OC s ao aLu ; A MD

Aprewetiowithe

mosteStacauste

tiobesugshicoripof

53cesinthifut

themefoccrerecma

AnIncreon

ation of patients with suspected placentaaccreta because it can provide informa-

Dwbocendiaantivab65achcucrena

diaimMRcenun

ticilacleco

petarinvboplame

tieacimomatinidetidmaternal fetal medicine, general surgery,

FroDePaSuAnTexDivDepartment of Obstetrics and Gynecology (DrGei), Methodist Hospital, Houston, TX.

Reacc

The

Re

000 2doi

ofmetiver inintotra.

atio

Reviews www.AJOG.org

52tion on depth of invasion and may beparticularly useful in the diagnosis ofposteriorly located placentas.5MRI find-ings suggestive of placenta accreta in-clude lower uterine bulging, heteroge-neous placenta, and dark intraplacental

urology, vascular surgery, interventionalradiology, blood bank, and neonatology.Maternal morbidity is reduced in womenwithplacental accretismwhodeliver in ter-tiary care centers.9

Recent evidence questions the needfor serial fetal growth USs in the setting

ceived April 1, 2011; revised May 11, 2011;epted June 2, 2011.

authors report no conflict of interest.

prints not available from authors.

2-9378/$36.00011 Mosby, Inc. All rights reserved.BSTETRICS

utting-edge advancef obstetrical hemorrhis D. Pacheco, MD; George R. Saade, MD

27-year-old patient with a historyof 3 previous cesarean sections

sents for her fetal anatomy scan at 22eks. On ultrasound (US) examina-n, an anterior placenta previa is notedthmultiple lacunae and attenuation ofretroplacental space.

Hemorrhagic shock is the most com-n form of shock encountered in ob-tric practice. In 2005, in the Unitedtes, hemorrhage was the third leadingse of maternal death because of ob-tric factors.1

Historically, themost frequent indica-n for a peripartum hysterectomy hasen uterine atony. Recent literaturegests that this indication may befting, with abnormal placentation be-ming themost common reason for pe-artumhysterectomy.2,3 The incidenceplacenta accreta is estimated at 1 in

m the Division of Maternal-Fetal Medicine,partment of Obstetrics and Gynecology (Drscheco, Saade, and Hankins) and Division ofrgical Critical Care, Department ofesthesiology (Dr Pacheco), The University ofas Medical Branch, Galveston; and theision of Maternal-Fetal Medicine,

Hemorrhagic shock is the most common formInterventions that may limit transfusion requireuse of recombinant activated factor VII, selecventional radiology, and the use of the cell savethe mechanisms of acute coagulopathy callslines, leading to a tendency to apply massiveresuscitation despite lack of prospective data

Key words: hemorrhage, hemostatic resuscitlin: 10.1016/j.ajog.2011.06.009

6 American Journal of Obstetrics& Gynecology DEin the medical mangelfredo F. Gei, MD; Gary D. V. Hankins,

3 pregnancies.4 With the increasingarean section rate as well as a decreasevaginal birth after cesarean section,s number is likely to increase in theure.In this article, we will address some ofnew concepts in themedicalmanage-nt of obstetric hemorrhage. We willus on a theoretical case of placenta ac-ta; however, many of the therapeuticommendations apply to any cause ofssive obstetric bleeding.

tepartum carethe vast majority of cases, placenta ac-ta may be presumptively diagnosedthe basis of US alone. Sonographicdings suggestive of accreta include thesence of placental lacunae giving awiss cheese appearance, loss of thermal retroplacental hypoechoic space,d increased vascularity with uterinell vessel invasion as noted by the use oflor Doppler.In recent years, there has been in-ased interest in the use of magneticonance imaging (MRI) for the evalu-

shock encountered in obstetric practice.nts include normovolemic hemodilution,embolization of pelvic vessels by inter-traoperatively. Current understanding ofquestion the current transfusion guide-nsfusion protocols based on hemostatic

n, pregnancyear bands on T2-weighted images.6 of

CEMBER 2011gement

In a multicenter retrospective study,yer et al7 compared the accuracy ofthUS andMRI in the diagnosis of pla-tal accretism. The sensitivities for thegnosis of placenta accreta with USd MRI were 93% and 80%, respec-ely. Specificities (negative study in thesence of the condition) were 71% and%, respectively. Neither differenceieved statistical significance. The ac-racy for the diagnosis may be in-ased by complementing the abdomi-l US with transvaginal sonography.7

