How do we manage blood product support in the massively hemorrhaging obstetric patient?

Obstetric hemorrhage remains a leading cause of maternal mortality with more than 140,000 deaths annually worldwide. Abnormal placentation has increased to become the most common diagnosis requiring massive blood transfusion in obstetrics, with uterine atony a close second. At our institution, as well as nationwide, there has been a steady increase in pregnancies complicated by abnormal placentation, including accreta, increta, and percreta. Providers at our facility created the New England Center for Placental Disorders in May 2015 to address these complex patients. The incidence of accreta has actually increased 10-fold over the past 50 years, becoming the most common reason for cesarean hysterectomy in highly industrialized countries. The most common risk factor for accreta is repeat cesarean sections, particularly those with associated placenta previa. Contemporary cesarean section rates have risen, with more than 1.2 million women having had a cesarean section in the United States in 2014. We present a case vignette of a multiparous woman presenting with heavy vaginal bleeding at 30 weeks' gestation with imaging concerning for placenta accreta and possible percreta. We describe our approach to the management of these complicated patients.