Coagulopathy in surgical management of placenta accreta spectrum

Alireza A. Shamshirsaz, Karin A. Fox, Hadi Erfani, Steven L. Clark, Shiu Ki Hui, Amir A. Shamshirsaz, Atefeh Rezaei, Ahmed A. Nassr, Yasmin N. Lake, Jun Teruya, Michael A. Belfort

Research output: Contribution to journalArticlepeer-review

13 Scopus citations

Abstract

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/mm 3 , 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.

Original languageEnglish (US)
Pages (from-to)126-130
Number of pages5
JournalEuropean Journal of Obstetrics and Gynecology and Reproductive Biology
Volume237
DOIs
StatePublished - Jun 2019
Externally publishedYes

Keywords

  • Abnormal invasive placenta
  • Coagulopathy
  • Disseminated intravascular coagulation
  • Multidisciplinary approach
  • Placenta accreta spectrum

ASJC Scopus subject areas

  • Reproductive Medicine
  • Obstetrics and Gynecology

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