The use of paramagnetic contrast me-in MRI (gadolinium) likely would

prove the diagnostic performance ofI; however, the agent crosses the pla-ta, and the effects on the fetus areknown.At present, it appears that the diagnos-abilities of both US andMRI are sim-r. In cases where the diagnosis is un-ar, MRI and US may be used asmplementary tests.8

In patients with suspected placentarcreta, we recommend a complemen-y MRI to better define the extent ofasion to adjacent organs (eg, bladder,wel) so that appropriate preoperativenning may be undertaken (eg, place-nt of ureteral stents).Once the diagnosis is suspected, pa-nts should receive iron and/or folicd as needed to maintain normal he-globin values. Occasionally, patientsy require recombinant erythropoie-as adjuvant therapy. Patients shouldally be referred to a center with amul-isciplinary team available, includingfinpreSnoanwaco

creresplacenta previa without accretism, as

it dinesusom3-4deO

hetivdoprestodagloiroInfaclimprevenlecmanecoforallwhne

cenjecsuggesnioluncovancogesofthesusbedecenthahedewea cthetatvofewede

IntWonqushotompasudvascueveoubetalwigicneeraA

maroobeis ppablomotoragecoeit(3:stawisurtiecostohosomcocenciismalofor

terflareptiolimlatAnpla

tiolivor

octiometroI

sucrhacalervmoproagucel80ter

neglogivBetioofrenlismamtheredofpuAFfecblo

cenphhaindgercustelevStatheexacoO

subare(enist

www.AJOG.org Obstetrics Reviewsoes not increase the risk of intrauter-growth restriction.10 In the setting ofpected accretism, however, we rec-mend sonographic follow-up everyweeks to evaluate placental location,

pth of invasion, and fetal growth.ccasionally, patients at risk for severe

morrhagemay benefit from preopera-e autologous blood donation. Patientsnate units of their own blood duringgnancy, and such products will bered in the blood bank for use on they of surgery. Theoretically, the hemo-bin will recover (patients will be onn supplements) between donations.11

practice, however, anemia is a limitingtor, and patients usually donate only aited number of units throughoutgnancy. This technique will not pre-t the risks associated with blood col-tion, storage, and administration andy not be acceptable to Jehovahs Wit-sses.11 Overall, the technique is notst effective and is recommended onlypatients with rare blood types and/oroimmunization to rare antibodies forom immediate availability of alloge-ic blood products may be limited.11

Timing of delivery inwomenwith pla-tal accretism is a controversial sub-t. A recent decision analysis modelgested that delivery at 34 weeks oftation may be optimal and that am-centesis for determination of fetalg maturity does not improve out-mes and is not recommended.12 Ad-ced planning and interdisciplinary

llaboration are fundamental, and astational age increases, so does the riskemergent bleeding. We concur withse recommendations: patients withpected accretism should be deliveredtween 34 and 37 weeks. Recent evi-nce suggests that patients with pla-ta previa and a cervical length lessn 30 mm have a higher risk of acutemorrhage.13 In deciding whether toliver patients closer to 34 weeks vs 37eks, cliniciansmay consider obtainingervical length by transvaginal US. Ifcervix is less than 30mmand the ges-ional age more than 34 weeks, we fa-r delivery as opposed to waiting aw more weeks (no later than 37

eks) to prevent bleeding and emergentliveries. tiorapartum interventionshen massive blood loss is expected,e question that comes to mind fre-ently is which anesthetic techniqueuld be used. A complete sympathec-y (eg, spinal anesthesia) could im-

ir the patients ability to cope withden hypovolemia, as the capacity tooconstrict and increase systemic vas-lar resistances will be limited. How-r, regional anesthesia with a continu-s epidural technique is safe and mayappropriate for patients with placen-accretism.14,15 Emergent situations,

th active bleeding, particularly if sur-al access to the upper abdomen iseded, may be better served with gen-l anesthesia.cute normovolemic hemodilution (ANH)y be undertaken in the operativem before starting cases presumed toat high risk of bleeding. A central linelaced, and blood is collected from thetient into citrated blood bags from theod bank. Patients should have a he-globin level above 10 g/dL andnohis-y of cardiovascular disease. On aver-, 500-1000 mL whole blood may bellected and concurrently replacedwithher colloid (1:1 ratio) or crystalloid1 ratio) to maintain hemodynamicbility. During surgery, any blood lossll have a lower red cell content. Oncegical bleeding is controlled, the pa-nt is given back the blood previouslyllected. The collected blood may bered at room temperature for up to 6urs.11 This technique is acceptable toe Jehovahs Witnesses as long as the

llection bag remains connected to thetral venous line at all times (avoidrcuit disconnections). Overall, thereinimal evidence to suggest that ANHne has a significant effect on the needallogeneic blood.11

