ANTENATAL: Multidisciplinary Planning: elective repeat cesarean delivery (CD) in hybrid OR with surgical prep to the xiphoid, regional anesthesia, blood products prepared.
DAY OF CD: Patient admitted with tachycardia to130s, low grade fever, TTE with moderate effusion, no tamponade (Fig 3).
PRE-PROCEDURE: Large-bore IV access x 2, 5% albumin,
Midazolam for anxiolysis followed by arterial line placement.
ANESTHETIC: Dural-puncture epidural (DPE) using 2% lidocaine with epinephrine, co-load 5% albumin; controlled epidural administration to achieve T4 level
INTRA-OP: Substantial blood loss of 6L, massive transfusion (Table) with intermittent phenylephrine. Hysterectomy performed; regional anesthesia maintained with patient awake and comfortable under minimal sedation.
POST-OP: mild dyspnea, fever, chest X-ray with pulmonary edema, possible pneumonia, furosemide with good effect; monitored bed.
POST-OP Day 1: TTE with early tamponade physiology, stable vital signs with mild dyspnea; expectant guarded management.
POST-OP day 4: Stable and discharged home.
2 MONTHS POSTPARTUM: Trivial effusion on TTE.