Case Report
Acute normovolemic hemodilution, intraoperative cell salvage and PulseCO hemodynamic monitoring in a Jehovah’s Witness with placenta percreta

https://doi.org/10.1016/j.ijoa.2007.07.005Get rights and content

Summary

A Jehovah’s Witness who had had four previous cesarean deliveries was referred to our institution for management of a complete placenta previa at 34 weeks of gestation. A subsequent ultrasound scan was suggestive of placenta percreta with bladder involvement. After erythropoietin and iron supplementation, cesarean hysterectomy was performed. Using PulseCO technology for continuous hemodynamic monitoring, preoperative acute normovolemic hemodilution and intraoperative cell salvage were used resulting in a successful cesarean hysterectomy with a 5500-mL estimated blood loss. The PulseCO system provides continuous, real-time hemodynamic data by applying pulse power analysis to the arterial pressure waveform. A bolus of oxytocin given after delivery produced profound hypotension, the hemodynamics of which were elucidated with the PulseCO system. To our knowledge, the combined use of acute normovolemic hemodilution, intraoperative cell salvage and PulseCO hemodynamic monitoring for cesarean hysterectomy has not been reported previously. These techniques may be particularly useful in managing patients who refuse blood products and/or in whom the baseline hemoglobin is suboptimal.

Introduction

Life-threatening intraoperative hemorrhage is a known and feared complication of placenta percreta. Patients who refuse blood transfusion, for religious or other reasons, present an additional challenge for anesthetic management. Well-planned strategies for blood conservation and decisive surgical technique can help to achieve an acceptable outcome.

Section snippets

Case report

A 42-year-old, 100-kg woman, gravida 6, para 4, who had had four previous cesarean deliveries, was referred to our institution at 34 weeks of gestation for management of placenta previa. Ultrasound was highly suggestive of placenta percreta with bladder involvement.

The patient was a Jehovah’s Witness who adamantly refused transfusion of blood products and expressed full understanding of the consequences of this decision. She said she would accept erythropoietin injections and oral iron.

Discussion

The success of this case depended on extensive advance discussion and planning. Our first goal was to make sure that the patient fully understood the implications of her decision not to receive blood products. She was interviewed alone, so that no undue influence might be applied to her by family members or religious advisors. Both the obstetrical and anesthesia teams talked with the patient at length and were convinced that she sincerely would rather die than receive blood products. Before

References (9)

  • N.M. Estella et al.

    Normovolemic hemodilution before cesarean hysterectomy for placenta percreta

    Obstet Gynecol

    (1997)
  • A. Rhodes et al.

    Arterial Pulse Power Analysis: The LiDCO System

  • Thomas D (proposer), Clark V (opposer). Controversies in obstetric anesthesia: Facilities for blood salvage (cell saver...
  • Waters J H, Santrach P J. Pro/con debate: Is cell salvage a safe technique for the obstetric patient?. SOAP Newsletter...
There are more references available in the full text version of this article.

Cited by (0)

View full text