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Synchronous autotransfusion during cesarean hysterectomy
Case Report
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Synchronous autotransfusion during cesarean hysterectomy Tamera Hatfield, MD, PhD; Heidi Kraus, MD; Douglas McConnell, MD; Michael Nageotte, MD
W
ith the increasing frequency of cesarean delivery in the United States, the incidence of placenta accreta has increased significantly1 with inherent complications related to hemorrhage and massive transfusion.2,3 We report a case of placenta accreta managed with cesarean hysterectomy and synchronous autotransfusion using a standard cardiopulmonary bypass machine to reduce the need for blood products. While the cardiopulmonary bypass equipment was used for the autologous transfusion, it should be emphasized that the patient was not placed on bypass.
C ASE R EPORT The patient was a 36-year-old gravida 4 para 2022 with a complete anterior placenta previa and history of 2 cesarean deliveries. At 25 weeks, 3-dimensional ultrasound angiography confirmed complete previa with a chaotic vascular pattern highly suggestive of accreta. The patient’s antepartum course was complicated by 3 episodes of vaginal bleeding ultimately requiring hospitalization at 29 and 6/7 weeks for antenatal corticosteroids. The potential for cesarean hysterectomy was discussed with the patient as was the idea of using a standard cardiopulmonary bypass machine for synchronous autotransfusion at the time of surgery. Consultations were obtained from anesthesia and cardiothoracic surgery. The
From the Department of Obstetrics and Gynecology, University of California, Irvine, Orange, CA (Drs Hatfield and Kraus); and MemorialCare Heart and Vascular Institute (Dr McConnell) and MemorialCare Center for Women (Dr Nageotte), Long Beach Memorial Medical Center, Long Beach, CA. Received July 7, 2009; revised Sept. 1, 2009; accepted Sept. 24, 2009. Reprints not available from the authors. 0002-9378/free © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2009.09.032
Placenta accreta is associated with major morbidities including massive hemorrhage. We report a cesarean hysterectomy for placenta accreta with synchronous autotransfusion using a standard cardiopulmonary bypass machine. This technique requires complete intraoperative heparinization yet has the advantage of autotransfusion of autologous clotting factors and platelets in addition to red blood cells. Key words: autotransfusion, cesarean hysterectomy, placenta accreta
potential risks and benefits were extensively presented and informed consent was obtained. Following assessment of fetal lung maturity, delivery occurred at 37 weeks. The cesarean hysterectomy took place in the cardiac surgical suite. Peripheral arterial and central venous lines were placed by anesthesia. The cardiothoracic surgeon placed a right femoral vein 15F catheter that was connected to the cardiopulmonary bypass device and used for the subsequent autotransfusion. This option provides the specific and unique ability to rapidly transfuse blood, clotting factors, and platelets as compared to other devices such as cell saver. General anesthesia was initiated and a classic cesarean section was performed avoiding the placenta. Pelvic gutters were packed with laparotomy sponges to absorb amniotic fluid. A viable 2763-g male infant was born with Apgar scores of 7 at 1 minute and 9 at 5 minutes. The placenta was left in situ, liberal irrigation was used, sponges were removed, and uterine edges were oversewn. Full anticoagulation was then achieved with 35,000 U of heparin (as determined by the plasma activated clotting time [ACT]). Further ACT measurements were obtained throughout the case to verify the level of anticoagulation. Suction devices specific to the bypass equipment were activated and the hysterectomy performed. These suction devices retrieved blood from the field that was subsequently filtered into a reservoir. From there, blood was pumped to a heat exchanger and through a 35-m Pall filter (Pall Corporation, Port Washington, NY) and returned through the patient’s femoral
vein catheter. A total of 2500 mL was autotransfused while fully anticoagulated. Following the hysterectomy, anticoagulation was reversed with 300 mg of protamine (1 mg/100 U heparin) and autotransfusion ceased. The patient’s final ACT was within normal limits. Prior to closing, bleeding of approximately 1000 mL occurred from a pedicle on the left pelvic sidewall. Preoperative hematocrit was 33% and at surgical closure was 23.8%. Packed red blood cells (2 U) were transfused. The total estimated blood loss for the procedure was 4000 mL. However, when accounting for the 2500 mL autotransfused, the net estimated blood loss was 1500 mL. The patient remained hemodynamically stable and received an additional 3 U of packed red blood cells and I U of fresh frozen plasma. On postoperative day 2, her hematocrit was stable at 28.9%. The patient was discharged home on postoperative day 4. Final pathology report confirmed the diagnosis of placenta accreta.
