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Acute Normovolemic Hemodilution for a Jehovah's Witness with Polyhydramnios Presenting for Urgent Cesarean Delivery
Abstract Number: S-76
Abstract Type: Case Report/Case Series
Most Jehovah’s Witnesses (JW) do not accept transfusion of blood products. Anesthesiologists can employ acute normovolemic hemodilution (ANH) to decrease red blood cells lost during surgery while providing autologous blood, kept in continuity with the patient, for reinfusion as needed.1
A 32 year-old G1P0 at 31 weeks with a twin gestation complicated by polyhydramnios presented for an urgent cesarean delivery (CD) for suspected sudden amnio-chorion separation. The patient is a JW and refused blood products. Physical exam was notable for a gravid uterus out of proportion to dates and 3+ pitting edema of the left lower extremity. A combined spinal epidural (spinal: bupivacaine 5mg, fentanyl 15mcg, morphine 0.15mg) was performed. An arterial line (AL) and a central venous catheter (CVL) were placed. The procedures were well tolerated and she remained hemodynamically stable.
Starting hematocrit (Hct) was 34. 2L of blood was removed via the AL into 6 citrate-phosphate-dextrose-adenine (CPDA) units kept in continuity with the patient. Serial Hct and hemodynamics were used to guide fluid replacement (6L of lactated ringers total). Prior to surgery Hct was 28. Epidural catheter was dosed with 2% lidocaine 15ml and fentanyl 50mcg. Twins were delivered uneventfully. Uterine tone was achieved with oxytocin, methylergonovine and misoprostol. Blood loss was 800mL and ending Hct was 24. Due to hypotension, the autologous blood was reinfused. Blood was reinfused via the CVL, which was in continuity with the CPDA units and the patient at all times. After transfusion of all 6 units, furosemide 10mg IV was given prophylactically. Despite this, she developed pulmonary edema that responded to further diuresis. Final Hct was 26.
Due to this patient’s increased risk of post partum hemorrhage (PPH), the benefits of ANH outweighed the risks. The decision to reinfuse blood is challenging and ideally reinfusion should be done once hemostasis has been achieved or when hemodynamic derangements resulting from hypovolemia and anemia can no longer be supported by vasopressors and crystalloids. Since the risk of uterine atony and PPH persists post-operatively, all 6 units were reinfused as the autologous units expire after 4 hours. It is essential to provide adequate diuresis during the reinfusion process.
1. Am J Obstet Gynecol. 1998 Jan;178:156-60.