Placenta previa and placenta percreta are 2 obstetric conditions independently associated with life-threatening hemorrhage. Eighty-eight percent of patients with placenta percreta require blood transfusions with 41% requiring >5 units of packed red blood cells intraoperatively.1 This high likelihood of massive blood loss presents a management challenge in parturients with abnormal placentation who refuse allogeneic blood transfusion.
The medical literature includes only 2 cases of acute normovolemic hemodilution (ANH) performed during cesarean hysterectomies. Both patients were Jehovah’s Witnesses with abnormal placentation, but neither patient underwent a delayed hysterectomy.2,3 For cases of morbidly adherent placenta, delaying hysterectomy can significantly reduce blood loss by allowing for uterine involution and diminished blood flow before surgery.4 Combining a delayed hysterectomy with blood conservation techniques may be life-saving in this unique patient population that cannot be supported by allogeneic blood transfusion. Institutional review board exemption and written informed consent from the patient were obtained for publication of this case report.
A 35-year-old morbidly obese woman (body mass index 45 kg/m2) at 34 weeks of gestation with 1 prior cesarean delivery for breech presentation presented for consultation regarding a placenta previa with placenta percreta. One week before presentation, she was treated with one dose of erythropoietin and IV iron (dose and formulation unknown). She then self-referred for consultation because she refused transfusion of blood products as a matter of her Jehovah’s Witness faith. At our institution’s Center for Blood Conservation, she received in-depth consultation and confirmed refusal of allogeneic transfusion therapy with whole blood, red blood cells, unfractionated plasma, platelets, cryoprecipitate, and cryo-poor plasma. She indicated that she would accept minor fractions, including human plasma protein fraction and fibrinogen concentrate, as well as blood salvage strategies involving her own blood such as ANH and intraoperative cell salvage when kept in closed circuit with her own circulation. The patient was counseled extensively that refusal of allogeneic blood products could result in organ or tissue damage and even death.
On admission, magnetic resonance imaging showed complete placenta previa and placenta percreta within the inferior and right lateral aspects of the uterus. At 35 weeks of gestation, after interdisciplinary care planning among maternal–fetal medicine, gynecologic oncology, obstetric anesthesiology, the Center for Blood Conservation, perfusion, interventional radiology, transfusion medicine, and neonatology, the patient underwent a cesarean delivery in a hybrid operating room with capability for intraoperative interventional radiology. A radial arterial line, large-bore peripheral IV access, and a central venous catheter were obtained before the placement of a combined spinal epidural anesthetic with 12 mg hyperbaric bupivacaine, 15 μg fentanyl, and 150 μg morphine. Hemodynamic stability was maintained with a prophylactic phenylephrine infusion. With the patient in the supine position with left uterine displacement, the interventional radiologist obtained right femoral arterial access for potential embolization of uterine vessels. ANH was performed with the assistance of a perfusionist by collecting 900 mL of the patient’s whole blood through the central venous catheter into citrate–phosphate–dextrose bags, which were kept in closed circuit with the patient while oscillated at room temperature. During the harvest, 750 mL human plasma protein fraction 5% and 1 L of crystalloid were administered to maintain euvolemia. Her preoperative hemoglobin was 12.5 g/dL, and post-ANH hemoglobin was 10.1 g/dL. A separate circuit was established for cell salvage. The patient then underwent cesarean delivery through a vertical midline incision of a vigorous female infant with Apgar scores of 8 and 8 at 1 and 5 minutes of life, respectively. One gram tranexamic acid was administered after delivery. After inspection of the uterus, the decision was made to delay hysterectomy because of the extensive placental invasion through the myometrium into the broad ligament and the likelihood for massive blood loss. The placenta was left in situ, the hysterotomy was closed, and the uterine arteries were embolized. There was no evidence of intrauterine or vaginal bleeding, so the abdomen was closed (Fig. 1). The estimated blood loss for the cesarean delivery was 700 mL, and 900 mL of harvest blood was reinfused. Postoperatively, the patient remained inpatient on the obstetric unit because of bleeding and infection risk posed by the in situ placenta. She had no vaginal bleeding but was followed closely by physical examination and serial complete blood counts for the risk of occult intrauterine bleeding. A postoperative anemia (hemoglobin nadir of 8.4 g/dL) was treated with a 13-day course of 300 U/kg erythropoietin daily plus 2 doses of IV iron dextran, each 1000 mg. Her hemoglobin increased to 13.5 g/dL, and 26 days after cesarean delivery, the patient underwent a total abdominal hysterectomy. A low thoracic epidural was placed for postoperative pain control before induction of general anesthesia. A radial arterial line and central venous access were obtained for ANH. Autologous whole blood (1350 mL) was removed through the central line and kept in closed circuit with the patient. This was replaced with 250 mL human plasma protein fraction 5% and 1 L of crystalloid. Her post-ANH hemoglobin was 11.3 g/dL. Other blood conservation techniques included the use of tranexamic acid and cell salvage. She tolerated the hysterectomy well with no hemodynamic instability and an estimated blood loss of 1200 mL. There was insufficient blood in the cell saver to process, so only the 1350 mL of autologous whole blood was reinfused. Her postoperative hemoglobin was 11.8 g/dL. The patient had an uneventful recovery and was discharged home on hospital day 34, postoperative day 4 after hysterectomy. She was prescribed enoxaparin therapy for 30 days postoperatively for deep vein thrombosis prophylaxis. At her first postoperative visit, she reported doing well with no complications.
