Placenta praevia with accreta signs in a Jehovah's Witness refusing blood
A 34-year-old woman, para 1 by caesarean section four years ago, now at 35+2 weeks, has a complete anterior placenta praevia with two of four ultrasound signs of accreta (intraplacental lacunae, loss of the clear zone) over the previous caesarean scar. She is a baptised Jehovah's Witness and states clearly, in writing and repeatedly, that she refuses transfusion of red cells, platelets, plasma and any allogeneic blood product. She accepts crystalloids, colloids, tranexamic acid, iron, erythropoietin, fibrinogen concentrate and, after discussion, intraoperative cell salvage with a leucocyte filter. She is fully informed and has capacity, and has discussed her decision with her husband and her congregation elders. She is otherwise well; haemoglobin 121 g/L, ferritin 45 µg/L, blood group O positive with no antibodies. She is currently in a district hospital without an intensive care unit or interventional radiology; a tertiary perinatology centre with a level III NICU, vascular radiology and a blood bank is 60 km away. She has had no bleeding.
1. Set out the legal and ethical framework that governs her refusal, and describe how you would handle the discussion and the documentation. What would you refuse to do?
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Framework
- A competent adult patient may refuse any health-care intervention, including life-saving transfusion. Consent and refusal are governed by the Czech Act on Health Services (zákon č. 372/2011 Sb., o zdravotních službách): treatment requires free and informed consent, and refusal must be respected and documented. Section 36 provides for a previously expressed wish (dříve vyslovené přání), which is useful here because it can apply if she later loses capacity, but her current explicit refusal is already binding.
- Refusal of blood is not suicide and does not engage the criminal law in a way that requires a court order. There is no legal route to override a capacitous refusal. The fetus's interest does not override the mother's autonomy; coercive transfusion would be battery.
- Her refusal is component-specific, not absolute: she accepts albumin-type fractions, clotting factors, tranexamic acid and cell salvage. Always work from her own list, in writing, and re-confirm it on the day of surgery - people sometimes change their position, and she has the right to do so.
Handling
- Confirm capacity: she understands the diagnosis, the risk of massive haemorrhage, the alternatives, and the likely consequence of refusing (death).
- Explain concretely, not in generalities: with a praevia and two accreta signs over a scar, the risk of accreta is substantial and the risk of massive transfusion is high; give the numbers you would give any woman, then explain what can be done instead.
- Offer a second senior opinion and ethics committee involvement, involve her husband only with her permission, and remove any pressure or persuasion that could be perceived as coercion.
- Offer written information and time; document her exact words, the components accepted and refused, the alternatives offered, that she has capacity, and who was present. Ask her to sign an explicit refusal (negativní revers) and to complete an advance directive if she wishes.
What I would refuse to do: administer blood products covertly or under another name, give a product she has refused 'as a colloid', or let a colleague transfuse without her consent. I would also refuse to deny her other care: refusing blood does not mean refusing ICU admission, surgery or cell salvage.
2. Where should she deliver, at what gestation, and what should the operative plan be given her refusal? Include preoperative optimisation and the intraoperative strategy.
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Place and timing
- She must deliver at the tertiary centre with a level III NICU, adult intensive care, interventional radiology (internal iliac balloon occlusion or embolisation), a blood bank and cell salvage. Transfer her antenatally, non-urgently, in a stable state; a 60 km journey in a district hospital with no ICU is an unacceptable place to manage this.
- For suspected accreta with praevia and a previous caesarean, planned delivery around 34+0 to 36+0 weeks is standard practice, balancing prematurity against the risk of emergency surgery. At 35+2 weeks the plan should be a scheduled caesarean within days rather than expectant management to term; document the reasoning and let the multidisciplinary team decide the exact day.
- Antenatal corticosteroids: a course can be considered if delivery is planned before 37 weeks, but at this gestation the benefit is modest; it is a shared decision, not a mandatory step.
- Preoperative optimisation: iron studies with intravenous iron if ferritin is low (hers is borderline), erythropoietin, a high-protein diet, and correction of any anaemia to a target haemoglobin well above 110–120 g/L before surgery. Reconfirm group and save and antibody screen, and confirm her acceptance of cell salvage with the perfusion team in advance.
Operative plan
- Multidisciplinary team: consultant obstetrician experienced in accreta, senior anaesthetist, urologist, interventional radiologist, ICU, neonatology, and a haematologist to advise on non-transfusion haemostatic support.
- Laparotomy (midline if accreta is likely), prophylactic ureteric stents, and a plan for caesarean hysterectomy: the placenta is left in situ, the baby is delivered through a fundal or high transverse incision away from the placenta, the cord is cut, and hysterectomy follows without attempting placental removal.
- Prophylactic tranexamic acid 1 g at the start, cell salvage running, aortic or internal iliac balloon occlusion if available, uterotonics, and surgical measures: uterine artery ligation, compression sutures where applicable, and packing as a damage-control option.
- Reserve ICU bed and have a massive haemorrhage protocol activated, explicitly noting which components she has refused.
3. During caesarean hysterectomy she loses an estimated 2.5 L, the haemoglobin falls to 48 g/L, she becomes tachycardic and hypotensive, and she is still refusing blood. Describe your management, including what you say to the family.
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Immediate management
- Continue and escalate surgical control: identify the bleeding source, proceed with hysterectomy and secure pedicles, and call the second consultant surgeon. Consider aortic compression or a aortic clamp, pelvic packing, and interventional radiology for embolisation as soon as feasible.
- Non-blood volume and haemostatic support consistent with her stated wishes: balanced crystalloid and colloid, tranexamic acid (a second 1 g dose is reasonable if ongoing bleeding), fibrinogen concentrate to keep fibrinogen above 1.5–2 g/L, calcium replacement, active warming, correction of acidosis, and cell salvage reinfusion with a leucocyte filter.
- Discuss in advance or at this point the off-label use of recombinant factor VIIa and prothrombin complex concentrate, checking her specific list; she has accepted clotting factor concentrates and fibrinogen, so these are legitimate to offer with an explanation of what they are.
- Anaesthesia: convert to general anaesthesia if not already, invasive monitoring, vasopressors, and ICU admission postoperatively.
What not to do: do not give red cells, platelets or plasma covertly or under another name, and do not let the urgency override her refusal. This is the hardest part of the case: her refusal is the treatment plan, not an obstacle to be bypassed.
Talking to the family
- Speak to her husband together with a second clinician, in a private room, in plain language: she is bleeding heavily, she has refused blood products, we are respecting that, and she may die. Do not ask him to consent to transfusion - he cannot, and asking creates a false expectation and a future conflict.
- Ask whether he knows of any change in her wishes or any additional written statement, and if she remains conscious and competent, ask her directly and record her answer.
- Involve the ethics committee and the hospital's legal adviser early, and document everything contemporaneously: who said what, when, and the treatment given. Arrange a debrief for the team afterwards.