Preoperative bilateral common iliac ar-y balloon catheter placement with in-tion after delivery of the fetus has beenorted. Theoretically, balloon infla-n leads to bilateral vessel occlusion,iting blood loss. The efficacy of theter approach has been questioned.16,17

other option involves preoperativecement of femoral access by interven-

nal radiology with selective emboliza-

tivloc

DECEMBER 2011 Americn of uterine vessels at the time of de-ery using polyvinyl alcohol, gel foam,coils.18

In our institution, the use of balloonclusion catheters in the pelvic circula-n did not reduce transfusion require-nts compared with historic con-ls.19 We do not use this technique.ntraoperative cell salvage has beencessfully used in obstetric hemor-ge. Blood is aspirated from the surgi-field and filtered into a collecting res-oir. Filters in the device will removelecules like tissue factor, alpha feto-tein, platelets, and circulating proco-lants.20 After filtration, packed redls concentrated to a hematocrit of 55-% are obtained and can be readminis-ed to the patient.Postoperatively, patients who are Rhgative should receive anti-D immuno-bulin as soon as possible with a doseen according to results of a Kleihauertke stain to prevent alloimmuniza-n.11 A theoretical concernwith the usethe cell saver in obstetrics is the occur-ce of iatrogenic amniotic fluid embo-(AFE) because small amounts of

niotic fluid will bypass the filters ofdevice and be present in the packedcells. However, more than 400 casescell saver use in obstetrics have beenblished, and no evidence of iatrogenicE exists. This technique is safe and ef-tive in obstetric cases where massiveod loss is expected.21

Recombinant factor VIIa (rFVIIa) is li-sed for use in patients with hemo-ilia and inhibitory alloantibodies.22 Its increasingly been used for off-labelications including trauma, heart sur-y after cardiopulmonary bypass, vas-lar surgery, warfarin reversal, and ob-tric hemorrhage. More than 75% ofel I trauma centers in the Unitedtes recommend the use of rFVIIa inir massive transfusion protocols. Anmple of a massive transfusion proto-l is provided in Figure 1.nce endothelial injury has occurred,endothelial collagen and tissue factorexposed to the circulation. Factor VIIdogenously and exogenously admin-ered) will bind to tissue factor and ac-

ate the clotting cascade, leading toal fibrin deposition. Systemically, rF-

an Journal of Obstetrics& Gynecology 527

VIleatheshoabtioofartpavaningforonbeshousemihabri3calciltin

alshepa

he(egog[PtincupreingbavelplatiocosisdyM

actingcaudrofre

coluttinofmahemeporegmothrproanfacfibmifibobinecreaguresearearlysouH

cep1.

2.

otoCo nt a

SyPhBaTemINRPla

On of and atienot d Fcry er nex inapat uld ter

tel

nit

tor

Ro

Ro

Ro

If bFFP ssive

Pac

Reviews Obstetrics www.AJOG.org

52Ia will also bind activated platelets,ding to fibrin formation away fromsite of injury. Despite having a veryrt half-life (2-6 hours), concernsout thromboembolism as a complica-n are real. A recent systematic reviewthe literature showed a higher risk oferial thrombosis (not venous) amongtients who received rFVIIa as an adju-t therapy for life-threatening bleed-.23 rFVIIa is not a first-line treatmenthemorrhage and is effective only

ce major sources of bleeding haveen controlled. The use of this productuld be combined with best practiceof blood products.24 Before ad-

nistration, the patient should ideallyve a platelet count 50,000/mm3, fi-nogen 50-100 mg/dL, temperature2C, pH 7.2, and normal ionizedcium.24 These preconditions will fa-itate adequate functioning of the clot-g cascade.Seventeen randomized controlled tri-in which rFVIIa was used to control

FIGURE 1Example of a massive transfusion prnsider activation of a MT protocol when patie

stolic blood pressure < 90 mmHg < 7.1se deficit > 6 meq/L

perature below 34C > 2.0telet count < 50,000/mm

ce activated, the blood bank will send 6 units 10 units of cryoprecipitate. After this, if the p being inactivated), 6 more units of PRBC anoprecipitate. The latter product is given in ordt step of the protocol is to administer recombients hemorrhage stops, the blood bank shominated.

