Placenta percreta is an obstetric complication, where the placenta invades through the myometrium into next variety meats, is frequently associated with dangerous torrential bleeding. The hemorrhage is normally controlled by medical intervention including Pitocin and prostaglandins ; or surgical agencies including ligation of uterine or internal iliac arterias, hysterectomy or intra-arterial embolisation ( ) . However, in terrible instances, it normally requires intensive resuscitation, blood constituents and curdling factors. Massive transfusion frequently leads to circulate intravascular coagulopathy ( DIC ) because of bleeding secondary to curdling and thrombocyte ingestion.

Our monolithic transfusion protocol presently relies on conventional curdling trial consequences before fixing blood constituents. This finally leads to major holds in administrating constituents which so, may non be relevant to the current clinical state of affairs. For the instance documented below, where monolithic bleeding was anticipated, we decided to utilize a preset blood merchandise disposal protocol in an attempt to extenuate and handle coagulopathy by early, equal curdling factor disposal, therefore taking the hold in telling, fixing and subsequent disposal of blood constituents.

However, in some instances, even equal replacing therapy fails to command dangerous shed blooding ensuing in exsanguination. Alternative haemostatic interventions, which are efficacious in such a scene, might be life-saving and cut down ruddy cell transfusion demands. Fibrinogen dressed ore ( Haemocomplettan® ) and activated recombinant factor VII ( rFVIIa, Novoseven® ) may be possible campaigners. The experience of utilizing factor I dressed ores and rFVIIa in OBs is really limited. However, other surgical fortes have successfully used both merchandises in both contraceptive and curative indicants ( Wissa 2009 ) . This study will besides analyze our experience of the usage of factor I dressed ore together with rFVIIa in an effort to command monolithic bleeding.

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Case 1

A 29-year-old parity one, with one old cesarean subdivision was scanned at 21 hebdomads ‘ gestation. The ultrasound scan revealed a low-lying placenta. Consecutive scans showed placenta previa with the anterior placenta covering the os, full thickness invasion of the myometrium and indenture of the vesica. She was otherwise good with no history of PV hemorrhage or abdominal hurting. At 33 hebdomads ‘ gestation she was admitted and cesarean subdivision planned for 3 hebdomads subsequently.

A lower transverse scratch through the old scratch was made in the womb to present the babe. Following bringing the hemorrhage from the placental bed was alert and heavy as efforts were made to take the placenta. A determination for a peripartum hysterectomy was agreed in position of the unmanageable bleeding and failure of other medical and surgical haemostatic techniques.

29 units of ruddy cells were transfused, together with 14 units of fresh frozen plasma, 4 units of pooled cryoprecipitate, and 6 units of thrombocytes. Haemostasis was finally achieved following the disposal of 3 doses of 8mg rFVIIa ( Novoseven ) and 6g of factor I dressed ore ( Haemocomplettan® , CSL Behring, Marburg, Germany ) . The patient spent 2 yearss in the intensive attention unit. The postoperative recovery was uneventful and the patient was discharged 9 yearss after bringing.

Consequences

Haemoglobin, thrombocyte count and prothrombin clip were monitored throughout the process ( figure 1 ) . rFVIIa was given at xxx and factor I dressed ore at xxx.

Discussion

Placenta percreta is defined as a morbidly adherent placenta ( accrete ) that penetrates through the uterine musculus into the vesica and/or other next variety meats ( Miller 1997 ) . The incidence of placenta accreta is 1 in 2,500 bringings. Placenta percreta occurs in 5-7 % of all unnatural placentations. Parallel with the dramatic and relentless rise in cesarean bringing rates, the incidence of placenta accreta is increasing ( Oyelese 2006 ) . However, limited information is available to steer optimum direction and, in peculiar, transfusion direction. The intent of this survey was to reexamine our experience with placenta percreta and measure the transfusion schemes employed.

Major obstetric bleeding can frequently take to consumptive coagulopathy, increased fibrinolysis, and impaired map of thrombocytes and curdling factors. Emerging pattern requires the early and aggressive usage of blood constituents. It was agreed pre-operatively that packed ruddy cells in a 2:1 ratio with plasma would be used since it has been associated with a decrease in mortality in the exsanguinating patient ( Kushuk 2008 ) . This ab initio worked good, nevertheless shed blooding continued in malice of optimum blood constituent replacing, hysterectomy and internal iliac arteria ligation. A determination was made to handle more sharply utilizing newer haemostatic agents, rFVIIa and factor I dressed ore. rFVIIa has been shown to supply effectual hemostasis in a broad scope of shed blooding conditions. It is frequently used as a last resort and is found that shed blooding lessenings in most instances taking to important decreases in ruddy cell transfusion demands.

The first dosage of rFVIIa given to the patient did non look to move sufficiently due to the loss of curdling factors and thrombocytes during sustained bleeding. The efficaciousness of rFVIIa is mostly dependent on the presence of high degrees of factor I. A sufficient haemostatic consequence was obtained with rFVIIa during the disposal of the 2nd dosage because both thrombocytes and cryoprecipitate were transfused instantly anterior to disposal. By the clip the 3rd dosage was given normal hemostasis was achieved, shed blooding was dramatically reduced and the surgery was completed. No farther blood constituents were required.

Prior to the 3rd dosage of rFVIIa, factor I dressed ore was administered. Haemocomplettan is a extremely purified, lyophilised, virally inactivated factor I dressed ore obtained from human plasma that can be quickly reconstituted without the demand for dissolving and crossmatching. Fibrinogen dressed ore was originally reserved for replacing therapy in inborn factor I lack, and in the UK, Haemocomplettan is merely approved for this indicant. However the function of factor I, a important haemostatic curdling factor in guaranting hemostasis during serious hemorrhage, has been a topic of increasing involvement.

The chief determination from this instance survey was that permutation therapy with factor I dressed ore was associated with a important decrease in blood loss, so much so that no farther blood constituents were used. There was besides a important betterment in curdling parametric quantities. No serious inauspicious events were recorded.

Fibrinogen constitutes an of import constituent of the haemostatic procedure, including its functions in formation of thrombocyte sums and coevals of a sufficiently stable fibrin web. Adequate sums of functional factor I are besides required to accomplish an optimum consequence of other haemostatic intercessions such as extract of antifibrinolytic drugs, rFVIIa and thrombocyte transfusions. During progressive blood loss, factor I appears to stand for the curdling factor foremost making a critical low threshold and notably hypofibrinogenaemia may emerge before the development of important thrombopenia. In add-on, haemodilution with colloid plasma expanders predisposes to development of a functional factor I lack. Hence, it seems sensible to foretell an overall good haemostatic consequence of factor I disposal as auxiliary intervention in monolithic hemorrhage patients. Serious hemorrhage in obstetric complications is frequently associated with hyperfibrinolysis ensuing in really low degrees of plasma factor I and high degrees of fibrin D-dimer that makes factor I permutation even more sensible in this cohort of patients.

In decision, the present instance suggests that permutation therapy with fibrinogen dressed ore may lend to cut down transfusion demands and decreased blood loss. Prospective clinical tests taking at measuring the haemostatic potency of factor I permutation therapy in massively bleeding patients are extremely desirable.