Case Report

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 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-μm 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.