PRBC FFP Pla

6 units 6 units 6 u

6 units 6 units

Recombinant activated Fac

und 1

und 2

und 3

leeding persists, the sequence is started again., fresh frozen plasma; INR, international normalized ratio; MT, ma

heco. Medical management of obstetric hemorrhage. Am J Omorrhage in different subgroups oftients have been published. Four stud- pre

8 American Journal of Obstetrics& Gynecology DEfound a reduction in transfusion re-irements or blood loss, but none re-rted a survival benefit.25 Overall, itpears that rFVIIa is effective in limit-the amount of blood products trans-ed, but data on survival benefit areking.The obstetric literature has numerouse reports and case series involving theof rFVIIa. Publication bias is a major

ncern, and we are not aware of anyblished randomized trials involvingIIa in obstetric practice. The optimal

se is still unknown. Many reports instetric hemorrhage have used a dose ofmg/kg. If used in obstetric cases, weommend deep venous thrombosisphylaxis once the bleeding risk is

nsidered to be low.

nsfusion therapyassically, hemorrhage resuscitations been centered around administra-n of crystalloids and packed red bloodls (PRBC). Use of other blood prod-ts like fresh frozen plasma (FFP), cryo-

colctively bleeding and any of the following:

PRBC, 6 units of FFP, 6 units of platelets, nt remains bleeding (the protocol has

FP will be prepared along with 20 units of to elevate the fibrinogen level since the nt activated factor VII. At any point, if the be notified so that the protocol can be

ets Cryoprecipitate

s 10 units

20 units

VII (40 micrograms/kg)

transfusion; PRBC, packed red blood cells.

Gynecol 2011.cipitates, and platelets is indicated if

CEMBER 2011matologic parameters are abnormal, platelet count50,000/mm3, fibrin-en 100 mg/dL, prothrombin timeT], or activated partial thromboplas-time [aPTT]1.5 normal). Theserrent transfusion guidelines fail tovent coagulopathy in massive bleed-s.26 Patients with crystalloid/PRBC-sed resuscitation will frequently de-op dilution of clotting factors andtelets, leading to the so called dilu-nal coagulopathy. The latter may bemplicated by hypothermia and acido-, both of which lead to coagulationsfunction.assive crystalloid resuscitation may

ually worsen bleeding before achiev-surgical control of hemorrhage be-se of increases in intravascular hy-static pressures and dislodgement ofsh clots at sites of endothelial injury.27

Recent evidence has shown that earlyagulopathymay occur before hemodi-ion and before consumption of clot-g factors takes place. This mechanismearly coagulopathy has been studiedinly in trauma; however, obstetricmorrhage may share some of thechanisms involved.27 Early tissue hy-perfusion leads to endothelial up-ulation of the receptor thrombo-dulin. This receptor interacts withombin, leading to activation of thetein C pathway. Protein C is a naturalticoagulant that irreversibly inhibitstors Va and VIIIa and also enhancesrinolysis through inhibition of plas-nogen activator inhibitor 1.28 Increasedrinolytic activity has been described instetric hemorrhage secondary to uter-atony, placental abruption, and ac-tism.27 These newmechanisms of co-lopathy have challenged the currentuscitation guidelines, suggesting thatly clotting factor replacement andly identification of excessive fibrino-is may be associated with improvedtcomes.emostatic resuscitation is a new con-t that involves 3 main aspects:Limiting early aggressive crystalloiduse and considering permissive hy-potension.Early administration of FFP andiesqupoapingfuslac

casusecopurFVdoob90recproco

TraClhatioceluc

bstetplatelets (with concomitant packed

3.A

avoearcrevotrosiotwlimhytiehoanpreE

letearrosdetiohigicanothetheuntothabesicwhplaratnudreRBcluratreqFFranUntraofrFVtocste

blocidinjim

sugthaplathublo

HeCoantiopreanan(TmanebeplastistritastrtatdeTEtimityforlatvelcreObcansisidemamalikcapWthe

