Presurgical preparation: blood supplies key to placenta percreta surgery.(Obstetrics)

MAUI, HAWAII -- Prepare for patient blood loss before you start surgery for placenta percreta, Dr. Michael A. Belfort said.

Patients lose an average of 3,000-5,000 cc of blood in these surgeries, and 90% of all patients with accreta will need a transfusion. Ensure that adequate stores of blood will be available, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Units of unusual blood types can be hard to get at many community hospitals, said Dr. Belfort, professor of ob.gyn. at the University of Utah. Salt Lake City.

He recommends considering use of erythropoietin therapy in patients with known placenta accreta who are anemic, possibly preceded by a total-dose infusion of iron dextran to ensure adequate iron levels before starting erythropoietin.

He also keeps recombinant factor VIIa nearby when performing these surgeries or any surgery that risks massive hemorrhage. "I'd advise every hospital that does surgery with the potential for massive blood loss to have this on hand," Dr. Belfort said at the meeting, sponsored by Boston University and the Center for Human Genetics.

NovoSeven Coagulation Factor VIIa (Recombinant) was approved in 1999 to treat bleeding episodes in hemophilia A or B patients with clotting inhibitors to Factor VIII or Factor IX. Off-label use of NovoSeven is a reasonable last-ditch effort in patients with massive hemorrhage, because these patients "will die otherwise," he said.

At least two cases have been reported in which NovoSeven was used off label in ob.gyn. patients with life-threatening bleeding. It controlled bleeding within 10 minutes in a patient with postpartum hemorrhage whose condition did not resolve with uterotonic drugs, suturing, ligation of internal iliac arteries, subtotal hysterectomy, pelvic packing, and blood transfusion (Obstet. Gynecol. 101[6]:1174-76, 2003).