A Standardized Approach for Transfusion Medicine Support in Patients With Morbidly Adherent Placenta

Abstract

Based on our experience and on the findings of our retrospective analysis, patients presenting with either antepartum radiological evidence or clinical suspicion of morbidly adherent placenta will benefit from a standardized protocol for clinical management, including transfusion medicine support. We found that massive hemorrhage is predictable when abnormal placentation is identified predelivery and that blood product support is substantial regardless of the degree of placental invasiveness. The protocol at our institution provides immediate access to sufficient volumes and types of blood products at delivery for patients at highest risk for life-threatening obstetric hemorrhage. Therefore, for patients with a diagnosis of morbidly adherent placenta scheduled for planned cesarean delivery with possible hysterectomy, a programmatic checklist that mobilizes a multidisciplinary team, including proactive transfusion medicine support, represents best practices.

Placenta Accreta Spectrum

“…There have been no controlled studies of the best ratios for blood product replacement in obstetrics. However, data from other surgical disciplines support the use of a 1:1:1 to 1:2:4 strategy of packed red blood cells: fresh frozen plasma: platelets (Table 2) (69,70). The use of autologous cell-saver technology is an option, particularly now given that theoretical concerns regarding safety and risks from fetal blood and other debris have been reduced with current filtering technologies (71e73).…”

Placental Abnormalities

“…The current estimated incidence of PAS is 3.0 per 1000 pregnancies [81]. Secondary to the rise in frequency of operative procedures (specifically cesarean deliveries, with an estimated incidence increasing from 12.5% in 1982 to 32.2% in 2014 [78,81]), there was a concomitant estimated increase in PAS of 0.8 per 1000 deliveries during the 1980s to the current estimate of 3.0 per 1000 pregnancies [78,[81][82][83][84][85][86]. Undiagnosed PAS can lead to massive intrapartum and postpartum hemorrhage, consumptive coagulopathy, disseminated intravascular coagulopathy, hypovolemic shock, and maternal mortality [71,79,87,88].…”

“…In the absence of a decidual layer, separation between the placental cotyledons and the uterine spiral arteries does not occur, and the uterus continues to perfuse the cotyledons, which, in turn, leads to hemorrhage [77]. The current estimated incidence of PAS is 3.0 per 1000 pregnancies [81]. Secondary to the rise in frequency of operative procedures (specifically cesarean deliveries, with an estimated incidence increasing from 12.5% in 1982 to 32.2% in 2014 [78,81]), there was a concomitant estimated increase in PAS of 0.8 per 1000 deliveries during the 1980s to the current estimate of 3.0 per 1000 pregnancies [78,[81][82][83][84][85][86].…”

Patient’s blood management in obstetric practice with placenta accrete

“…При развитии острой массивной кровопотери необходимо адекватное проведение инфузионно-трансфузионной терапии. Причем чем глубже инвазия плаценты, тем более ожидаемо значительное кровотечение, которое требует большего объема компонентов крови, гемостатических препаратов, и тем выше общая частота осложнений [15,16].…”