PoPahedetiodesidlaxcolax

ten

momoswdrocryleawiComadueunafacpretheselheanAnsynpominocretoCephmohy

A cclofunfacis trelaprobrinrapappRepof N

PacAm

www.AJOG.org Obstetrics Reviewsred blood cells), achieving a ratio of1:1:1 without waiting for coagulationlaboratory tests.Early use of rFVIIa.ggressive crystalloid resuscitation isided to prevent hemodilution andly clot dislodgement secondary to in-ases in blood pressure as a result oflume expansion. Before surgical con-l of hemorrhage, permissive hypoten-n with systolic blood pressures be-een 80-100 mmHgmay be optimal toit ongoing blood loss.27 Permissivepotension may be considered in pa-nts with postpartum hemorrhage;wever, no data is available during thetenatal period, as uterine perfusionssure may be compromised.arly administration of FFP and plate-

swithPRBC in a ratio of 1:1:1 preventsly development of coagulopathy. Ret-pectivemilitary and civilian data havemonstrated absolute mortality reduc-ns between 15-62% with the use ofher ratios of FFP:PRBC.29,30 A signif-nt limitation of the available, mostlynrandomized, studies on this topic ispresence of survival bias. On average,median time to obtaining the first

it of PRBC is 18 minutes, as opposedmore than 1 hour for FFP (needs to bewed).31 Sicker patients will likely diefore availability of FFP, whereas lessk patients will survive to the momenten FFP is available. The latter may ex-in why patients with high FFP:PRBCios had better survival. A limitedmber of studies have specifically ad-ssed the survivor bias in high FFP:C studies.When early deaths were ex-ded, no survival benefit for higherios was noted.32 Prospective trials areuired to validate the benefit of earlyP administration. Despite the lack ofdomized trials, many centers in theited States have adopted massivensfusion protocols involving the usehigh FFP:PRBC ratios and early use ofIIa.33 Thesemassive transfusion pro-ols are frequently used inmassive ob-tric hemorrhage.Administration of large amounts ofod products could lead to a higher in-ence of transfusion-related acute lung

ury (TRALI) and transfusion-relatedmunomodulation (TRIM).34 Others

tiocligest the opposite, with the rationalet early administration of FFP andtelets achieves hemostasis earlier,s decreasing the total number ofod products given.26

mostasis monitoringnventional plasma-based coagulationalyses like the PT, aPTT, and interna-nal normalized ratio (INR) are poordictors for transfusion requirementsd do not identify specific coagulationomalies.35 The thromboelastographEG) is an easy test that provides infor-tion regarding the specific compo-nt of the coagulation process that mayaffected. A small amount of blood isced into a cuvette, and the blood isrred with an agitator connected to aain gauge. As themovement of the ag-tor is impeded by the forming clot, theain gauge depicts a graphic represen-ion of the strength of the clot. Figure 2picts the main components of theG. Both the reaction time/clottinge and the alpha angle reflect the activ-of clotting factors. Once the clot ismed, the maximum amplitude corre-es with platelet function. Lastly, theocity at which the amplitude de-ases correlateswithfibrinolytic activity.stetric hemorrhage often has a signifi-t component of enhanced fibrinoly-.36 Conventional clotting tests fail tontify such anomaly, whereas the TEGy easily detect it, leading to a change innagementwhere antifibrinolytic agentse tranhexamic acid or epsilon amino-roic acid should be administered.here available,we recommend theuseofTEG to guide transfusion therapy.

stpartum considerationstients who have had massive obstetricmorrhage are frequently at high risk ofveloping thromboembolic complica-ns after delivery. Immediately afterlivery, if the bleeding risk is still con-ered elevated, mechanical prophy-is devices should be used. As soon asnsidered safe, pharmacologic prophy-is should be instituted.Not infrequently, oliguria and hypo-sion persist after massive resuscita-n. The typical approach to the latter

