Reminder of important clinical lesson
Case report
Department of Obstetrics and
Gynecology, University of
Toyama, Toyama, Japan
Correspondence to
Professor Shigeru Saito,
​s30saito@​med.​u-​toyama.​ac.​jp
Accepted 9 October 2018
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re-use. See rights and
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To cite: Tachi S, Yoneda N,
Yoneda S, et al. BMJ Case
Rep Published Online First:
[please include Day Month
Year]. doi:10.1136/bcr-2018-
226486
Successful treatment of total placenta previa by
multidisciplinary therapy in a Jehovah’s Witness
patient who refused blood transfusions
Sayaka Tachi, Noriko Yoneda, Satoshi Yoneda, Shigeru Saito
Summary
A 35-year-old Jehovah’s Witness patient with total
placenta previa was referred to our hospital at 30
weeks of gestation. She refused autologous and
allogeneic blood transfusions, but agreed to receive
acute normovolaemic haemodilution, intraoperative
blood salvage and biological products. At 35 weeks,
she underwent emergent caesarean delivery because
of labour pains. Multidisciplinary therapy, including the
insertion of balloon catheters into the bilateral common
iliac arteries, acute normovolaemic haemodilution and
intraoperative blood salvage, avoided hysterectomy;
however, blood loss included amniotic fluid which
was estimated to be 1910 mL. These treatments may
be effective for total placenta previa in blood-refusal
patients.
Background  therapy with obstetricians, gynaecologists, anaes-
Only nine previous case reports have described
patients with placenta previa who refused blood
transfusions,1–9 and there have been no case
reports of the application of balloon catheters to
the common iliac arteries10–14 of these patients in
order to reduce blood loss (table 1). This is based
on a systematic search of literature (search engine:
PubMed, search terms: previa or placenta and Jeho-
vah’s, time: limitless, and languages: English).
We herein report a case of total placenta previa
in a Jehovah’s Witness patient who refused blood
transfusions and was managed with multidisci-
plinary therapy including balloon catheters in
the common iliac arteries, closed-circuit acute
normovolaemic haemodilution (ANH), closed-cir-
cuit intraoperative blood salvage (IBS) and biolog-
ical products.
Case presentation
A 35-year-old woman (G4P3 without a previous
history of caesarean delivery), a Jehovah’s Witness,
was referred to our hospital for the management of
total placenta previa at 30 weeks of gestation (we
have decided on expected date of delivery based on
last menstrual period) and was admitted to hospital
at 30 weeks and 3 days of gestation to be treated
as soon as possible if massive haemorrhage has
occurred.
We performed MRI at 32 weeks of gestation.
Ultrasonography showed that total placenta previa
covered the internal cervical os posteriorly, and
Tachi S, et al. BMJ Case Rep 2018. doi:10.1136/bcr-2018-226486
MRI suggested the coexistence of placenta accreta
because the boundary between the placenta and
retroplacental myometrium was unclear (figure 1).
When we explained the necessity of blood trans-
fusions for massive bleeding in caesarean delivery,
she adamantly refused autologous and allogeneic
blood transfusions for religious reasons, but agreed
to receive ANH, IBS and biological products,
including albumin and fibrinogen. We obtained a
written disclaimer following our hospital’s guide-
lines for blood-refusal patients. We explained her
that there was no guarantee she could recover
completely and be alive if she refused blood trans-
fusions. And she understood the explanations
and signed consent form. We planned to perform
hysterectomy without hesitating if her bleeding was
massive because she did not desire for next child.
We planned the following multidisciplinary
thesiologists, neonatologists and interventional
radiologists: (1) the preoperative insertion of
balloon catheters into the bilateral common iliac
arteries even when emergent surgery is necessary,
(2) elective caesarean delivery at 36 weeks of gesta-
tion in order to avoid emergent surgery and prema-
ture infant’s complications based on Bishop score
and (3) the use of ANH and IBS and administration
of biological products during surgery.
The patient had no episodes of antepartum
haemorrhage after her admission. At 31–32 weeks
of gestation, she was administered an iron injec-
tion for anaemia (her haemoglobin concentration
was 9.4 g/dL). Her haemoglobin concentration was
improved to 12.0 g/dL after iron injection. During
the pregnancy, non-stress testing and biophys-
ical profile score were no problems and the fetal
growth was normal. We planned to do elective
caesarean delivery at 36 weeks. Antenatal cortico-
steroid therapy was not administered to our patient
because we use steroid to women who will deliver
by before 34 weeks.
At 35 weeks and 6 days of gestation, she under-
went emergent caesarean delivery because of
labour pains without genital bleeding. Interven-
tional radiologists placed balloon catheters into the
bilateral common iliac arteries immediately before
caesarean delivery. It took 50 min to place common
iliac artery catheters. We moved from radiology
to operating room in a hurry after catheter place-
ment. It took about 10  min. Anaesthesiologists
1
 Reminder of important clinical lesson

