21-year-old G3P1A1 with a history of a prior cesarean delivery presented at 38w in active labor with ruptured membrane days prior, unaware of her pregnancy

Timeline:

12PM - Presents to ED complaining of abdominal pain found to be 38w in active labor with ruptured membrane days prior, unaware of pregnancy

2PM - Obstetric exam revealed foul smelling meconium, FHT showing late decelerations

2:45PM - taken for ASAP cesarean section

3PM - combined spinal epidural placed

3:31PM - baby delivered, noted foul smelling amniotic fluid and placenta

4:14PM - persistent profound uterine atony despite multiple interventions including oxytocin bolus, carboprost x3, methylergonovine, rectal misoprostol, and tranexamic acid; MTP initiated, arterial line placed, and patient emergently induced and intubated for emergent hysterectomy due to rapid blood loss

5:08PM - worsening blood loss due to ruptures of tissues of the infected uterus, code blue called for PEA arrest despite rapid infusion of products; chest compressions and epinephrine given with eventual ROSC; ECMO team on site but not initiated due to significant bleeding

5:40PM - liver lacerations caused by chest compressions leading to further increased blood loss, 40L of blood products given via rapid infuser causing frank pulmonary edema, leading to inability to ventilate and sustained hypoxia; PEA arrest again and ACLS followed

5:55PM - due to worsening sustained hypoxia with a PaO2 of 29 mmHg, patient cannulated for ECMO, heparinized, and femoral VA ECMO was started leading to eventual ROSC

6:40PM - general surgery consulted, abdomen packed and patient taken to the CVICU to stabilize

11:30PM - patient returned to OR to control bleeding with general surgery for hepatorrhaphy and cholecystectomy, abdomen repacked

Postoperative course - patient started on CRRT for her pulmonary edema; the following day had North-South syndrome and was converted to VAV ECMO with improved upper body oxygenation, then to VV ECMO 3 days later, and decannulated the following day (POD5); extubated POD6; underwent several open procedures to control bleeding and ultimately close the abdomen; transferred to the floor POD9 and discharged on POD19 without neurologic deficits

Placental pathology demonstrated severe necrotizing chorioamnionitis with visible clusters of cocci

This case illustrates fulminant hemorrhage secondary tochorioamnionitis and breakdown of infected uterus tissue

Multiple transfusions aimed at correcting hypovolemia are associatedwith transfusion related acute lung injury (TRALI) and pulmonary edema

ECMO may be the only option to treatsevere hypoxia, but heparinization in the presence of ongoingcoagulopathy and unrepaired liver lacerations was controversial

Ultimately, use of ECMO was the correct measure to preventimmediate death and long-term neurologic injury in this patient 

This case underscores the complexity of decision-making processes and highlights the use of in-OR ECMO in managingwomen with severe hemorrhage, cardiopulmonary failure, and ongoingcoagulopathy and organ injury.