Antenatal erythropoietin and intra‐operative cell salvage in a Jehovah's Witness with placenta praevia

A 34 year old parous Jehovah’s Witness was booked at 13 weeks of gestation to her regional hospital. All antenatal investigations were normal, including her haemoglobin concentration (128 g/L). However, a mid-trimester ultrasound scan demonstrated an anterior low lying placenta completely covering the internal os. Her antenatal course was uneventful until 28 weeks of gestation when she had a small painless antepartum haemorrhage. She was haemodynamically stable, her uterus was lax and non-tender and her cervix long and closed on speculum examination. A cardiotocogram was reactive. Corticosteroids were administered to bring about fetal lung maturity and the woman was transferred to the Mercy Hospital for Women. Her haemoglobin concentration was 109 g/L, her Kleihauer test was negative and she had a normal coagulation profile but mild iron deficiency. An ultrasound scan showed normal fetal growth and wellbeing, but confirmed a major degree of placenta praevia, with the placenta positioned centrally over the internal os. The woman was admitted to hospital and advised regarding the risk of major obstetric haemorrhage and the need for caesarean section. Consistent with her religious beliefs, she refused to accept all blood products, but consented to crystalloid or non-human colloid solutions for resuscitation. She was administered iron supplements and remained in hospital. She continued to have small episodes of vaginal bleeding. At 29 weeks of gestation, her haemoglobin concentration was unchanged. She was asked to consider recombinant erythropoietin. After discussion with church leaders, she agreed to its administration as long as it was not suspended in human albumin. Erythropoietin was subsequently administered at a dose of 50 iu/kg twice weekly. Apart from mild flu-like symptoms, the woman had no ill effects. A parenteral iron infusion was administered at 30 weeks of gestation. Erythropoietin resulted in a rise in haemoglobin concentration from 109 g/L at 28 weeks of gestation to 133 g/L six weeks later. The woman was also asked to consider intra-operative cell salvage. She was reviewed by an anaesthetist and clinical perfusionist, and consented to a ‘cell saver’, provided that the blood remained in a continuous extracorporeal circuit, and that the circuit itself was primed with non-blood products. At 34 weeks of gestation, the woman experienced several episodes of antepartum haemorrhage, resulting in a semi-elective caesarean section under general anaesthesia. Arterial and central venous catheters were inserted. The cell salvage device was a Cobe autotransfusion system. Simultaneously, an extracorporeal circuit was set up with a Cobe roller pump, with tubing 28 ft long and 1/4 inches in diameter, giving a total capacity of 550 mL. All circuit components were heparin bonded (Carmeda) and the circuit was primed with Hartmann’s solution. After cannulation of the right internal jugular vein with a 7.5 French gauge sheath cannula, the primed circuit was connected and the pump was run at 50 mL/minute, simultaneously drawing off 1 mL/minute of acid citrate dextrose at the proximal takeoff point. The distal end of the circuit was connected to a blood collection bag, which in turn was connected to a 14-gauge cannula in the left cubital fossa. This resulted in a total extracorporeal volume of 1000 mL in a closed circuit, allowing a greater degree of haemodilution with about 3 L of crystalloid, and resulted in a pre-operative haemoglobin concentration of 105 g/L. All blood salvaged was collected into the autotransfusion system, where each bowl was washed free of amniotic fluid and debris with 2 L of normal saline, delivered to a re-infusion bag and immediately re-infused into the woman. About 350 mL of blood was re-infused. Suction of amniotic fluid and blood for delivery of the baby was separate and not connected to the cell saver, BJOG: an International Journal of Obstetrics and Gynaecology May 2003, Vol. 110, pp. 524–526