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Management of a Jehovah's Witness Parturient with Placenta Accreta
Abstract Number: F-43
Abstract Type: Case Report/Case Series
Introduction: A parturient with placenta accreta has the potential for significant hemorrhage. The morbidity increases when blood products can not be transfused due to religious beliefs. We report the anesthetic management of a Jehovah’s Witness parturient with a complete anterior placenta previa and accreta. Management required all medical subspecialties to develop a care plan that not only respected the patient’s religious beliefs but allowed for effective management of the patient.
Case Report: A 32 year old woman gravida 2, para 0-0-1-0 with the diagnosis of a complete anterior placenta previa, was admitted to our institution at 30 weeks gestation after an acute episode of hemorrhage. An ultrasound confirmed a placenta previa and an MRI showed a focal 3 cm placenta increta and early percreta into the lower anterior uterine segment. The hematocrit on admission was 23.6% decreased from 37%. The patient refused all blood products. After further discussion with the patient and her family she agreed to albumin less than 4% and cell saver only in a continuous circuit. After the initial bleeding episode the patient remained stable and the fetus showed no signs of distress. Maternal fetal medicine recommended expectant inpatient management with administration of erythropoietin and intravenous iron therapy. A multidisciplinary conference with obstetrics, anesthesiology and bioethics took place. Transfusion practice as a life saving measure was thoroughly discussed with the patient and her health care proxy and she still declined. At 34 weeks, the hematocrit was 34.1%. The risk of hemorrhage and the refusal of blood products outweighed the benefit of further medical management and a cesarean section was scheduled.
Internal iliac artery occlusion balloons were placed under epidural anesthesia. The cell saver was placed in a continuous circuit with a leukocyte depletion filter to assist in removal of the amniotic fluid contents. 3 liters of lactated ringers was infused prior to induction for hypervolemia to allow blood loss to occur at a lower hematocrit. General Anesthesia was planned due to the potential for a large blood loss. A total intravenous anesthetic technique was used to limit uterine atony. A high fundal incision was made to avoid the placenta and limit blood loss. The amniotic fluid was suctioned using standard wall suction and then the cell saver was used. The placenta was removed and a focal area of accreta in the lower uterine segment was sutured and the obstetrician was able to preserve the uterus. The estimated blood loss was 1800 ml. The patient was hemodynamically stable and extubated at the end of the procedure.
Discussion: Respect for the patient’s religious beliefs may alter normal anesthesia practice and resuscitation measures. Thorough understanding of a patient’s wishes along with careful planning and a multidisciplinary approach allowed for a favorable outcome for mother and baby.