losartan-potassium and Placenta-Previa

A review of the clinical decisions, diagnostic, and surgical methods in managing patients with placenta percreta was done by conducting a MEDLINE computerized search from January 1991 to January 1997 using the key words "placenta percreta," "placenta previa," "acute normovolemic hemodilution," and "erythropoietin use." Additional sources were identified through cross-referencing. We reviewed all published reports and articles regarding the clinical and surgical management of placenta percreta and nontraditional ways to treat or prevent anemia in these cases (including acute normovolemic hemodilution and erythropoietin use). The diagnosis of placenta percreta using different ultrasonographic criteria is reliable. Clinical and surgical methods of managing placenta previa with a high risk of percreta are all based on prevention of uncontrolled hemorrhage. Ninety percent of these patients will lose more than 3000 ml intraoperatively and will require blood transfusion. To avoid serious maternal morbidity secondary to hypovolemia, several options are available: erythropoietin use, acute normovolemic hemodilution, selective arterial embolization, prophylactic uterine, or hypogastric artery ligation. With the increasing incidence of placenta percreta, the clinician must use all available methods to accurately diagnose this condition. Adequate preparation and good surgical technique will help reduce maternal mortality and morbidity related to this condition.

Topics: Erythropoietin; Female; Hemodilution; Humans; Hysterectomy; Placenta Diseases; Placenta Previa; Postoperative Care; Pregnancy; Recombinant Proteins; Ultrasonography, Prenatal; Uterine Hemorrhage

Placenta percreta is increasing in incidence and is associated with the risk of life-threatening haemorrhage. Patients who do not accept blood products present a unique challenge to obstetrician-gynaecologists. In this case report, we present the case of a 42-year-old pregnant Jehovah's Witness with a complete placenta previa and confirmed percreta at 26 weeks' gestation. Due to her religious beliefs against the use of blood products, she was managed with a stepwise surgical approach which involved caesarean delivery with internal iliac (hypogastric) artery ligation, weekly methotrexate and delayed hysterectomy 6 weeks later. Non-traditional, alternative approaches to the management of abnormal placentation in patients declining blood products warrant exploration.

Topics: Adult; Blood Transfusion; Cesarean Section, Repeat; Erythropoietin; Female; Humans; Hysterectomy; Jehovah's Witnesses; Magnetic Resonance Imaging; Methotrexate; Placenta Accreta; Placenta Previa; Pregnancy; Treatment Refusal; Ultrasonography, Prenatal; Uterine Hemorrhage

Abnormal placentation can be associated with significant blood loss and massive blood transfusions. Caring for parturients with abnormal placentation who refuse blood transfusion is very challenging. We present a 35-year-old, gravida 3, para 1, Jehovah's Witness at 35 weeks of gestation with placenta percreta, who underwent cesarean delivery and delayed hysterectomy. A multidisciplinary team developed a plan, including the use of perioperative erythropoietin and IV iron dextran, intraoperative acute normovolemic hemodilution, cell salvage, tranexamic acid, and uterine artery embolization. This strategy was successful in avoiding the need for allogeneic transfusion and ensuring an uneventful recovery after both surgical procedures.

Topics: Adult; Bloodless Medical and Surgical Procedures; Combined Modality Therapy; Erythropoietin; Female; Hemodilution; Humans; Iron-Dextran Complex; Jehovah's Witnesses; Placenta Accreta; Placenta Previa; Pregnancy; Tranexamic Acid; Treatment Outcome; Uterine Artery Embolization

A massive obstetric hemorrhage resulting in an extremely low hematocrit (5.9%) required innovative intraoperative and postoperative management. We used a combination of rapid intraoperative volume replacement, aortic compression, chemical coma, high-dose erythropoietin, and enteral iron replacement to elevate the hematocrit in a patient refusing blood transfusions.

Topics: Adult; Blood Transfusion, Autologous; Deep Sedation; Erythropoietin; Female; Humans; Hysterectomy; Jehovah's Witnesses; Placenta Accreta; Placenta Previa; Pregnancy; Treatment Refusal

Hemorrhage is a serious threat with placenta accreta, often requiring aggressive operative intervention by hysterectomy and resuscitative measures with large-volume blood replacement to ensure survival. Refusal to accept transfusion makes management especially difficult.. We report a Jehovah's Witness patient who had 9 previous cesarean deliveries and presented with anemia and placenta previa percreta invading the bladder wall. Management objectives were to enhance the patient's status, using erythropoietin and autologous transfusion, and to minimize the chance of hemorrhage by prophylactic uterine artery embolization. The placenta was left in situ after the delivery with no untoward consequences. Methotrexate was held in readiness, but was not required as adjuvant therapy.. Effective care of such patients requires close collaborative team effort and advanced planning to ensure a good outcome.

Topics: Adult; Blood Transfusion; Combined Modality Therapy; Embolization, Therapeutic; Erythropoietin; Female; Follow-Up Studies; Humans; Jehovah's Witnesses; Placenta Previa; Pregnancy; Pregnancy Trimester, Second; Risk Assessment; Transplantation, Autologous; Treatment Outcome; Uterine Hemorrhage

Topics: Adult; Blood Transfusion, Autologous; Cesarean Section; Christianity; Erythropoietin; Female; Humans; Intraoperative Care; Placenta Previa; Pregnancy