Original Article
The use of cell salvage in women undergoing cesarean hysterectomy for abnormal placentation

https://doi.org/10.1016/j.ijoa.2013.05.007Get rights and content

Abstract

Background

Although transfusion of autologous blood obtained from cell salvage has increased, its role in obstetric practice remains controversial. This case series reports the use of cell salvage in an attempt to avoid allogeneic transfusion in women undergoing cesarean hysterectomy for placenta accreta.

Methods

This prospective observational study, conducted in a large public maternity hospital, included 41 women with an antenatal diagnosis of placenta accreta, of whom 20 underwent cesarean hysterectomy and 15 received autologous blood after cell salvage. Intraoperative cell salvage was used for autologous blood transfusion, and salvaged blood was monitored for prewash and postfiltration squamous cells, fetal hemoglobin, and potassium concentration. Pre- and postoperative hemoglobin, platelet count and coagulation profile were compared.

Results

Twenty women underwent caesarean hysterectomy. Cell-salvaged blood was collected in 18 women and re infused in 15 women (83.3%). The mean volume of reinfused salvaged blood was 1476 ± 247 mL. Mean potassium concentrations (1.4 ± 1.2 versus 3.7 ± 0.42 mEq/L) and median squamous cell counts (0 [0–1] versus 8 [3–12]/high power field) were significantly lower postfiltration compared to prewash values. There were no instances of intraoperative or postoperative amniotic fluid embolism, hypotension, sepsis or coagulopathy. Of the 15 women who received autologous blood, 13 (86.7%) did not require allogeneic red blood cell transfusion.

Conclusions

Autologous transfusion of salvaged blood can be used to minimize allogeneic transfusion in women undergoing cesarean hysterectomy for placenta accreta.

Introduction

Cell salvage and autologous blood transfusion are used increasingly because of the reduced need for allogeneic blood transfusion and its associated risks of postoperative infection, acute lung injury, perioperative myocardial infarction, postoperative low cardiac output failure, and increased mortality.1 Cell salvage was first introduced in the 1970s, but was complicated by hemolysis, air embolism, and coagulopathy.2 The use of cell salvage in obstetrics may be limited partly because bleeding often occurs in the setting of vaginal delivery, when planning for cell salvage is difficult.3 Its popularity is increasing as some causes of bleeding are predictable, such as placenta accreta associated with a history of cesarean delivery and placenta previa. Here, the use of cell salvage may reduce the need for allogeneic transfusion. This case series evaluated transfusion of cell-salvaged blood in an effort to avoid allogeneic blood transfusion in women undergoing cesarean hysterectomy for placenta accreta.

Section snippets

Methods

This prospective observational study was conducted at the North West Armed Forces Maternity Hospital, Tabuk, Saudi Arabia from January 2011 to October 2012, after approval from the local hospital ethics and research committee. Participants were recruited from women with placenta accreta at 36−37 weeks of gestation who were scheduled for cesarean delivery with possible hysterectomy. Preoperative diagnosis of placenta accreta was based on findings of color Doppler ultrasound and magnetic resonance

Statistical analysis

Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) for Windows, version 15.0. Data are presented as mean ± standard deviation (SD) for numeric parametric data, median [range or interquartile range (IQR)] for numeric non-parametric data and number and proportion for categorical data. Variables were compared using Student t-test, Mann–Whitney U-test, Fisher’s exact and Chi. A P value <0.05 was assumed to be significant.

Results

Fifteen women were included in the analysis (Fig. 1). The mean age of participants was 37 ± 2.5 years, median [range] parity 5 [3–7], mean body weight 87 ± 11.1 kg, mean body mass index 33.3 ± 2.7 kg/m2, and median duration of hospital stay 5 [3–10] days. According to institutional protocol, all these women were admitted to the HDU after delivery.

Data on hemoglobin, platelet count, PT, PTT, and INR at the different time points are shown in Table 1. Potassium concentrations and squamous cell count were

Discussion

The use of cell salvage in obstetrics has been controversial due to the theoretical risk of AFE. Failure of the washing process to completely remove amniotic fluid components represents a potential source of emboli during reinfusion of salvaged RBCs.3 It is now widely accepted that the risk of AFE has been overestimated. The clinical manifestations of AFE are similar to those of anaphylactic and septic shock, but the component of the amniotic fluid responsible for the syndrome remains unclear.4

Disclosure

The authors received no external funding for this study and have no conflicts of interest to declare.

Acknowledgement

The authors would like to thank Mr. Thembelani Nyushman from the perfusion team in North West Armed Forces Hospitals, Tabuk, Saudi Arabia for his assistance in conducting this work.

References (30)

  • M.P. Rainaldi et al.

    Blood salvage during caesarean section

    Br J Anaesth

    (1998)
  • A. de Souza et al.

    Antenatal erythropoietin and intra-operative cell salvage in a Jehovah’s Witness with placenta praevia

    BJOG

    (2003)
  • S.J. Catling et al.

    Clinical experience with cell salvage in obstetrics: 4 cases from one UK centre

    Int J Obstet Anesth

    (2002)
  • J. Fong et al.

    An analysis of transfusion practice and the role of intraoperative red blood cell salvage during cesarean delivery

    Anesth Analg

    (2007)
  • S. Catling

    Intraoperative cell salvage in obstetrics

    Clin Risk

    (2008)
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