Patient’s blood management in obstetric practice with placenta accrete

Abstract

Placenta accreta is one of the most severe anomalies of attachment, due to the high risk of massive bleeding. At present, the paradigm of organ-preserving delivery is laid. The implementation of this tactic is possible in the context of the introduction into the obstetric practice of patient blood management (PBM).Objective:to evaluate the effectiveness of blood preservation methods in the management and delivery of pregnant women with placenta placenta accrete.Materials and methods:The study group consisted of 59 pregnant women with placenta accreta in age from 20 to 40 years old (32,43 ± 5,05), who were examined in «Scientific Medical Research Center of Obstetrics”. Clinical, special (ultrasound and magnetic pelvic magnetic resonance imaging) and laboratory methods were used. A program of preparation for delivery was developed using the principles of the PBM: treating anemia at the preoperative stage; a multidisciplinary operating team was prepared (two obstetricians, a surgeon, anesthesiologist and resuscitator, anesthetist, transfusionist, physician, who provides work for Cell Saver, laboratory assistant). Operational tactics included a bottom cesarean section using one of the methods of surgical prevention and arrest of bleeding - bilateral ligation of the internal iliac arteries (1st group) (19 women), temporary stop of blood flow in common iliac artery by means of vascular clamps Satinsky (18 patients – 2ndgroup); bilateral overlay of turnstile harnesses on the base of the wide ligaments and the cervical-neck area, supplemented by a controlled balloon tamponade of the uterus (22 patients – 3rd d group). The operation was carried out under conditions of intraoperative reinfusion of autoerythrocytes on the apparatus “Cell-Saver 5”, donor FFP and erythrocyte component, tranexam preparations, rFVIIa (KoagilVII) were administered. In 80% of women, operations were performed under combined spinal-epidural anesthesia.Results:the lowest blood loss was detected in the 3rd group with compression complex hemostasis: 1286 ± 510 ml. Accordingly, the volumes of infusion and transfusion therapy were also the smallest in this group. The volume of reinfused autoerythrocytes ranged from 260 ml to 1420 ml and averaged 801,7 ± 414,18 ml with a hematocrit of 55-60%. Donor erythrocytes were transfused to only 27 patients in an average volume of 785,1 ± 134,2 ml. rFVIIa (Koagil) was administered to four patients: three from the first group and one from the second group: a significant decrease in the speed and volume of bleeding was noted, and he performed an organ-sparing operation. Hysterectomy was performed on five women (8,77%). In the postoperative period was carried out antianemic therapy. The hospital stay averaged 7,9 ± 1,8 days.Conclusion:The special role in the management and delivery of pregnant with placenta accreta plays the use of various PBM techniques , which include rational therapy of preoperative and postoperative anemia with modern iron preparations, rational surgical tactics, red blood cell autotransfusion, use of modern hemostatic agents and blood substitutes. A comprehensive multidisciplinary approach to this problem allows reducing blood loss, minimizing the volume of donor blood components and implementing organ-preserving tactics in a significant number of women.

Anesthetic management for Placenta Accreta

“…Родоразрешение у таких пациенток должно осу ществляться в медицинских учреждениях высокого уровня, с применением инновационных хирургиче ских и анестезиологических технологий и наличием достаточного запаса компонентов крови [11,19,21]. Помимо применения инновационных хирургических технологий, не менее важную роль играет и анестезио логический менеджмент.…”

“…При оперативном вмешательстве по поводу пред лежания и врастания плаценты ранее рекомендовалась общая многокомпонентная анестезия с ИВЛ; счита лось, что это позволяет обеспечить лучший контроль за повреждением, реанимацией и коагуляцией. Однако исследования последних лет показывают, что примене ние общей анестезии связано со значительно большей предполагаемой кровопотерей и более высокими тре бованиями для переливания крови, чем те операции, которые выполняются под нейроаксиальной анестезией [8,9,11,19,21,32], и только когда предполагается мас сивная кровопотеря при врастании плаценты, рекомен дована общая многокомпонентная анестезия с ИВЛ.…”

“…Одно из первых мест среди причин материнской смерт ности занимают акушерские кровотечения, среди ко торых плацентарные факторы -до 30 % прикрепление и предлежание плаценты -являются одной из основных причин массивных кровотечений [3,7,10,11,19,32].…”