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Cesarean Delivery, Embolization, Methotrexate, and Hysterectomy for a Jehovah's Witness Parturient with Placenta Percreta
Abstract Number: F-59
Abstract Type: Case Report/Case Series
A 42 year old G5P2022 parturient at 27 weeks gestation with a history of 2 prior cesarean deliveries presented with vaginal bleeding. She had a known history of placental percreta. The patient was a Jehovah’s Witness and refused all blood products, however she did accept cell salvage and erythropoietin. Multidisciplinary planning was coordinated among maternal fetal medicine, gynecology and oncology, urology, neonatology, interventional radiology, vascular surgery, trauma surgery, nursing, the center for blood conservation and obstetric anesthesiology. It was decided to proceed with cesarean hysterectomy.
General anesthesia was elected, access included two large bore peripheral IVs and a central line, and invasive monitoring was done with bilateral radial arterial lines. The patient’s core temperature was maintained between 34-35 degrees to minimize oxygen consumption. Cell salvage was available. Before hysterotomy, embolization of the uterine blood supply was attempted while ultrasound was performed in a sterile fashion for fetal monitoring. However, embolization was abandoned due to extensive vascularity and the concern regarding excessive fetal radiation exposure if embolization was done. Cesarean delivery was performed uneventfully. The placenta was invading the pelvic wall, thus hysterectomy was foregone and the placenta remained in situ to avoid massive hemorrhage. Estimated blood loss was 500 mL; no cell salvage was given. She remained hemodynamically stable and was extubated.
Postoperatively, conservative management of the placenta percreta was attempted with IM methotrexate. Six weeks later, the patient had a few episodes of vaginal bleeding with cramping. Repeat MRI showed no placental regression and increased uterine vascularity due to collaterals. Thus, she was first taken to interventional radiology for embolization, then to the OR for hysterectomy. Embolization and hysterectomy were performed without complications.
Maternal morbidity and mortality substantially increase with the number of repeat cesarean deliveries. The majority of the risk is related to abnormal placentation, massive hemorrhage and the need for hysterectomy (1). The preoperative approach of a Jehovah’s Witness parturient undergoing major surgery should involve coordinated multidisciplinary care, preoperative supplementation with iron, epoetin alfa and folate and a surgical and anesthetic plan aiming to avoid excessive blood loss (2). Pharmacological therapies that may be considered for these patients include antifibrinolytics, prothrombin complex concentrates and desmopressin. Lastly, conservative management of morbidly adherent placenta with methotrexate and delayed hysterectomy may reduce the risk of hemorrhage, however further investigation is needed.
1.Silver RM. Obstet Gynecol. 2015;126:654-68.
2.Mason CL, Tran CK. Anesth Analg. 2015; 121:1564-9.