C OMMENT We present the first case of synchronous autotransfusion during cesarean hysterectomy using a standard cardiopulmonary bypass circuit. The primary objective was to minimize the need for transfusion of multiple blood products, avoidance of disseminated intravascular coagulopathy, and its attendant need for prolonged intensive care. There are considerable theoretical advantages with this approach. Retrieving blood intraoperatively and autotransfusing through this circuit allows for the patient’s own
JANUARY 2010 American Journal of Obstetrics & Gynecology
e15
Case Report blood cells, clotting factors, and platelets to be directly and rapidly retrieved. Other autotransfusion technologies (such as cell saver) interrupt retrieval, take time, and return washed red blood cells devoid of platelets and clotting factors. Our patient did ultimately receive some blood products. We believe more products would have been necessary without using autotransfusion. A portion of the products received by our patient can be attributed to our conservative management (she was transfused to a hematocrit of 28.9% and international normalized ratio was always within normal limits) given our unconventional approach as well as the bleeding that occurred once the patient had been reversed and unable to be autotransfused. Whether or not this can be attributed to the previously heparinized state (a distinct possibility) can only be addressed in properly designed research studies.
e16
www.AJOG.org Surgical approach and potential complications of the case were considered in advance. Of paramount concern was the potential morbidity associated with performing a hysterectomy in a fully heparinized patient. While this technique is common in cardiothoracic surgery without significant complications attributed to the anticoagulated state,4 it has not to our knowledge been previously reported in a cesarean hysterectomy case. A second concern was the potential risk of contamination with debris, fetal cells, or amniotic fluid. Measures were taken intraoperatively to reduce this risk by packing the gutters, using 2 wall suctions for rapid clearance of fluid, and copious irrigation prior to heparinization. Clearly, future studies are necessary to determine the usefulness of such a technique. We suggest that efforts should be made to objectively assess the benefits and delineate any increased risk of full
American Journal of Obstetrics & Gynecology JANUARY 2010
anticoagulation with cardiopulmonary bypass circuit for synchronous autotransfusion during cases at risk for masf sive hemorrhage. REFERENCES 1. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 2005;192:1458-61. 2. Silver RM, Landon MD, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107: 1226-32. 3. Imudia AN, Awonuga AO, Dbouk T, et al. Incidence, trends, risk factors, indications for, and complications associated with cesarean hysterectomy: a 17-year experience from a single institution. Arch Gynecol Obstet 2009;280: 619-23. 4. Mangoush O, Purkayastha S, Haj-Yahia S, et al. Heparin-bonded circuits versus nonheparinbonded circuits: an evaluation of their effect on clinical outcomes. Eur J Cardiothorac Surg 2007;31:1058-69.
www. AJOG.org
Synchronous autotransfusion during cesarean hysterectomy Tamera Hatfield, MD, PhD; Heidi Kraus, MD; Douglas McConnell, MD; Michael Nageotte, MD
W
ith the increasing frequency of cesarean delivery in the United States, the incidence of placenta accreta has increased significantly1 with inherent complications related to hemorrhage and massive transfusion.2,3 We report a case of placenta accreta managed with cesarean hysterectomy and synchronous autotransfusion using a standard cardiopulmonary bypass machine to reduce the need for blood products. While the cardiopulmonary bypass equipment was used for the autologous transfusion, it should be emphasized that the patient was not placed on bypass.
C ASE R EPORT The patient was a 36-year-old gravida 4 para 2022 with a complete anterior placenta previa and history of 2 cesarean deliveries. At 25 weeks, 3-dimensional ultrasound angiography confirmed complete previa with a chaotic vascular pattern highly suggestive of accreta. The patient’s antepartum course was complicated by 3 episodes of vaginal bleeding ultimately requiring hospitalization at 29 and 6/7 weeks for antenatal corticosteroids. The potential for cesarean hysterectomy was discussed with the patient as was the idea of using a standard cardiopulmonary bypass machine for synchronous autotransfusion at the time of surgery. Consultations were obtained from anesthesia and cardiothoracic surgery. The
From the Department of Obstetrics and Gynecology, University of California, Irvine, Orange, CA (Drs Hatfield and Kraus); and MemorialCare Heart and Vascular Institute (Dr McConnell) and MemorialCare Center for Women (Dr Nageotte), Long Beach Memorial Medical Center, Long Beach, CA. Received July 7, 2009; revised Sept. 1, 2009; accepted Sept. 24, 2009. Reprints not available from the authors. 0002-9378/free © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2009.09.032
Placenta accreta is associated with major morbidities including massive hemorrhage. We report a cesarean hysterectomy for placenta accreta with synchronous autotransfusion using a standard cardiopulmonary bypass machine. This technique requires complete intraoperative heparinization yet has the advantage of autotransfusion of autologous clotting factors and platelets in addition to red blood cells. Key words: autotransfusion, cesarean hysterectomy, placenta accreta
