CASE SERIES
Non-invasive measurement of hemoglobin during cesarean hysterectomy: a case series

https://doi.org/10.1016/j.ijoa.2011.03.009Get rights and content

Abstract

Obstetric patients diagnosed with abnormal placentation (placenta accreta, increta or percreta) are at increased risk of major postpartum hemorrhage and cesarean hysterectomy. Obstetric anesthesiologists are primarily involved in intraoperative transfusion management in these cases. Hemoglobin assessment is invaluable for assisting transfusion decision-making during the acute period of obstetric hemorrhage. However, laboratory and point-of-care tests of hemoglobin concentration are time-dependent and intermittent, and do not provide a real-time assessment of change during the acute phase of blood loss. A new non-invasive hemoglobin monitor has been introduced recently, which provides real-time measurement of hemoglobin values (SpHb) using multi-wavelength pulse co-oximetry. We present a review of five patients with suspected abnormal placentation who received SpHb monitoring during cesarean hysterectomy at our institution. We discuss the potential clinical utility of non-invasive hemoglobin monitoring for pregnant patients at high risk of obstetric hemorrhage, and the potential role of SpHb in guiding transfusion therapy.

Introduction

Obstetric hemorrhage is a major complication for pregnant patients with abnormal placentation,1 and transfusion therapy is often an integral component in the management of severe obstetric hemorrhage. Although transfusion guidelines recommend red blood cell (RBC) transfusion for hemoglobin (Hb) values between 6 and 7 g/dL,2, 3, 4 there may be insufficient time to await the results of laboratory Hb concentrations before transfusion in the acutely bleeding and hemodynamically unstable patient.5 As a result, anesthesiologists often rely on clinical assessment and experience to judge whether surgical patients require transfusion during the intraoperative period.6

The use of real-time non-invasive Hb measurement may be valuable for assessing the development of acute anemia, and may also provide valuable information to aid transfusion decision-making during anticipated hemorrhage (e.g. suspected placenta accreta) or unanticipated hemorrhage (e.g. uterine atony). Recent technological advances in the field of multi-wavelength pulse oximetry have led to commercial release of new co-oximeter instruments (Masimo Corp., Irvine, CA, USA) that non-invasively estimate total Hb (SpHb).7

We present a review of five patients with suspected abnormal placentation who received SpHb monitoring during cesarean hysterectomy at our institution.

Section snippets

Case series

Five parturients who had preoperative diagnoses (by ultrasound or magnetic resonance imaging) of placenta accreta underwent cesarean hysterectomy at Lucile Packard Children’s Hospital (a tertiary care obstetric center) between June and August 2010. Written consent was obtained from each patient for publication of data presented in this case series.

SpHb monitoring was used for all cases using a Rainbow SET® Radical 7 Pulse CO-Oximeter (Masimo Corp., Irvine, CA). A pulse co-oximeter probe was

Discussion

Abnormal placentation has been identified as the most common factor associated with uncontrolled postpartum hemorrhage leading to emergency postpartum hysterectomy.8 Although patients with suspected placenta accreta are likely to undergo scheduled cesarean hysterectomy,9 the risks of major obstetric hemorrhage requiring transfusion therapy are high for these patients irrespective of the timing and urgency of delivery. Furthermore, the rising rates of cesarean delivery in the United States

Disclosure

Rainbow SET® Radical 7 Pulse CO-Oximeters and Trendcom™ software were provided by Masimo Corp., Irvine, CA, USA. Masimo Corp. had no input in the clinical application of the pulse co-oximeters for these cases, data collection, data analyses, or manuscript preparation.

This case series was funded internally by the Department of Anesthesia, Stanford University School of Medicine. A.J. Butwick has previously received funding towards research efforts from Masimo Corp. (Irvine, CA, USA).

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