Authors: Kotsev S N et al.
Cureus, 17(10): e95589, October 2025 DOI: 10.7759/cureus.95589
Summary
This case report describes catastrophic obstetric hemorrhage in a 38-year-old gravida 9 para 8 with suspected abnormally adherent placenta and multiple prior cesarean deliveries, culminating in an estimated blood loss exceeding 25 liters during a scheduled cesarean section at 34 weeks. The authors present this as the highest reported blood loss during cesarean delivery with maternal survival. The clinical story underscores how placenta percreta can rapidly evolve from “planned high-risk” to “near-unsurvivable” bleeding despite preparation, and it highlights the importance of decisive hemorrhage control strategies, coordinated multidisciplinary response, and real-time transfusion guidance.
The patient had multiple comorbidities (obesity, anemia, chronic hypertension, gestational diabetes) and substantial risk factors for placenta accreta spectrum. A multidisciplinary plan was established in advance, major blood products were staged in the OR, and large-bore/rapid-infusion vascular access was obtained (two large rapid infusion peripheral catheters, arterial line, and a large-bore central introducer). After delivery via a fundal uterine incision away from the placenta, the team initially attempted conservative management with the placenta left in situ. Shortly after uterine closure, torrential hemorrhage occurred, forcing conversion to hysterectomy. During the hysterectomy, major complications occurred including injuries to the bladder, ureter, and iliac vessels, driving uncontrolled bleeding that outpaced even dual rapid infusers.
A key turning point was temporary proximal control of hemorrhage using infrarenal/infraceliac aortic occlusion. While manual aortic compression was used initially, vascular surgeons then placed a temporary aortic cross-clamp (Mattox maneuver), after which the patient’s hemodynamics improved within minutes and definitive repair of iliac vessels and urologic injuries became possible. Damage-control strategies were used (pelvic packing and loose abdominal closure), with ICU ventilation overnight and return to the OR the next day for pack removal and formal closure.
Transfusion and resuscitation were substantial: 40 units PRBCs, 29 units plasma, 48 cryoprecipitate, and 12 platelet pools plus crystalloids. The report emphasizes “personalized transfusion” and frequent physiology-based reassessment rather than a purely formulaic approach. Rapid viscoelastic testing and serial blood gases were used to guide component therapy, along with frequent focused echocardiography, ultrasound-based assessments of fluid responsiveness, and lung ultrasound to balance bleeding control against complications of massive transfusion and fluid overload. Notably, the patient reportedly did not require inotropic support, with bedside echo suggesting a hyperdynamic left ventricle during the event. Postoperatively, she recovered without major sequelae and was transferred out of ICU by day 5.
In the discussion, the authors argue that attempted conservative management of abnormally adherent placenta can precipitate sudden uncontrollable bleeding when partial separation occurs, and they advocate that preemptive or early proximal aortic control may be life-saving when invasion of surrounding organs predicts extreme hemorrhage risk. They also caution against “unprepared” internal iliac ligation and emphasize that leadership, clear roles, and process organization influence outcomes in these complex, high-stakes cases.
Key Points
• Placenta percreta can produce hemorrhage that outpaces standard massive transfusion capabilities, even with preparation
• Attempted conservative management (placenta left in situ) may convert abruptly to uncontrolled bleeding after uterine closure
• Temporary aortic occlusion/cross-clamping can provide rapid proximal hemorrhage control and “buy time” for definitive repair
• Viscoelastic testing plus serial physiologic assessment can guide component therapy during extreme massive transfusion
• Damage-control surgery principles (packing, staged closure, ICU stabilization) can be critical to survival
What You Should Know
For anesthesia and OB hemorrhage teams, this case is a reminder that preparation is necessary but not sufficient—when bleeding exceeds infusion capacity, definitive hemorrhage control (proximal occlusion, surgical control, and rapid escalation to vascular help) becomes the main determinant of survival. It also illustrates the practical value of ultrasound/echo and point-of-care coagulation trends to steer transfusion away from indiscriminate volume replacement and toward targeted correction while watching for TACO/TRALI, edema, and abdominal compartment physiology. Finally, the case shows how quickly a “plan” can be invalidated once conservative management fails, so contingency planning and explicit triggers for escalation matter as much as the initial strategy.
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