Two lives, one REBOA: Hemorrhage control for urgent cesarean hysterectomy in a Jehovah’s Witness with placenta percreta

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A 39-year-old G3P2002 Jehovah’s Witness with two prior cesarean deliveries and scant prenatal care presented with preterm premature rupture of membranes at 24 weeks’ gestation. Ultrasound demonstrated complete anterior placenta previa and placenta percreta, with bladder invasion on magnetic resonance imaging. She had iron-deficient anemia with a hemoglobin of 9.8 g/dL, which precluded acute normovolemic hemodilution. The patient was counseled regarding the high risk of morbidity and mortality associated with continuing her pregnancy. Maternal mortality for the planned procedure was quoted in excess of 80%, with a risk of major morbidity near 100%. Drawing on the literature, risk of maternal mortality due to obstetric hemorrhage was quoted as 130 times higher than it would be if she accepted blood. She declined gravid hysterectomy in favor of cesarean hysterectomy and continued to decline all blood products except cryoprecipitate and albumin.

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