We present a 36-year-old Jehovah’s Witness patient with complete placenta previa, placenta accreta, and a history of 2 prior C-sections who was transferred to MedStar Georgetown University hospital for management. The patient was successfully treated with various disciplines working together as a team. Our multi-disciplinary approach involved the departments of obstetrics and gynecology, hematology, bloodless medicine, anesthesiology, urology, interventional radiology, and neonatology.
The Jehovah’s Witness surgical patient presents the surgeon and anesthesiologist with special medical and ethical considerations that arise from refusal of blood transfusion. There is great heterogeneity in blood product acceptance among antenatal patients of the Jehovah’s Witness faith. Jehovah’s Witnesses represent 0.8% of the US population. Although some blood products are generally forbidden, such as red blood cells, granulocytes, plasma and platelets, the choice to accept or decline others, including the use of hemodilution and cell salvage, is left to the individual’s conscience. The peripartum setting in a Jehovah’s Witness patient strikes fear in many surgeons’ hearts. Candid preoperative discussion with the patient about the risks and options for bloodless care is essential in managing these patients.
Obstetrical hemorrhage is the leading cause of death during childbirth worldwide. Allogeneic transfusion has been a major factor for reducing the impact of hemorrhage in the peripartum period. The refusal of allogeneic transfusion presents a particular challenge for the Jehovah’s Witness patient, given the risk of hemorrhage and resulting potential for morbidity and mortality in both mother and fetus. Combined with a placental abnormality such as placenta previa or placenta accrete, this risk escalates substantially.
A 38-year-old G6 P2033 with a history of two prior C-sections presented to our hospital transfer of care at 32+1 weeks due to complete placenta previa with possible accreta. The patient was a Jehovah’s Witness and refused blood products due to religious beliefs; she was transferred to take advantage of our bloodless medicine program.
Candid preoperative discussion with the patient about the risks and options for bloodless care is essential in managing these patients.
Upon evaluation by maternal-fetal medicine, the fetus was found to be growth-restricted at 3rd percentile during her 32+1 weeks ultrasound.
Delivery was recommended at 34 weeks with Betamethasone for fetal lung maturity prior to delivery. Twice weekly antenatal testing was initiated. A bloodless medicine surgery program consultation was performed and the patient declined red blood cells, fresh plasma, and platelets. The patient was willing to accept albumin, clotting factors, immunoglobulins, platelet gel autologous, sealants, and interferon. At 33+1 week she received an IV iron infusion per consultation with our bloodless team and outside consultation with Dr. Jonathan Waters, Chief of Anesthesiology at UPMC Magee-Womens Hospital, to increase her hematocrit and optimize cell salvage. Iron infusion approximately 10 days prior to the procedure had increased the patient’s hemoglobin and hematocrit from 12.9 mg.dL-1/37.7% up to 13.2 mg.dL-1/38.7%.
She was admitted for inpatient observation at 33+4 weeks. An MRI was done, which showed iron deposits in the placenta due to patient’s iron infusion. This posed some challenges and difficulty in interpretation by the radiologist. An anterior placenta previa was confirmed, with edge of the placenta about 4 cm above the umbilicus. The surgeon reviewed the MRI with the radiologist in order to provide the safest approach for uterine incision, to minimize cutting and separation of the placenta, and to decrease potential blood loss. The fetus was found to be in a breech presentation. There was no evidence of placental invasion into adjacent pelvic structures but heterogeneity in the supra-vesicular region was concerning.
On the day of surgery the anesthesiologist went to the interventional radiology suite to place an epidural, and a hypogastric artery balloon was placed bilaterally. The patient was immediately transferred to the operating room for immediate cesarean section and hysterectomy.
The anesthesiologist proceeded to place arterial line and multiple large-bore catheters and initiated acute normovolemic hemodilution with a lower hemoglobin goal of about 10 mg.dL-1. By intentionally diluting the intravascular red blood cell concentration, total cell mass loss per milliliter of surgical blood is reduced proportionately.
The patient was placed in a dorsal lithotomy position with the interventional radiologist in the operating room to position patient’s legs, to allow easy access to hypogastric artery balloon catheters in the event of severe hemorrhage.
A urologist performed cystoscopy and bilateral ureteral stent placement. The cystoscopy was found to be unremarkable.
The neonatal ICU team was present intraoperatively to receive the newborn, perform resuscitation if needed, and transfer to the neonatal ICU. Gestational age at delivery was 34 weeks 5 days,
A midline vertical incision was done from 2 cm above the pubic symphysis to just above the umbilicus. A fundal incision was made to avoid the placenta in the anterior location, and the fetus was delivered through this incision. Of note: for suction, a double setup system was used: one for the amniotic fluid, and the second for autologous blood salvage recovery after closure of the uterus. Suction pressure was minimized unless severe hemorrhage ensued; this ensured that damage to recovered red blood cells was minimized. A PDS loop suture in a running lock fashion was used to close the uterus with placenta still in situ.
We also rinsed all lap sponges in normal saline and suctioned via Cell Saver. We set up a double suction so that most of the amniotic fluid was diverted into the wall suction system. A Pall RS1 leukocyte applied patient filter was used after processing the salvaged blood.
We used the LigaSure device to incise the round ligament and develop the bladder flap bilaterally. The ureteral stent was palpated throughout the procedure and noted to be out of the surgical field. Bilateral utero-ovarian ligaments were cauterized and cut with the LigaSure device. With the bladder dissected off the lower uterine segment below the level of the cervix, the uterine vessels were ligated bilaterally using Heaney clamps. On the left side the endometrium was significantly thin to the point where the placenta was practically visible.