nical situation is administration of

tilaair

DECEMBER 2011 Americre intravenous fluids. Although inst cases fluid therapy may be the an-er, abdominal compartment syn-me must always be considered. Bothstalloid and colloid administrationd to third spacing of fluid (crystalloidll third space earlier than colloid).nsequently, bowel edema and ascitisy ensue. Extensive surgical proce-res are commonly associated with il-s, which may also favor intraabdomi-l hypertension. Put together, all thesetors may increase the intraabdominalssure to a pointwhere compressionofabdominal and retroperitoneal ves-

s will compromise preload to theart, leading to a drop in cardiac outputd, consequently, in blood pressure.other important component of thisdrome is oliguria, as the kidney isorly perfused secondarily to compro-sed cardiac output and the kidney ve-us system is also compressed by in-ased extravascular pressure, leadinga decrease in the gradient of perfusion.phalad displacement of the dia-ragm leads to bibasal atelectasies, withre right-to-left shunt and consequentpoxemia. Patients onmechanical ven-tors will display sudden increases in

FIGURE 2Thromboelastogram

AC

D

B

orresponds to the reaction time. B indicatestting time. A, B, and the angle reflect thection of clotting factors. In cases of clottingtor deficiency, both times will be prolonged. Che maximum amplitude of the clot, and it cor-tes with platelet function. The amplitude isportional to platelet function. D indicates fi-olysis. Cases of hyperfibrinolysis will show aid resolution of the clot, giving a tear dropearance.

rinted with permission from Obstetrics and Gynecology Clinicsorth America.40

heco. Medical management of obstetric hemorrhage.J Obstet Gynecol 2011.way pressures. Central vascular pres-

an Journal of Obstetrics& Gynecology 529

DVT

Pac

Reviews Obstetrics www.AJOG.org

53FIGURE 3Key aspects involved in the medical management of a patient at risk of severe obstetric hemorrhage, deep venous thrombosis; EPO, erythropoietin; Fe, iron; MRI, magnetic resonance imaging; TEG, thromboelastograph.

heco. Medical management of obstetric hemorrhage. Am J Obstet Gynecol 2011.

0 American Journal of Obstetrics& Gynecology DECEMBER 2011

surmoa pelerisme

thiofbloonansusobabshothetennamaHgasFindroan

ssuknwome5.2cautiecesmm

pasiomaoranficloiovgesagehe

vopa

SuObcoancre

thefrecasvenqumoemvenceltectiocenagerenofthevobaspeeffishosio

REF1. KDe2002. KEmspeGy3. StomcidGy4. WmaOb5. Bcenfind6. TFKuat64:7. Dnatphysou8. BCocin9. EMamaparnec10.JP

11.obest12.ofwitcol13.dergrain pnec14.eanstuaes15.et ahigpraInt16.accandMa17.I, Cwitces20018.E,ofges20119.tipiesAm20.tra21.Boean22.Retremo20023.Sado36324.ageEu25.MaAc26.Nefroque20027.

www.AJOG.org Obstetrics Reviewses (central venous pressures or pul-nary pressures recorded by means ofulmonary artery catheter) will also bevated as the intrathoracic pressurees secondarily to the upward displace-nt of the diaphragm.Obstetricians need to be familiar withs complication, as the administrationmore fluid in an attempt to increaseod pressure and urine output willly worsen intraabdominal pressuresd hemodynamics. If the condition ispected, a bladder pressure should betained at the bedside as a surrogate fordominal pressure.37 Bladder pressureuld be measured with the patient insupine position and the bladder dis-ded with 25 mL saline after the uri-ry catheter has been clamped.37 Nor-l abdominal pressures are 0-10 mm. Abdominal hypertension is definedan intracavitary pressure12mmHg.ally, abdominal compartment syn-me includes a pressure 20 mm Hgd at least 1 organ compromised.37

Normal values of intraabdominal pre-re in the postpartum period are notown. A recent publication involvingmen after a cesarean section foundan intraabdominal pressures of 6.4 mm Hg. Interestingly, and likely be-se of higher risk of third spacing, pa-nts with preeclampsia who underwent aareansectionhadmeanvaluesof119Hg.38

Once the diagnosis is established,mosttients will require surgical decompres-n, and the open abdomen may benagedwith a vacuum-assisted closurea Bogota bag or silo.37 Enteral feedingd limitation of fluid therapy are bene-ial. If fluids are required, the use of col-ds (eg, albumin) is recommendeder crystalloids. Limited evidence sug-ts that temporal use of paralyticnts while the abdomen is open maylp achieve primary fascial closure.39

