Authors: Kotsev S N et al.
Cureus 17(10): e95589, October 2025. DOI: 10.7759/cureus.95589
This extraordinary case describes a 38-year-old gravida 9, para 8 woman with placenta percreta who experienced more than 25 liters of intraoperative blood loss during cesarean section—one of the highest volumes reported in a surviving patient. Despite prior cesarean deliveries, obesity (BMI 46.6 kg/m²), and gestational diabetes, her pregnancy was otherwise stable until surgery revealed placental invasion into the urinary bladder and adjacent pelvic structures. After the baby was delivered via a fundal incision, massive hemorrhage began, prompting activation of the massive transfusion protocol. Injuries to the bladder, right iliac vessels, and left ureter compounded the blood loss.
Manual aortic compression followed by infraceliac aortic cross-clamping achieved temporary hemostasis, enabling vascular repair. Over the nine-hour operation, the patient received 40 units of packed red blood cells, 29 units of plasma, 48 cryoprecipitates, and 12 platelet pools, in addition to crystalloids, calcium, tranexamic acid, and recombinant factor VIIa. Rapid thromboelastography and frequent echocardiography guided transfusion and volume resuscitation, maintaining stable hemodynamics without vasopressor support. The patient was extubated the next day and transferred out of the ICU by postoperative day 5, recovering without complications.
The authors emphasize that risk mitigation through family counseling, preemptive planning, and clearly defined multidisciplinary roles are essential in such catastrophic obstetric cases. They advocate considering prophylactic aortic occlusion or resuscitative endovascular balloon occlusion (REBOA) in high-risk placenta percreta, noting that infraceliac clamping can stabilize hemodynamics without major cardiac strain. Conservative placental management carries high risk, and prompt hysterectomy remains the safer option when invasive bleeding occurs.
What You Should Know:
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Aortic cross-clamping can be lifesaving when conventional methods fail to control obstetric hemorrhage.
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Real-time hemodynamic and coagulation monitoring (e.g., TEG, ultrasound, ABG) allows personalized transfusion and reduces unnecessary product use.
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Conservative management of invasive placentation can result in unpredictable, catastrophic bleeding; hysterectomy is often definitive.
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Multidisciplinary readiness, efficient communication, and streamlined leadership structure are critical for survival in such extreme cases.
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Proactive decision-making, not reactive response, determines outcomes in massive obstetric hemorrhage.
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