Table 1  Cases of placenta previa with the refusal of blood transfusions

Gestational
age at Insertion
Case Authors Maternal delivery Birth Blood Placenta of balloon Arterial ligation
number (Year) age (years) (week) weight (g) loss (g) accreta catheters or embolisation ANH IBS Hysterectomy
1
1 Estella et al 30 36 2740 1200 Yes No Ligation, IIA Yes NA Yes,
(1997) intraoperative
2 de Souza et al2 34 34 2700 1000 No No No NA No No
(2003)
3 McGurgan et al3 31 32 NA 1700 No No No Yes Yes No
(2004)
4 Weistein et al4 38 39 NA 100 Yes No Embolisation, UtA NA NA No
(2005) (spontaneous
expulsion)
5 Nagy et al5 (2008) 42 34 3450 5500 Yes No Ligation, UtA Yes Yes Yes,
intraoperative
6 Belfort et al6 28 18 NA 1500 Yes NA NA NA Yes Yes
(2011)
7 Mauritz et al7 35 35 NA 1900 Yes No Embolisation, UtA Yes Yes Postoperative
(2016) 26th day
8 Russo et al8 39 26 NA 3000 Yes Yes, aorta Embolisation, UtA Yes NA Yes,
(2017) intraoperative
9 Wong et al9 42 27 NA 1850 Yes Yes, IIA Ligation, IIA NA Yes Postoperative
(2018) 6 weeks
10 Present case 35 35 2773 1910 No Yes, CIA No Yes Yes No
ANH, acute normovolaemic haemodilution; CIA, common iliac artery; IBS, intraoperative blood salvage; IIA, internal iliac artery; NA, not applicable; UtA, uterine artery.

used perioperative transfusions, including 400 mL of ANH,
and 260 mL of IBS. Four hundred millilitres of maternal blood
was removed via a closed circuit, and 500 mL of hydroxyethyl
starch solution, 1050 mL of glucose lactated Ringer’s solution
and 1250 mL of 5% albumin were then administered in order
to maintain a normal haemodynamic status. Her body weight
before pregnancy and at 35 weeks of gestation was 55 kg and
64 kg, respectively. We considered that the target haemoglobin
during ANH was 8.0 g/dL, because typically healthy human’s
acceptable haemoglobin before operation is from 7 to 8 g/dL. We
used heart rate monitor and non-invasive and invasive arterial
blood pressure to assess haemodynamic status. Under general
anaesthesia, she delivered a 2773 g female infant. The interval
between induction of anaesthesia and fetal delivery was 4 min.
Apgar scores were 2 points at 1 min and 6 points at 5 min, and
the pH of the umbilical artery was 7.315. The infant had no
remarkable episodes such as a neonatal respiratory disorder.
After delivery, balloon catheters were dilated immediately. An
intravenous injection of 0.2 mg methyl ergometrine maleate and
intravenous drip of oxytocin at 5 IU per hour were adminis-
tered. The placenta was spontaneously removed from the uterus.
Bleeding from the endometrial surface was under control after
several sutures. Balloon occlusion of the bilateral common iliac
arteries continued for 9 min and 20 s. The Bakri balloon cath-
eter was inserted into the uterine cavity for atonic bleeding after
deflation of the bilateral balloon catheters and oxytocin (5 IU)
was injected into the uterus intramuscularly. We returned the
maternal blood returned to her just before closing a surgical inci-
sion. Blood loss included amniotic fluid which was estimated to
be 1910 mL. ANH, IBS, albumin and fibrinogen products also
maintained stable vital signs and hysterectomy was avoided
(figure 2).

Outcome and follow-up

Her postoperative course was unremarkable, except for postop-
erative ileus. We used tranexamic acid of 1000 mg/day for 3 days,
iron injection of 80–120 mg/day for 10 days and oral iron of
100 mg/day for 5 days after operation. However, her postopera-
tive haemoglobin level was 6.7 g/dL, and anaemia was alleviated
by iron supplementation on postoperative day 16 (her haemo-
Figure 1  MRI of total placenta previa covering the internal cervical globin concentration was 10.3 g/dL). She and her baby were
os. OS, ostium uteri. discharged on the 16th postoperative day in good condition.
2 Tachi S, et al. BMJ Case Rep 2018. doi:10.1136/bcr-2018-226486