Figure 3 summarizes the key aspects in-lved in the medical management of therturient at risk of massive hemorrhage.

mmarystetric hemorrhage is one of the mostmmon causes of maternal morbidityd mortality worldwide. Placental ac-

tism, just like the patient described in

gro330vignette, is becoming increasinglyquent and is responsible for mostes of peripartumhysterectomy. Inter-tions that may limit transfusion re-irements include normovolemic he-dilution, use of rFVIIa, selectivebolization of pelvic vessels by inter-tional radiology, and the use of thel saver intraoperatively. The use ofhniques like hypotensive resuscita-n and the TEG should be limited toters with vast experience in the man-ment of these complex patients. Cur-t understanding of the mechanismsacute coagulopathy calls into questioncurrent transfusion guidelines in fa-

r of massive transfusion protocolssed on hemostatic resuscitation. Pro-ctive trials are required to validate thecacy of this approach. Obstetriciansuld be familiar with current transfu-n protocols. f

ERENCESung HC, Hoyert DL, Xu JQ, Murphy SL.

aths: final data for 2005. Natl Vital Stat Rep8;56:1-120.wee A, Bots ML, Visser GH, Bruinse HW.ergency peripartum hysterectomy: a pro-ctive study in The Netherlands. Eur J Obstetnecol Reprod Biol 2006;124:187-92.mith J, Mousa HA. Peripartum hysterec-y for primary postpartum haemorrhage: in-ence and maternal morbidity. J Obstetnaecol 2007;27:44-7.u S, Kocherginsky M, Hibbard JU. Abnor-

l placentation: twenty-year analysis. Am Jstet Gynecol 2005;192:1458-61.aughman WC, Corteville JE, Shah RR. Pla-ta accreta: spectrum of US andMR imagingings. Radiographics 2008;28:1905-16.eo TH, Law YM, Tay KH, Tan BS, Cheah. Use of magnetic resonance imaging in eval-ion of placental invasion. Clin Radiol 2009;511-6.wyer BK, Belogolovkin V, Tran L, et al. Pre-al diagnosis of placenta accreta: sonogra-or magnetic resonance imaging? J Ultra-nd Med 2008;27:1275-81.elfort MA. Placenta accreta. Publications

mmittee, Society for Maternal-Fetal Medi-e. Am J Obstet Gynecol 2010;203:430-9.ller AG, Bennett MA, Sharshiner M, et al.ternal morbidity in cases of placenta accretanaged by a multidisciplinary care team com-ed with standard obstetric care. Obstet Gy-ol 2011;117:331-7.Harper LM,OdiboMO,MaconesGA, Crane

, Cahill AG. Effect of placenta previa on fetal

wth. Am J Obstet Gynecol 2010;203:.e1-5.

age201

DECEMBER 2011 AmericCatling S. Blood conservation techniques instetrics: a UK perspective. Inter J Obstet An-hesia 2007;16:241-9.Robinson BK, Grobman WA. Effectivenesstiming strategies for delivery of individualsh placenta previa and accreta. Obstet Gyne-2010;116:835-42.Stafford IA, Dashe JS, Shivvers SA, Alexan-JM, McIntire DD, Leveno KJ. Ultrasono-

phic cervical length and risk of hemorrhageregnancies with placenta previa. Obstet Gy-ol 2010;116:595-600.Parekh N, Husaini SW, Russell IF. Caesar-section for placenta previa: a retrospective

dy of anaesthetic management. Br J An-th 2000;84:725-30.Ioscovich A, Mirochnitchenko E, Halpern S,l. Perioperative anaesthetic management ofh order repeat caesarean section: audit ofctice in a university affiliated medical center.J Obstet Anesth 2009;18:314-9.Levine AB, Kuhlman K, Bonn J. Placentareta: a comparison of cases managed withwithout pelvic artery balloon catheters. J

tern Fetal Med 1999;8:173-6.Mok M, Heidemann B, Dundas K, Gillespielark V. Interventional radiology in womenh suspected placenta accreta undergoingarean section. Int J Obstet Anesthesia8;17:255-61.Angstmann T, Gard G, Harrington T, Ward