In 1945, leaders of the Jehovah’s Witness religion officially prohibited their members from receiving blood transfusions based on their interpretation of scripture from the Bible. As the practice of medicine has evolved, The Watch Tower Society that governs Jehovah’s Witnesses has created guidelines to assist their members in navigating decisions involving a multitude of blood salvage options.5 The medical community has adapted to these constraints in treating Jehovah’s Witnesses by using novel techniques in place of blood transfusions.
At our institution, patients who refuse allogeneic blood transfusions are evaluated by the Center for Blood Conservation to determine what blood products and procedures are acceptable, which is detailed in a signed consent form. Patients are educated on the different blood conservation methods available and, if appropriate, treated with erythropoiesis-stimulating agents, iron and folate, to correct preoperative anemia. The information from this consultation as well as suggestions to practitioners to minimize phlebotomy and use pediatric-sized tubes for blood collection are made available to all the practitioners involved in the perioperative care. After this consultation, an antenatal conference with all consultants was held for delivery planning. This multidisciplinary approach to managing high-risk blood-refusal patients improves the quality of care delivered by facilitating discussion of all management options available.6
The major deterrent to the use of ANH during pregnancy is the risk of decreasing oxygen delivery to the fetus. For this reason, our target post-ANH hemoglobin for the cesarean delivery was 10 g/dL, which is considered the lower limit of normal for pregnant women, and our target for the hysterectomy was 8 g/dL. The formula used to calculate the harvest volume is as follows: harvest volume = estimated blood volume × [(current hemoglobin − target hemoglobin)/current hemoglobin]. Monitoring the patient’s mental status throughout the first operation allowed for real-time measurement of adequate cerebral oxygenation, which in combination with monitoring fetal heart tones gave reassurance that maternal oxygen-carrying capacity after ANH was adequate for both the mother and fetus. To increase the margin of safety, we delayed the initiation of ANH until after femoral access was obtained, and the obstetricians were ready to make an incision to minimize the period of anemia.
Intraoperatively, we used a cell salvage device because current evidence supports its use in obstetrics.7 During the cesarean delivery and the subsequent hysterectomy, we prophylactically treated the patient with 1 g tranexamic acid in an attempt to decrease the amount of blood loss. Tranexamic acid, an antifibrinolytic, is a promising agent for the prevention of obstetric hemorrhage.8 Its usefulness in improving outcomes, including decreasing the need for blood transfusion in obstetrics, is being evaluated by the World Maternal Antifibrinolytic Trial (WOMAN) trial.9
In cases of morbidly adherent placenta, there is no clear consensus for optimal management with respect to delivery timing, attempted removal of the placenta, vascular occlusion, timing of hysterectomy, or even relative necessity of hysterectomy. Delayed hysterectomy, or closure of the hysterotomy after infant delivery leaving the placenta in situ with intent to perform hysterectomy at a later date, has been reported to reduce maternal morbidity in cases of placenta percreta involving the bladder.10 Given many reports of spontaneous placental regression after delivery, it stands to reason that reduced volume of the uterus and reduced vascularity at the planes of dissection would significantly decrease the risk of life-threatening hemorrhage; thus, a delayed hysterectomy rather than a cesarean hysterectomy was chosen.
After the significant anemia that occurred after the cesarean delivery, the risks and benefits of erythropoietin in our parturient were considered. Although the risk of thrombosis may be increased, the benefit of improving hemoglobin stores outweighs this risk in a patient who refuses blood products pending an invasive surgery associated with significant blood loss.11 Given the increased thrombotic risk with erythropoietin therapy, sequential compression devices were used instead of pharmacologic anticoagulation for thromboprophylaxis in the interval between cesarean delivery and hysterectomy because of the potential for hemorrhage in the setting of anticoagulation with a retained placenta. Erythropoietin is ineffective without adequate iron stores; therefore, 2 doses of IV iron dextran were administered to maintain ferritin >100 ng/mL and iron saturation >20%. The patient was also continued on her daily oral prenatal vitamins that included iron and folate.
In summary, we have described the blood-conservation strategies used for a parturient with abnormal placentation, who refused allogeneic blood transfusion. These strategies included erythropoietin and iron supplementation, tranexamic acid for antifibrinolysis, ANH and intraoperative cell salvage in combination with uterine artery embolization, and delayed hysterectomy.
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