Figure 2  Progress during surgery. ANH, acute normovolaemic haemodilution; BP, blood pressure; CIA, common iliac artery; CIABO, common iliac
artery balloon catheter occlusion; Hb, haemoglobin; HR, heart rate; IBS, intraoperative blood salvage; UmApH, umbilical arterial pH.
Discussion
Table 1 shows 10 case reports including ours of a Jehovah’s
Witness patient with placenta previa who refused consent for
blood transfusions.1–9 In six cases (case numbers: 2, 3, 5, 6, 8
and 9), patients had premature babies born earlier than 35 weeks
of gestation. Blood loss in surgery ranged between 100 and
5500 mL, and there were seven cases of placenta accreta (case
numbers: 1, 4–9). In seven cases (case numbers: 1, 4, 5, 7–10),
uterine artery embolisation, arterial ligation or artery balloon
occlusion was performed. ANH and/or IBS were used in eight
cases (case numbers: 1, 3, 5–10). Hysterectomy was performed
in six cases (case numbers: 1, 5–9) (6 out of 10 cases: 60%).
We discussed the reason why it was possible to avoid hyster-
ectomy in the present case. The insertion of balloon catheters
into the bilateral common iliac arteries preoperatively may have
reduced massive bleeding from the uterus after separation of the
placenta. Furthermore, adequate transfusions of ANH, IBS and
biological products, such as albumin and a fibrinogen prepara-
tion, may have been sufficient to compensate for bleeding during
surgery. In addition, the placenta separated spontaneously
without placenta accreta.
Previous reports described the effects of balloon occlusion of
the abdominal aorta,15 balloon obstruction of the internal iliac
artery and artery embolisation,16 temporary obstruction of the
internal iliac artery17and temporary obstruction of the common
iliac artery10–14 at caesarean delivery. Balloon obstruction of
the common iliac artery has since been performed at some
institutions.
There are several studies about the use of balloon catheters in
the common iliac arteries for placenta previa with accrete,10–14
but the effectiveness of the prophylactic use for placenta previa
is unclear.13 To the best of our knowledge, this is the first case
Tachi S, et al. BMJ Case Rep 2018. doi:10.1136/bcr-2018-226486
Reminder of important clinical lesson
report of multidisciplinary therapy, including the preoperative
insertion of balloon catheters into the bilateral common iliac
arteries, potentially being useful for patients with total placenta
previa who refuse blood transfusions for religious reasons.
Since the risks of reperfusion injury and thrombosis increase in
patients with the longer interruption of the common iliac artery,
we interrupt its blood flow for a maximum of 20 min. In the
present case, the interruption time was only 9 min and 20 s.
We need preoperative multidisciplinary consultation about
the treatment of each Jehovah’s Witness patient because their
acceptance of blood products varies widely and consultation
may alter decision-making.18 The present case was a Jehovah’s
Witnesses who refused blood transfusions, but agreed to ANH
and IBS. Previous studies have evaluated the efficacy of preop-
erative ANH in reducing the need for allogeneic blood transfu-
sion.19 Closed-circuit ANH is a blood conservation technique
that involves the removal of blood from the patient shortly
after the induction of anaesthesia, with the maintenance of
normovolaemia using crystalloid and/or colloid replacement. In
this case, we removed 400 mL of blood preoperatively from a
central venous catheter and infused it during and after surgery.
Closed-circuit IBS is a blood conservation technique that involves
aspirating blood lost within the surgical field that is centrifuged
and washed to produce red blood cells, which are subsequently
transferred to patients. The American College of Obstetricians
and Gynecologists propose that IBS is considered when placenta
accreta is suspected.20 In the present case, we aspirated as much
intra-abdominal amniotic fluid after amniotomy as possible and
used the leucocyte-removing filter to avoid a mixture of amni-
otic fluid and leucocytes.
Jehovah’s witnesses may increase the risk for maternal
mortality and serious maternal morbidity because of obstetric
3
 Reminder of important clinical lesson
haemorrhage.21 Maternal death due to massive bleeding during
caesarean delivery is a life-threatening complication in patients
with placenta previa who refuse blood transfusions for reli-
gious reasons. In order to minimise this issue, multidisciplinary
therapy, including the insertion of balloon catheters into the
common/internal iliac artery, ligation/embolisation of the uterine
artery, ANH, IBS and the administration of biological products,
is recommended. It is important to understanding their indi-
vidual acceptance of alternatives to blood transfusion. Alterna-
tives to blood transfusion including ANH and IBS is very useful,
because many Jehovah’s Witness patients accept these therapy.22
Hysterectomy needs to be performed immediately for patients
with refractory bleeding after multidisciplinary therapy.
Learning points
10 Shih JC, Liu KL, Shyu MK. Temporary balloon occlusion of the common iliac artery:
►► Multidisciplinary therapy, including the preoperative insertion
of balloon catheters into the bilateral common iliac arteries,
acute normovolaemic haemodilution and intraoperative
blood salvage, may be effective for the management of
blood-refusal patients with total placenta previa.
►► It is important to plan multidisciplinary therapy in advance
for blood-refusal patients with total placenta previa along
with obstetricians, gynaecologists, anaesthesiologists,
neonatologists and interventional radiologists.
►► We need to confirm the treatment of each Jehovah’s Witness
patient because their interpretation of blood transfusion
varies.
►► We need to obtain a written disclaimer from Jehovah’s
Witness patients about their treatment regarding the refusal
of blood transfusions.
Contributors  ST and NY: drafting the case report. SY and SS: revising the
manuscript critically for important intellectual content.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests  None declared.
Patient consent  Obtained.
Provenance and peer review  Not commissioned; externally peer reviewed.
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2003;110:524–6.
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