Thomson A, Giles W. Surgical managementplacenta accreta: a cohort series and sug-ted approach. Am J Obstet Gynecol0;202:38.e1-9.Zacharias N, Gei AF, Suarez V, et al. Ballooncatheter occlusion of the hypogastric arter-for the management of placenta accreta.J Obstet Gynecol 2003;189:S128.Tawes RL Jr. Clinical applications of auto-

nsfusion. Semin Vas Surg 1994;7:89-90.Rainaldi MP, Tazzari PL, Seagliarini G,rghi B, Conte P. Blood salvage during cesar-section. Br J Anaesth 1998;80:196-8.Stanworth SJ, Birchall J, Doree CJ, HydeC.combinant factor VIIa for the prevention andatment of bleeding in patients without hae-philia. Cochrane Database Syst Rev7;18:CD005011.Levi M, Levy JH, Andersen HF, Truloff D.

fety of recombinant activated factor VII in ran-mized clinical trials. N Engl J Med 2010;:1791-9.Spahn DR, Cerny V, Coats TJ, et al. Man-ment of bleeding following major trauma: aropean guideline. Crit Care 2007;11:R17.Johansson PI, Ostrowski SR, Secher NH.nagement of major blood loss: an update.ta Anaesthesiol Scand 2010;54:1039-49.Nascimento B, Callum J, Rubenfeld G,to JB, Lin Y, Rizoli S. Clinical review: freshzen plasma in massive bleedings-morestions than answers. Crit Care 2010;14:2.Ickx BE. Fluid and blood transfusion man-

ment in obstetrics. Eur J Anaesthesiol0;27:1031-5.

an Journal of Obstetrics& Gynecology 531

28. Brohi K, Cohen MJ, Davenport RA. Acutecoagulopathy of trauma: mechanism, identifi-cation, and effect. Curr Opin Crit Care 2007;13:680-5.29. Cotton BA, Gunter OL, Isbell J, et al.Damage control hematology: the impact of atrauma exsanguination protocol on survival andblood product utilization. J Trauma 2008;64:1177-82.30. Wafaisade A, Maegele M, Lefering R, et al.High plasma to red blood cell ratios are associ-atedwith lowermortality rates in patients receiv-ing multiple transfusion (4 red blood cell units10) during acute trauma resuscitation.J Trauma 2011;70:81-9.31. Snyder CW, Weinberg JA, McGwin G, et al.The relationship of blood product ratio to mor-tality: survival benefit or survival bias? J Trauma2009;66:358-62.

32. Scalea TM, Bochicchio KM, Lumpkins K, etal. Early aggressive use of fresh frozen plasmadoes not improve outcome in critically injuredtrauma patients. Ann Surg 2008;248:578-84.33. Rajasekhar A, Gowing R, Zarychanski R, etal. Survival of trauma patients after massive redblood cell transfusion using a high or low redblood cell to plasma transfusion ratio. Crit CareMed 2011;39:1507-13.34. Gonzalez EA, Moore FA, Halcomb JB, et al.Fresh frozen plasma should be given earlier topatients requiring massive transfusion. J Trauma2007;62:112-9.35. Reikvam H, Steien E, Hauge B, et al.Thromboelastography. Transfus Apher Sci2009;40:119-23.36. Brigitte EI. Fluid and blood transfusionman-agement in obstetrics. Eur J Anaesthesiol2010;27:1031-5.

37. Cheatham ML. Abdominal compartmentsyndrome. Curr Opin Crit Care 2009;15:154-62.38. Abdel-Razeq SS, Campbell K, Funai EF,Kaplan LJ, Bahtiyar MO. Normative postpartumintraabdominal pressure: potential implicationsin the diagnosis of abdominal compartmentsyndrome. Am J Obstet Gynecol 2010;203:149.e1-4.39. Abouassaly CT, Dutton WD, Zaydfudim V,et al. Post operative neuromuscular blocker useis associated with higher primary fascial closurerates after damage control laparotomy.J Trauma 2010;69:557-61.40. Pacheco LD, Gei AF. Controversies in themanagement of placenta accreta. Obstet Gy-necol Clin North Am 2011 [in press].

Reviews Obstetrics www.AJOG.org

532 American Journal of Obstetrics& Gynecology DECEMBER 2011

Cutting-edge advances in the medical management of obstetrical hemorrhageAntepartum careIntrapartum interventionsTransfusion therapyHemostasis monitoringPostpartum considerations

SummaryReferences