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Blood conservation strategies in a blood refusal parturient with placenta previa and placenta percreta
Abstract Number: S-04
Abstract Type: Case Report/Case Series
Introduction: Abnormal placentation can lead to massive postpartum hemorrhage. For blood refusal patients, blood conservation methods must be utilized. Acute normovolemic hemodilution (ANH) can be a useful technique to manage these challenging patients.
Case: A morbidly obese 35-year-old G3P1 Jehovah’s Witness with placenta previa and percreta presented at 35 weeks gestation after initial work-up at an outside hospital, where she was deemed high-risk and referred to our center after being treated with one dose of erythropoietin and intravenous iron. After multidisciplinary review, she underwent a cesarean delivery in an operating room with capability for intraoperative interventional radiology. A radial arterial line, large-bore peripheral intravenous access and a right internal jugular central venous catheter were obtained prior to the placement of a combined spinal epidural anesthesia. Right femoral arterial access was obtained by interventional radiology. ANH was performed by collecting 900ml of the patient’s whole blood via the central venous catheter into citrate-phosphate-dextrose bags, which were kept in closed circuit with the patient while oscillated at room temperature. Preoperative hemoglobin (Hb)=12.5 g/dL and post-ANH Hb =10.1 g/dL. Other blood conservation techniques included use of tranexamic acid and cell salvage. The patient then underwent cesarean delivery of a vigorous infant. After manual inspection of the uterus, the decision was made to delay hysterectomy due to the extensive placental invasion through the uterus 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 with an estimated blood loss of 700 ml. Postoperatively, the patient recovered on the obstetric unit while awaiting interval hysterectomy. She was treated for anemia (post-operative Hb nadir =8.4 g/dL) with a 13-day course of erythropoietin 300 units/kg daily, in addition to two doses of intravenous iron dextran 1000 mg. On post-operative day 26, with Hb =13.5g/dL, the patient underwent hysterectomy. A thoracic epidural was placed for postoperative analgesia prior to induction of general anesthesia. A radial arterial line and central venous access were obtained. 1350ml of autologous whole blood was removed for ANH with post-ANH Hb =11.3 g/dL. Cell salvage and tranexamic acid were also used. After surgical hemostasis was achieved, the estimated blood loss was 1200ml and the patient’s Hb =10.1 g/dL. The Hb increased to 11.8 g/dL after return of the autologous blood. She had an uneventful recovery and was discharged home on hospital day 34, post-operative day 4 following hysterectomy.
Discussion: We describe the successful use of ANH, along with other blood conservation strategies and delayed hysterectomy in a parturient with placenta percreta refusing blood transfusion.