Fig. 1). Intraoperative ultrasound was used to map the intrauterine placenta. A classical, trans-fundal incision was performed to deliver the viable intrauterine pregnancy and the hysterotomy closed in multiple layers. Intraoperative ultrasound was again used to locate the placenta of the extrauterine pregnancy, and a small incision was made in the amniotic sac distant to the placental site. A nonviable fetus was delivered with evidence of remote demise.

Fig. 1.

Intraoperative view of the pregnancy from the patient's right during the initial surgery, the uterus exteriorized and displaced caudad to expose the abdominal pregnancy.

Upon careful exploration, a torrential hemorrhage from the placental vasculature was incurred. Nine fibrin sealant surgical patches (Evarrest®, Johnson & Johnson) were applied along with pressure, which slowed bleeding but did not achieve hemostasis. At this point, there was no safe, viable option for surgical removal of the placenta. Therefore, TAC with abdominal packing and further resuscitation was undertaken. Twenty laparotomy sponges were placed into the placental bed, with the decision to leave the abdomen open and covered with open abdomen dressing (AbThera™, 3 M) for negative pressure wound therapy. Total estimated blood loss (EBL) was eight liters.

The patient was transfused throughout the case using institutional massive transfusion protocol. Perioperatively, she received 15 units of packed red blood cells, 12 units of fresh frozen plasma, and 1 unit of platelets.

The patient was taken to the interventional radiology suite and underwent fluoroscopy-guided embolization of the right uterine artery—the left was diminutive. She was then transferred to the intensive care unit intubated and sedated. Scheduled cefazolin (2 g every 8 h) and metronidazole (500 mg every 8 h) were administered intravenously due to the open abdomen and tranexamic acid 1 g was given every 6 h. Thromboelastography (TEG) was utilized to assess for and correct coagulopathy. By the first postoperative day, she had been weaned off vasopressors.

The patient's postoperative course will be referenced relative to time of delivery of the live fetus. On postpartum day 1, after approximately 36 h of resuscitation (with subsequent 1.5 l blood loss into the open abdomen dressing collection cannister), she was taken to the operating suite for re-exploration. The open abdomen dressing and the surgical sponges were removed. Hemostasis was appreciated in the placental bed. The placenta was adherent to the sigmoid colon and rectum, right ureter, and the right common iliac artery and vein (Fig. 2). The placenta could not be removed without multivisceral resection, so additional fibrin sealant patches were placed over the placenta and it was left in situ. Intraoperative x-ray was done to ensure all surgical sponges were removed, and the abdomen was closed primarily. She was taken back to the ICU, and on postpartum day 3 she was extubated and transferred to the floor for further recovery. She received ceftriaxone 1 g daily and metronidazole 500 mg every 8 h in the postoperative period following closure for the remainder of the hospitalization. The patient had received in total 19 units of packed red blood cells, 13 units of fresh frozen plasma, 3 units cryoprecipitate, and 5 units of platelets throughout the admission.

Fig. 2.

Reopening of the laparotomy after use of open abdomen dressing.

In the postoperative period, the patient explained she had not presented to follow-up visits as she did not want to believe that the risks of the pregnancy to both her and the fetuses were as grave as had been expressed to her. She desired contraception and after counseling, an etonogestrel implant (Nexplanon) was placed and she was discharged on postpartum day 8 on a 2-week course of amoxicillin-clavulanate 875-125 mg every 12 h. Serum beta human chorionic gonadotropin (bhCG) levels trended downwards while she was an outpatient, and reached zero on postpartum day 47. Following discharge, the patient did not develop any wound complications and the incision healed well. Approximately four months after delivery, computed tomography with and without contrast of the abdomen and pelvis showed decreased size of the placental tissue from 17 cm to 13 cm (maximal sagittal dimension). At this time, she was advised to return to follow-up with general obstetrics and gynecology with recommendation for a preconception visit prior to future pregnancies.

3. Discussion

Abdominal packing for control of hemorrhage is an essential technique well established for “damage control” in all surgical fields including obstetrics [4]. Most studies of its use in obstetrics are in patients with persistent hemorrhage following peripartum hysterectomy, the largest being a review by Touhami et al. of the clinical course of 104 patients who underwent packing after peripartum hysterectomy, which found that packing achieved control of hemorrhage in 78.8% of the patients, but sepsis was seen in up to 53% [5]. In 2019, a review was published sharing the practice of leaving the abdomen open with a translucent film to evaluate intra-abdominal conditions in obstetric hemorrhage [6]. There is a paucity of data on this technique used in abdominal placentation with pelvic organ salvage. Ramachandran and Kirk described a case of abdominal pregnancy where the placenta could not be fully resected; the abdomen was closed but eventually the patient was taken back for hemoperitoneum and at that time the abdomen was packed and an antishock suit was applied [7]. Once the patient was stable, she was taken back to the operating theater for removal of packs and closure of wound, with postoperative course complicated by an additional operation for infection [7].

As demonstrated in this case, with NPWT intra-abdominal blood loss could be quantified, informing resuscitation while avoiding compartment syndrome, and the wound could be closed by primary intention. Few reports could be found in the literature of TAC with NPWT utilized for catastrophic hemorrhage related to abdominal pregnancy or any other obstetric surgery [7].

The initial decision to leave the placenta in situ at the time of delivery was based on the risk of surgical removal and ability to control bleeding with procoagulants and direct pressure. On return to the operating room, resection of the placenta could not be accomplished without multivisceral resection, and given prior reports of management with the placenta left in situ, this was the preferred approach [1], [8]. Structural involution of an abdominal placenta can take years, but hormonal function is believed to decline within weeks of delivery; serum bhCG levels are trended to assess this [1].

A major strength of the method demonstrated through this case is the remarkable lack of postoperative morbidity, with no surgical site infection, hematoma, dehiscence or incisional hernia. Fortunately, abdominal pregnancies are rare enough that it is difficult to collect a large sample of patients to prove that open abdomen NPWT played a large role in the favorable surgical outcome.

In conclusion, TAC with NPWT is a useful tool in cases of advanced abdominal pregnancies in circumstances where removal is likely to result in massive hemorrhage and/or visceral resection. This is a commonly used practice within trauma surgery to temporize patients while resuscitation is carried out. Commonly available technology to limit the morbidity of TAC facilitates the adoption of this surgical technique.

Contributors

Faith Dunn contributed to patient care, conception of the case report, drafting the manuscript and undertaking the literature review.

Nina Mascia contributed to patient care and revising the article critically for important intellectual content.

Kelli McFarling contributed to patient care and revising the article for critically important intellectual content.

Skye Jacobson contributed to drafting the manuscript.

Eugene Chang contributed to patient care and revising the article critically for important intellectual content.

Justin Harold contributed to patient care, conception of the case report and revising the article critically for important intellectual content.

All authors approved the final submitted manuscript.

Patient consent

Written informed consent was obtained from the patient for publication of the case report and accompanying images.

Provenance and peer review

This article was not commissioned and was peer reviewed.

Funding

No funding from an external source supported the publication of this case report.

Declaration of competing interest

The authors declare that they have no competing interest regarding the publication of this case report.