potential risks and benefits were extensively presented and informed consent was obtained. Following assessment of fetal lung maturity, delivery occurred at 37 weeks. The cesarean hysterectomy took place in the cardiac surgical suite. Peripheral arterial and central venous lines were placed by anesthesia. The cardiothoracic surgeon placed a right femoral vein 15F catheter that was connected to the cardiopulmonary bypass device and used for the subsequent autotransfusion. This option provides the specific and unique ability to rapidly transfuse blood, clotting factors, and platelets as compared to other devices such as cell saver. General anesthesia was initiated and a classic cesarean section was performed avoiding the placenta. Pelvic gutters were packed with laparotomy sponges to absorb amniotic fluid. A viable 2763-g male infant was born with Apgar scores of 7 at 1 minute and 9 at 5 minutes. The placenta was left in situ, liberal irrigation was used, sponges were removed, and uterine edges were oversewn. Full anticoagulation was then achieved with 35,000 U of heparin (as determined by the plasma activated clotting time [ACT]). Further ACT measurements were obtained throughout the case to verify the level of anticoagulation. Suction devices specific to the bypass equipment were activated and the hysterectomy performed. These suction devices retrieved blood from the field that was subsequently filtered into a reservoir. From there, blood was pumped to a heat exchanger and through a 35-m Pall filter (Pall Corporation, Port Washington, NY) and returned through the patient’s femoral
vein catheter. A total of 2500 mL was autotransfused while fully anticoagulated. Following the hysterectomy, anticoagulation was reversed with 300 mg of protamine (1 mg/100 U heparin) and autotransfusion ceased. The patient’s final ACT was within normal limits. Prior to closing, bleeding of approximately 1000 mL occurred from a pedicle on the left pelvic sidewall. Preoperative hematocrit was 33% and at surgical closure was 23.8%. Packed red blood cells (2 U) were transfused. The total estimated blood loss for the procedure was 4000 mL. However, when accounting for the 2500 mL autotransfused, the net estimated blood loss was 1500 mL. The patient remained hemodynamically stable and received an additional 3 U of packed red blood cells and I U of fresh frozen plasma. On postoperative day 2, her hematocrit was stable at 28.9%. The patient was discharged home on postoperative day 4. Final pathology report confirmed the diagnosis of placenta accreta.
C OMMENT We present the first case of synchronous autotransfusion during cesarean hysterectomy using a standard cardiopulmonary bypass circuit. The primary objective was to minimize the need for transfusion of multiple blood products, avoidance of disseminated intravascular coagulopathy, and its attendant need for prolonged intensive care. There are considerable theoretical advantages with this approach. Retrieving blood intraoperatively and autotransfusing through this circuit allows for the patient’s own
JANUARY 2010 American Journal of Obstetrics & Gynecology
e15
Case Report blood cells, clotting factors, and platelets to be directly and rapidly retrieved. Other autotransfusion technologies (such as cell saver) interrupt retrieval, take time, and return washed red blood cells devoid of platelets and clotting factors. Our patient did ultimately receive some blood products. We believe more products would have been necessary without using autotransfusion. A portion of the products received by our patient can be attributed to our conservative management (she was transfused to a hematocrit of 28.9% and international normalized ratio was always within normal limits) given our unconventional approach as well as the bleeding that occurred once the patient had been reversed and unable to be autotransfused. Whether or not this can be attributed to the previously heparinized state (a distinct possibility) can only be addressed in properly designed research studies.
e16
www.AJOG.org Surgical approach and potential complications of the case were considered in advance. Of paramount concern was the potential morbidity associated with performing a hysterectomy in a fully heparinized patient. While this technique is common in cardiothoracic surgery without significant complications attributed to the anticoagulated state,4 it has not to our knowledge been previously reported in a cesarean hysterectomy case. A second concern was the potential risk of contamination with debris, fetal cells, or amniotic fluid. Measures were taken intraoperatively to reduce this risk by packing the gutters, using 2 wall suctions for rapid clearance of fluid, and copious irrigation prior to heparinization. Clearly, future studies are necessary to determine the usefulness of such a technique. We suggest that efforts should be made to objectively assess the benefits and delineate any increased risk of full
American Journal of Obstetrics & Gynecology JANUARY 2010
anticoagulation with cardiopulmonary bypass circuit for synchronous autotransfusion during cases at risk for masf sive hemorrhage. REFERENCES 1. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 2005;192:1458-61. 2. Silver RM, Landon MD, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107: 1226-32. 3. Imudia AN, Awonuga AO, Dbouk T, et al. Incidence, trends, risk factors, indications for, and complications associated with cesarean hysterectomy: a 17-year experience from a single institution. Arch Gynecol Obstet 2009;280: 619-23. 4. Mangoush O, Purkayastha S, Haj-Yahia S, et al. Heparin-bonded circuits versus nonheparinbonded circuits: an evaluation of their effect on clinical outcomes. Eur J Cardiothorac Surg 2007;31:1058-69.