It is important to note that upon placing Heaney clamps, the placenta must be avoided as much as possible, especially in placenta percreta, as this can cause significant bleeding and hemorrhage. Our practice is to place the Heaney clamps below the edge of the placenta, at the internal cervical loss level if possible, to avoid significant bleeding. This may be technically difficult. A supracervical hysterectomy was completed and the urologist removed the ureteral stents.
At the end of the case, estimated blood loss was 1200 mL; the patient was stable and did not require re-infusion of the salvaged red blood cells (since salvaged cells have been processed and therefore there is a measure of risk in the re-administration of salvaged blood, and the patient’s condition did not require it, the decision was made not to re-infuse). The interventional radiologist removed the balloons at the end of the procedure. Postop hemoglobin day 1 was 10.4 mg.dL-1 and hematocrit was 31.8.
Postop was complicated by left leg weakness, which was evaluated by neurology. This was believed to be the result of specific placement of the legs in the stirrups to allow access to the IR balloon without taking into consideration the wedge placed underneath the patient’s body at the beginning of the procedure, which distorted the angle between her body and her left leg. The left leg weakness resolved spontaneously within the next few days. She was discharged home on postoperative day 4.
The purpose of this case report is to provide a guideline for multidisciplinary management of placenta previa in an obstetrical patient who declined blood transfusion due to religious beliefs, or for any other reason.
Developing a multidisciplinary, team approach to a very difficult and high-risk obstetrical case can maximize the chance of achieving an optimal outcome for a Jehovah’s Witness patient at risk for severe hemorrhage, as in placenta previa and placenta accreta, which put the patient at high risk for excessive intraoperative blood loss. Cell salvage technology has been applied in a variety of clinical situations but has not been used extensively in obstetric hemorrhage. The justification for not applying cell salvage is a theoretical fear of reinfusing blood that contains amniotic fluid components, which could lead to an amniotic fluid embolism. Recent evidence suggests that cell salvage can be an important blood conservation strategy in the obstetric patient population.
Developing a multidisciplinary, team approach to a very difficult and high-risk obstetrical case can maximize the chance of achieving an optimal outcome for a Jehovah’s Witness patient at risk for severe hemorrhage.
It is important to mention the challenges that physicians face during this process. Although behind the scenes, physicians are challenged by their concern for the patient’s safety as they accept and respect the patient’s decisions and work with the patient despite their apprehensions about the risk. We are trained to manage medical problems according to standard protocols. It is vital to allow ourselves to realize “ Cura Personalis”: caring for the whole person requires that we recognize that there are beliefs behind life decisions that cannot be taken out of the picture. Although candid discussion of the risks should be included in order for the patient to make an informed decision, ultimately the process of healing and success are dependent upon the patient’s trust in the physician’s capabilities and empathy, and the physician’s acknowledgment of and respect for the patient’s faith. The goal is not to “scare” the patient and her family, but make them aware of risks while infusing trust and confidence in them. This patient communicated her fears with me every step of the way. Her previous physician had truthfully and correctly discussed with her the risks associated with refusal of blood transfusion, but did not take the time to instill a sense of trust in the patient. Trust in the physician’s capability of handling the medical obstacles without resorting to blood allows the patient to proceed with the reassurance that she will be optimally taken care of and that her choices will be respected. This level of empathy and trust can help the patient accept your recommendations and comply with your care.
Trust in the physician’s capability of handling the medical obstacles without resorting to blood transfusion allows the patient to proceed with the reassurance that she will be optimally taken care of and that her choices will be respected.
We believe that these general guidelines can be used in many patients for optimization starting in the antenatal period, regardless of their acceptance or non-acceptance of blood products:
- Optimization of the patient’s blood levels in the antepartum. Recognizing the need for iron replacement therapy in oral form and if not tolerated, by intravenous infusions. Recognizing that newer Iron infusions have less allergic reactions.
- Candid and empathic discussions with patient by our bloodless medicine team, the maternal-fetal medicine team, and a generalist OB/GYN were key factors.
- Consultation with the bloodless medicine team to clarify patient’s blood product acceptance, plan for iron infusions, and coordinate the availability and use of the Cell Saver.
- Anesthesia involvement with placement of appropriate lines for resuscitation, normovolemic hemodilution and appropriate fluid management, measures such as using tranexamic acid and uterotonic medications to decrease blood loss.
- Interventional radiology placement of hypogastric balloon catheters.
- Ureteral stents and evaluation of bladder by urology to assess for placental invasion and decrease risk of surgical damage.
- Meticulous and appropriate surgical technique with preoperative planning of incisions, and involving an experienced surgical team. The team should include a GYN oncologist or general surgeon in anticipation of invasion of vital organs by the placenta, which is not usually managed by the generalist OBGYN.
- Optimum positioning during potentially long procedures complicated by term pregnancy.
- Cell salvage using a double setup and leukocyte depletion filtering in anticipation of the need for oral locus blood transfusion. Good communication with an experienced cell salvage team and the use of normal saline to wash lap sponges and recycle via Cell Saver
- Accurate estimation of blood loss.
Caring for these patients has given me the advantage of a new way of thinking that has enabled me to treat many of my patients without blood. This practice, developed for Jehovah’s Witnesses, has made its way into the management of my other obstetrical and also surgical gynecology patients. This new way of thinking and practice benefits not only my Jehovah’s Witness patients, but also all my patients, regardless of their faith.