Packing is the last solution to control the bleeding that threatens the life of a mother

Introduction: Hemorrhage is the most important cause of death of pregnant mothers in the world and accounts for ۲۷% of the causes of maternal death. One of the causes of severe and fatal bleeding is placenta percreta, which is not easily controlled despite hysterectomy due to placental invasion to the pelvic organs and can cause coagulation disorders and maternal death.Case presentation: The patient is a ۳۴-year-old G۳P۲L۲ woman, twin pregnant at ۳۵ weeks of pregnancy, with chief complain of abdominal pain and urinary retention from ۱۰ days ago, had referred to the perinatology clinic of Kamali Hospital. The patient mentioned a history of ۲ previous cesarean sections - one urinary tract infection in the current pregnancy and high blood pressure since ۳ months ago. The patient's pregnancy was dichorionic- diamniotic twin pregnancy. The placenta of first fetus was posterior and previa. In the color Doppler ultrasound performed at the ۲۸th week of pregnancy, the possibility of placenta accreta of the first placenta was raised, and an MRI of the placenta was requested for further investigation. Unfortunately, the patient had not done proper follow-up for MRI and continued prenatal care and had performed MRI with a delay of one and a half months. Of course, when the patient referred to the perinatology clinic with an MRI result of placenta percreta, she was ۳۵ weeks pregnant and had symptoms and was hospitalized as an emergency. At the time of admission, the patient had severe oliguria, creatinine=۳.۱ , BUN=۴۶ , AST=۲۲۵ , ALT=۲۷۹ , LDH=۱۱۰۳ and Hb=۱۰.۲. Due to non-reassuring NST of the fetuses, the patient was a candidate for emergency cesarean hysterectomy. A surgical team including anesthesiologist, gynecologist, vascular surgeon, urologist and perinatologist was formed. The decision to insert a ureteral catheter was made before starting the laparotomy, but this procedure was unsuccessful due to severe bilateral ureteral obstruction. Laparotomy started with a midline incision. A classic caesarean section was performed and two babies were born with good general health and Apgar scores of ۹ and ۱۰. Then hysterectomy was performed, but despite the total hysterectomy, severe uncontrollable bleeding continued from the pelvic floor and vaginal cuff. Bilateral hypogastric vessels were ligated, but the bleeding continued and the hemodynamic status of the patient was deteriorating. Finally, the surgical team decided to pack the pelvis. Two long gauzes were packed inside the vagina and ۴ more long gauzes were packed in the pelvic floor, and the peritoneum of the pelvic floor was closed. During the operation, the patient received two grams of fibrinogen, ۶ units of packed-cells, ۶ units of Fresh Frozen Plasma and ۶ units of platelets. Due to unstable hemodynamics, she was transferred to the ICU intubated. During the first day after the operation, the patient had anuria and underwent ۲ hours dialysis. ۱۶ hours after the end of the operation, the patient was extubated. On the second day after the operation, the patient's urination was established and the vaginal long gauzes were removed. On the third day after the operation, the patient underwent a laparotomy again, and the long gauzes inside the pelvis were removed. Fortunately, complete homeostasis was maintained. The patient was discharged from the hospital ۸ days after the first operation with a good general condition and no complications.