Jehovah's Witness patient with Morbidly adherent placenta

•  Explore the option of  autologous donation and transfusion, as well as acute preoperative hemodilution.
• Also explore whether patient is amenable to
•  Iron therapy,
•  Pharmacologic stimulation of erythropoiesis (EPO), and
•  Autotransfusion with the use of a cell-saver system, as long as the autotransfusion circuit remained continuous with her circulation. 
• In consideration of the patient’s high risk of hemorrhage,and if she insists on no blood products, and resulting high risk of maternal death,
• Involve a  multidisciplinary team that includes representatives from 
• Maternal–fetal medicine,
• Hematology/ transfusion medicine 
• Social services,
• Hospital counsel, 
• Obstetric anesthesiology,
• Vascular surgery, 
• Urology, 
• Gynecologic oncology, 
• Midwifery team /obstetrical nursing, and
• Neonatology team
• 
  

Doctors need to be sure that patients understand the nature and consequences of their decisions. Because a patient’s understanding may be limited by education, language, and culture, doctors should work to overcome such barriers.

Doctors should also try to understand the foundations of a patient’s decision and, if possible, address concerns or elements that seem to compel patients to choose paths that are not recommended. Doctors  may 

also — on their own or with the help of respected others (e.g., friends, family, or clergy) — advocate

for a recommended position in an effort to influence a patient’s decision.

Advocacy, however, should not become coercion, and threatening or creating negative consequences for a patient  because of the patient’s decision is unethical. A physician’s role as advocate is also appropriately limited to areas of professional, but not personal, expertise; in our roles as physicians, we should advocate for medical care, not for religious practice.

In summary, in managing the care of such a patient, one should would make sure that patient understood

the potential implications of her plan not to receive blood products, including the possibility of death.

One should would revisit the matter during the course of her prenatal care, to ensure that all her questions were answered. If, in the end, her wish not to receive transfusions was clear, one should respect it and prepare for a delivery in which support with blood products was not an option.

If JW  patient wishes to ensure that blood products will not be used, JW patient would usually be asked

to execute a statement of refusal of blood products before the procedure. If JW patient is injured or dies

because no blood products were used during the procedure, this document will protect the doctors

from a claim that they should have avoided such injury or death by providing blood products

The execution of such a document should include a discussion between the treating provider and the patient about the risks of refusing blood products, and any questions that the patient may have about alternatives to the use of blood products should be answered at this time. The statement should include an affirmation that this discussion has been held and that all questions that the patient had were answered.

One should resolve and document in advance that the patient’s decision to decline a blood transfusion

would be honored, even if doing so would result in her death.

At the completion of 36 weeks of gestation, one should plan a repeat cesarean section to be followed

immediately by hysterectomy, without attempts to remove the placenta in the vascular surgery

suite of the main operating room. With input from the multidisciplinary team, one should plan a number of maneuvers not typically performed during a routine cesarean section. The maneuvers which can be useful are, establishment of large-bore intravenous access, placement of an arterial catheter to monitor blood pressure.

placement of an epidural anesthetic, preoperative placement of ureteral stents, and fluoroscopic intravascular

placement of occlusive balloons in the internal iliac arteries, which would be inflated immediately after delivery of the fetus. Also, plan for the use of a cell-saver autotransfusion device once the operative field had been cleared of amniotic fluid.

chose elective delivery at a gestational age of 36 weeks, believing that the neonatal risks of late preterm birth were outweighed by the difficulties that might be encountered by assembling the broad multidisciplinary

team and resources after hours in an emergency. Two days before the delivery, one should administer a course of betamethasone for the promotion of fetal lung maturity.

Minimizing blood loss in Morbidly Adherent Placenta

• More than 80% of patients with placenta percreta have concomitant placenta previa, with a risk of clinically significant blood loss of more than 3000 ml.
• Several techniques have been described to minimize the risk of peripartum blood loss in a patient such as JW  by decreasing pelvic blood flow
• Temporary clamping of the infrarenal aorta or the common iliac arteries has also been described.
• New operating room imaging suites now allow for the performance of these procedures in the operating room, eliminating the need to transfer patients to the radiology department, with catheters, guide wires, and sheaths in place.
• Such suites also provide immediate access to anesthesia and operating-room support staff, as well as instrumentation such as cell-saver autotransfusion devices and rapid-transfusion devices.
• In one study, balloon occlusion of the arterial inflow has shown to decrease the bleeding that is associated with placenta accreta
• One can choose balloon occlusion of the internal iliac arteries with hysterectomy, to minimize the risk of bleeding complications.

Role of Anesthetist on the day of surgery :

To place catheters for fluid administration and pressure monitoring, — two large-bore peripheral intravenous infusion catheters, an internal jugular catheter for central venous pressure, and a radial-artery catheter — followed by epidural anesthesia

Role of Urologist on the day of surgery :

To perform cystoscopy with 

the bilateral placement of ureteral stents

Role of Perfusionist on the day of surgery :

A perfusionist will operate 

the cell-saver device.

Procedure :

General anesthesia recommended

A vertical incision was made on the 

skin from the symphysis pubis to approximately 

4 cm above the umbilicus, followed by a vertical 

incision on the uterus above the implantation of  

the placenta.

After delivery, inflate the 

 balloons , and quickly close the 

uterus. Then examine the pelvis,

and  look for whether any  placental tissue  present 

outside the uterus, extending toward both pelvic

sidewalls.

Then  perform a hysterectomy, removing the uterus, cervix, and placenta in one piece. You may have to use   several figure-of-eight sutures to control the bleeding from the vascular pedicles. Make sure hemostasis persisted after the balloons were deflated. Check the bladder integrity with methylene blue dye testing.The incisions were closed in the usual fashion with drains to pelvis with Robinson's  and Skin with steel clips.