What is the immediate management for Accreta bleed and decomposition hypotension?

From the Guidelines

The immediate management for Accreta bleed and decomposition hypotension requires aggressive resuscitation and surgical intervention, prioritizing the administration of tranexamic acid 1g IV over 10 minutes within 3 hours of bleeding onset, as supported by 1.

Key Management Steps:

• Start with two large-bore IV access (16-18 gauge) for rapid fluid resuscitation using crystalloids (2-3L initially) and activate massive transfusion protocol targeting a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets, as recommended by 1.
• For hypotension, use vasopressors such as norepinephrine (starting at 0.05-0.1 mcg/kg/min) or phenylephrine (50-100 mcg boluses) to maintain mean arterial pressure above 65 mmHg.
• Surgical management is definitive and typically requires hysterectomy in severe cases, though uterine artery embolization may be considered in stable patients, as noted in 1 and 1.
• Ensure continuous monitoring of vital signs, urine output, and laboratory parameters (CBC, coagulation studies, fibrinogen), highlighting the importance of a multidisciplinary approach involving obstetrics, anesthesiology, blood bank, and interventional radiology, as emphasized by 1 and 1.

Rationale:

The management of Accreta bleed and decomposition hypotension is centered around preventing further morbidity and mortality. The use of tranexamic acid, as supported by 1, is crucial in reducing bleeding complications and mortality. The activation of a massive transfusion protocol and the administration of vasopressors are also vital in managing hypotension and ensuring adequate perfusion of vital organs. Surgical intervention, including hysterectomy, may be necessary in severe cases to control bleeding, as discussed in 1 and 1. A multidisciplinary approach, involving various specialties, is essential in providing comprehensive care and reducing maternal morbidity and mortality, as highlighted by 1 and 1.

From the Research

Immediate Management for Accreta Bleed and Decomposition Hypotension

The immediate management for accreta bleed and decomposition hypotension involves several key strategies:

• Hypotensive fluid resuscitation to avoid worsening of uncontrolled bleeding 2
• Use of blood products and restriction of other fluids to support coagulation and tissue oxygenation 2, 3
• Administration of tranexamic acid (TXA) to reduce blood loss 4, 5
• Uterine artery embolization to control bleeding 5
• Monitoring for and treatment of coagulopathy, which is strongly associated with blood loss and replacement 6

Resuscitation Strategies

Resuscitation strategies for accreta bleed and decomposition hypotension include:

• Damage control resuscitation (DCR), which involves early and aggressive prevention and treatment of hemorrhagic shock 3
• Hypotensive resuscitation to avoid dislodging blood clots and diluting coagulation factors and platelets 2, 3
• Use of component and crystalloid therapy, with a focus on hemostatic resuscitation with transfusion of red blood cells, plasma, and platelets in a 1:1:1 unit ratio 3

Monitoring and Treatment of Coagulopathy

Monitoring for and treatment of coagulopathy is crucial in the management of accreta bleed and decomposition hypotension:

• Coagulopathy is defined as a platelet count of <100,000/mm3, international normalized ratio >1.5, and/or fibrinogen <300 mg/dL 6
• Estimated blood loss ≥ 1500 mL has the best discriminating power for coagulopathy 6
• Aggressive monitoring for and treatment of coagulopathy is recommended when estimated blood loss exceeds 1500 mL 6