Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526–534.
Extirpative surgery in the form of hysterectomy—with or without partial bladder resection—is usually considered the treatment of choice for these conditions. A retrospective multicenter study reported maternal outcomes after conservative treatment of 167 women who had placenta accreta or percreta (18% had percreta). Conservative management included one or more of the following:
- stepwise uterine devascularization
- pelvic vessel ligation or embolization
- uterine-compression sutures
- administration of methotrexate and antibiotics.
Conservative treatment was successful in 131 (78.5%) cases. Eighteen women underwent primary hysterectomy, and 18 women underwent delayed hysterectomy. One woman died after intraumbilical methotrexate administration, and 10 women (6%) experienced severe morbidity.
Conservative management should be offered only in centers that have adequate equipment and resources for patients who are properly counseled and who are motivated and agree to close follow-up. Planned cesarean hysterectomy remains the treatment of choice for multiparous women, as well as for women who have multiple cesarean deliveries with accreta, and those who do not accept the risks or who are not motivated to undergo close and prolonged follow-up.
8. Beware of von Willebrand disease
Pacheco LD, Costantine M, Saade GR, et al. von Willebrand disease and pregnancy: a practical approach for the diagnosis and treatment. Am J Obstet Gynecol. 2010;203(3):194–200.
This disease can cause immediate and delayed postpartum hemorrhage and has a prevalence of approximately 1% in the general population. Sixteen percent to 29% of women who have von Willebrand disease will experience PPH within 24 hours after delivery, and 20% to 29% will experience delayed postpartum bleeding.
Patients who have this disease should be managed in consultation with a hematologist and blood bank personnel. It entails use of desmopressin, plasma concentrates that contain von Willebrand factor (Humate-P), or cryoprecipitate.
9. Have fibrinogen concentrate on hand
Bell SF, Rayment R, Collins PW, Collis RE. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anaesth. 2010;19(2):218–223.
Rahe-Mayer N, Sørensen B. Fibrinogen concentrate for management of bleeding. J Thromb Haemost. 2011;9(1):1–5.
This product can correct hypofibrinogenemia very rapidly. In women who have severe PPH, hypofibrinogenemia may develop as a result of dilutional coagulopathy or hypofibrinogemia in conditions such as abruptio placentae with fetal demise, acute fatty liver of pregnancy, or amniotic fluid embolism. Treatment requires a high volume of fresh frozen plasma or cryoprecipitate. Fibrinogen concentrate is stored at room temperature, requires no cross-matching, and can be prepared and infused within 3 minutes.
10. Implement a protocol for massive transfusion
Sibai BM. Evaluation and management of postpartum hemorrhage. In: Management of Acute Obstetric Emergencies. New York, NY: Elsevier; 2011:41–70.
A delay in the treatment of hypovolemic shock can cause ischemic injury to the kidneys, liver, myocardium, and brain and can lead to diffuse intravascular coagulation (DIC), adult respiratory distress syndrome, and death. The objectives for having a protocol for massive transfusion include:
- administration of adequate blood and blood products
- maintenance of tissue perfusion
- ensuring adequate oxygen delivery
- correction of DIC.
These objectives are vital while the team is working to control the source of bleeding.
BY EXPERT AUTHORS
- “Postpartum hemorrhage: 11 critical questions, answered by an expert”
Q&A with Haywood L. Brown, MD(January 2011) - “What you can do to optimize blood conservation in ObGyn practice”
Eric J. Bieber, MD; Linda Scott, RN; Corinna Muller, DO; Nancy Nuss, RN; and Edie L. Derian, MD(February 2010) - “Planning reduces the risk of maternal death. This tool helps.”
Robert L. Barbieri, MD (Editorial; August 2009) - “You should add the Bakri balloon to your treatments for OB bleeds”
Robert L. Barbieri, MD (Editorial; February 2009) - “Consider retroperitoneal packing for postpartum hemorrhage”
Maj. William R. Fulton, DO (July 2008) - “Give a uterotonic routinely during the third stage of labor”
Robert L. Barbieri, MD (Editorial; May 2007)
For a related malpractice case, read Medical Verdicts.
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