Parallel transverse uterine incisions combined with cell salvage minimized bleeding in a patient with pernicious placenta previa and an unexplained decrease in hemoglobin after transfusion of allogeneic red blood cells

Rationale: The incidence of pernicious placenta previa (PPP) and placenta accreta (PA) is increasing in China. Excessive blood loss in these women is an important cause of maternal death and emergency hysterectomy. Performing a traditional cesarean section (CS) in women with PPP is stressful for obstetricians because avoiding cutting the placenta is difficult. As a result, sudden life-threatening bleeding may be encountered. Therefore, there is an urgent need to establish a novel operative method for PPP and PA that is safe for both the mother and neonate, and less stressful for the surgeon. Patient concerns: We report an extremely rare case of PPP and PA complicated with anemia and an unexplained decrease in the hemoglobin (Hb) levels after transfusion of 3 units of allogeneic red blood cells. Diagnoses: The patient was diagnosed with unexplained anemia, and hemolysis resulting from donor red blood cell transfusion was suspected preoperatively. Interventions: To minimize blood loss for safety, a new operative technique, parallel transverse uterine incisions (PTUI) in CS (PTUI CS), was used under general anesthesia in this case. Inhaled volatile sevoflurane was used for uterine relaxation during PTUI. Cell salvage was also used. Outcomes: PTUI CS combined with cell salvage effectively reduced bleeding and preserved the uterus in our patient. Sevoflurane was effective for uterine relaxation during PTUI CS. Lessons: If PPP and PA are suspected, placental magnetic resonance imaging is recommended for definitively determining whether a transverse fundal incision can be made. If feasible, we strongly recommend that PTUI CS combined with cell salvage are used to minimize bleeding for high-risk patients with PPP and PA complicated with anemia and an unexplained decrease in Hb levels after transfusion of 3 units of allogeneic red blood cells. Anesthesiologists should be vigilant to maintain uterine relaxation from the time of delivery of the neonate to a second transverse incision in the lower segment of the uterus. This is a key element of successful PTUI CS. Additionally, the use of intraoperative cell salvage is recommended when it can be expected to reduce the likelihood of donor red cell transfusion.