Hemorrhagic shock due to ruptured left common iliac artery aneurysm during pregnancy

Abstract

consulted an obstetrician, who was unable to find any abnormalities. As the lumbar pain worsened in the evening and her face lost color, the patient was brought to our hospital by ambulance.On physical examination, she was conscious, but her face looked pale and the palpebral conjunctiva was anemic. She was sweating profusely. Her blood pressure was 62/20 mmHg and her heart rate was 120 bpm. However, no genital bleeding was found. Blood examination showed a hemoglobin level of 6.4 g·dl Ϫ1 and a total protein level of 3.4 g·dl Ϫ1 . Chest X-ray showed no sign of intrathoracic bleeding. Abdominal echography performed by an obstetrician showed no evidence of obstetric bleeding, such as abruptio placentae. Because the fetal heart rate decreased to 40 bpm, an emergency cesarean section was performed without further investigation of the cause of the hemorrhagic shock.On arrival at the operating room, her blood pressure was 60/10 mmHg and her heart rate was 125 bpm. Anesthesia was induced with ketamine 60 mg, and succinylcholine 90 mg was used to facilitate tracheal intubation. Anesthesia was maintained with sevoflulane (0.5%-1.0%) in 40% oxygen and 60% nitrous oxide using mechanical ventilation. Blood gas analysis revealed severe acidosis, with pH 6.98, PaCO 2 33 mmHg, PaO 2 212 mmHg, base excess (BE) Ϫ20.2 mmol·l Ϫ1 , and HCO 3Ϫ 7.8 mmol·l Ϫ1 . The hematocrit was below 15%. Three minutes after incision, a neonate was delivered. The Apgar score was zero at 1 and 5 min. The neonate could not be resuscitated. There were no abnormalities in the uterus and intraperitoneum. A huge hematoma, however, was found in the retroperitoneum, which was caused by a ruptured aneurysm in the left common iliac artery. For about 30 min, until the abdominal aorta was clamped, the systolic blood pressure remained around 40 mmHg. The blood pressure increased to 80-120 mmHg after the aorta was clamped. An artificial vessel replacement was performed. The