sulprostone and Placenta-Accreta

Major obstetric hemorrhage is a challenge for anesthesiologists because it remains responsible for over 10% of maternal deaths in high-income countries. A standardized multidisciplinary management, described in locally validated protocols and based on international guidelines is mandatory to prevent these deaths. The first difficulty relies on the systematic underestimation of the bleeding. Collection bags must be used to facilitate the diagnosis and therefore rapid management. The etiologies in antenatal or postpartum must be well-known in order to be treated adequately. A rapid recourse to prostaglandins (sulprostone in France) may reverse uterine atony. Invasive approach with surgery or radiology should be promptly implemented (uterine artery or internal iliac artery ligations±uterus plication) and hysterectomy should then be timely considered. Simultaneously, early and aggressive resuscitation with large-bore venous accesses should be implemented for rapid and massive transfusion (4:4:1 RBC:FFP:platelets ratio), along with an early use of fibrinogen concentrates and tranexamic acid. This transfusion strategy may be then guided by thromboelastography or thromboelastometry and bedside hemoglobin measurements. Activated factor VII remains indicated only before or after hysterectomy in case of uncontrolled bleeding. Management of placentation abnormalities (placenta previa, accreta, increta, percreta) must be well mastered as these etiologies may generate cataclysmic hemorrhages that can be and have to be anticipated.

Topics: Blood Component Transfusion; Combined Modality Therapy; Dinoprostone; Factor VIIa; Female; Fibrinogen; Humans; Hysterectomy; Iliac Artery; Ligation; Maternal Mortality; Operative Blood Salvage; Placenta Accreta; Placenta Previa; Postpartum Hemorrhage; Pregnancy; Pregnancy Complications; Recombinant Proteins; Tranexamic Acid; Uterine Artery; Uterine Artery Embolization; Uterine Hemorrhage; Uterine Inertia

To compare the impact of conservative and radical strategies for placenta accreta on maternal morbidity and mortality.. We retrospectively reviewed the medical records of all patients diagnosed with placenta accreta admitted to our tertiary center from January 1993 through October 2005. Two consecutive periods, A and B, were compared: during period A (january 1993 to June 1997), our written protocol called for the systematic manual removal of the placenta, to leave the uterine cavity empty. In period B (July 1997 to October 2005), we changed our policy and attempted to treat patients with a placenta accreta conservatively. The following outcomes over the two periods were compared: need for blood product transfusion, hysterectomy, intensive care admission, duration of stay in intensive care unit, sepsis and disseminated intravascular coagulation.. Fifty-one cases of placenta accreta were observed among 40281 deliveries (1.3/1000). Period B saw a reduction in the hysterectomy rate (11/13 versus 10/38; P < 0.01), the mean red blood cells transfused (3230+/-2170 versus 1081+/-1370 ml; P < 0.01) and disseminated intravascular coagulation (5/13 versus 1/38; P < 0.01) compared with period A. Seven cases of maternal infection were recorded during period B and none during period A (p = 0.22).. Conservative management of placenta accreta appears to be a safe alternative to radical management.

Topics: Abortifacient Agents, Nonsteroidal; Adult; Blood Transfusion; Clinical Protocols; Dinoprostone; Disseminated Intravascular Coagulation; Embolization, Therapeutic; Female; Humans; Hysterectomy; Ligation; Placenta Accreta; Pregnancy; Retrospective Studies