Coagulopathy in surgical management of placenta accreta spectrum
Alireza A Shamshirsaz1, Karin A Fox1, Hadi Erfani1
1Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.
Insights
Coagulopathy in placenta accreta spectrum (PAS) surgery is linked to significant blood loss. Aggressive monitoring and treatment are advised when estimated blood loss exceeds 1500 mL to prevent severe complications.
Area of Science:
- Obstetrics and Gynecology
- Maternal-Fetal Medicine
- Hematology
Background:
- Placenta accreta spectrum (PAS) is associated with severe complications, including coagulopathy.
- Coagulopathy detection, prevention, and treatment are critical for patient survival in PAS cases.
Purpose of the Study:
- To investigate factors associated with coagulopathy during the management of PAS.
- To analyze the relationship between blood loss, transfusions, and coagulopathy in PAS patients.
Main Methods:
- Retrospective review of 123 patients with pathologically proven PAS undergoing surgery.
- Definition of coagulopathy: platelet count <100,000/mm³, INR >1.5, or fibrinogen <300 mg/dL.
- Comparison of outcomes between patients with and without coagulopathy; ROC curve analysis for discriminating variables.
Main Results:
- 30.1% of PAS patients developed coagulopathy.
- Coagulopathy was significantly associated with higher estimated blood loss (median 2100cc vs. 1400cc) and greater red blood cell (RBC) transfusion requirements.
- Estimated blood loss ≥ 1500 mL was the strongest predictor of coagulopathy.
Conclusions:
- Coagulopathy in PAS hysterectomy is strongly linked to blood loss and transfusion volume.
- Protocols for aggressive coagulopathy monitoring and treatment should be implemented when estimated blood loss surpasses 1500 mL.
- Early intervention is crucial to prevent massive hemorrhage in PAS patients.
Background:
One of the major complications of the placenta accreta spectrum (PAS) is the development of coagulopathy. The detection, prevention and prompt treatment of coagulopathy may be lifesaving.
Objective:
Our objective was to study selected factors associated with coagulopathy in the management of PAS by a well-established multidisciplinary team.
Study Design:
This is a retrospective review of all patients with pathologically proven PAS (including placenta accreta, increta or percreta) who underwent surgery by our multidisciplinary team between January 2011 and February 2017. Coagulopathy in this setting was defined as a platelet count of <100,000/mm3, international normalized ratio >1.5, and/or fibrinogen <300 mg/dL based on institutional protocols developed by our Division of Transfusion Medicine & Coagulation. The outcomes of those patients with and without coagulopathy were compared with appropriate adjustments. Receiver operating characteristics curves (ROCs) were constructed to assess the ability of select variables to discriminate between women with and without coagulopathy, and the area under the curves (AUCs) were calculated.
Results:
Of 123 singleton patients with PAS, 37 (30.1%; 95%CI 22.1-39.0) developed coagulopathy and 86 (69.9%; 95%CI 61.0-77.9) did not. Baseline patient demographic characteristics did not differ significantly between these groups. Estimated blood loss (median and Inter-quartile range) was 2100cc (1800, 400) and 1400 (1000, 2500) in the presence and absence of coagulopathy, respectively (P < 0.01). The overall number of units of red blood cells (RBC) transfused was greatest in the coagulopathy group [3 (2, 9) vs. 1 (0, 4); P < 0.01]. Univariate regression analysis confirmed the association between coagulopathy and (i) the number of units of RBC's transfused, and (ii) the estimated blood loss. ROC curves showed that an estimated blood loss ≥ 1500 mL had the best discriminating power. Depth and/or severity of placental invasion were not associated with coagulopathy in patients with PAS.
Conclusions:
Coagulopathy in patients with PAS undergoing hysterectomy is strongly associated with blood loss and replacement. It may be prudent to establish protocols that aggressively monitor for, and treat, coagulopathy when EBL exceeds 1500 mL in such surgeries, prior to the development of clinical coagulopathy which if uncorrected may lead to massive blood loss.
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