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What Do You Do When The Fibroids Are Bigger Than The Baby In a Jehovah’s Witness
Abstract Number: F2D-3
Abstract Type: Case Report/Case Series
Introduction: The most common cause of maternal mortality is hemorrhage. Women with uterine fibroids are at risk for complications during pregnancy including a 4 fold increase in cesarean delivery (CD) rates (1). Patients are often consented for blood transfusions in the event they experience massive hemorrhage. However, some patients, including Jehovah’s Witnesses (JW) may refuse blood transfusion even for life-saving therapy. Jehovah’s Witnesses account for 0.8% of the US population and have a 65-fold increased risk of maternal death(3,2). This creates a clinical and ethical challenge for a medical team caring for a JW patient. We describe the management of a JW patient with large obstructing fibroids requiring a CD.
Case: Our patient is a 34 y/o JW, G2P0010 at 38W who was transferred late term from an OSH for a primary CD secondary to large obstructing fibroids. She refused any red blood cells, but did accept albumin, cryoprecipitate, FVII, PCC, TXA, cell salvage and ANH. Her pelvic ultrasound demonstrated 8 large fibroids surrounding the fetal head (largest being 10cm) that would prohibit a vaginal delivery, thus a CD was required. Her pre-op Hgb was 12.5 g/dL. Access included a CVL, a-line, and two large bore PIVs. Neuraxial analgesia was then obtained with a CSE. During neuraxial placement,1.5L of 0.9% NS was given. Blood (1100mL based on allowable Hct) was then harvested for ANH via her a-line over a 40 minute period and maintained in continuous circuit with the patient. After harvest, 1L of albumin was administered, after which Hgb was 8.2g/dL. During collection, bilateral internal iliac artery balloon occlusion catheters were placed under fluoroscopy by IR (which were inflated after delivery), and bilateral ureteral stents were placed by urology. After delivery, her Hgb was 8.0g/dL and 450mL of ANH was administered. After hemostasis was achieved the remaining 650mL was administered. Total estimated blood loss was 700mL. Her remaining postoperative course was uncomplicated with a postoperative Hgb of 10.2 g/dL.
Discussion: In JW patients at risk for significant hemorrhage, use of intraoperative ANH, cell salvage, internal iliac balloon occlusion catheters and administration of uterotonic agents after delivery may be used. Use of intraoperative ANH while maintaining a continuous circuit may be an acceptable option for JW patients. By inducing hemodilution, surgical loss of functional blood is minimized and concentrated blood is available if clinically indicated.
1. Lee HJ, Norwitz ER, Shaw J. Contemporary management of fibroids in pregnancy. Rev Obstet Gynecol. 2010;3(1):20-7.
2. Massiah N, et al. Obstetric care of Jehovah's Witnesses: a 14-year observational study. Arch Gynecol Obstet. 2007;276(4):339-43.
3. Religious Landscape Study, Pew Research Center’s Religion and Public Life Project. 2015.