Individualized perioperative decision-making for intraoperative cell salvage in an Rh(D)-negative patient with placenta percreta: a case report.

Placenta accreta spectrum (PAS), and particularly placenta percreta, is one of the most hemorrhage-prone conditions in obstetric surgery. In Rh(D)-negative women, the conventional toolkit of patient blood management is constrained: compatible allogeneic supply is scarce, and intraoperative cell salvage (ICS) raises a specific concern about residual fetal red cell exposure and Rh alloimmunization. We report the perioperative course of a 29-year-old gravida 3, para 2 woman with O Rh(D)-negative blood, preoperative anemia (hemoglobin 86 g/L), placenta percreta with suspected bladder invasion, and intrahepatic cholestasis of pregnancy, who underwent cesarean subtotal hysterectomy at 32 weeks of gestation after multidisciplinary planning. Hemorrhage control combined intermittent abdominal aortic balloon occlusion (IABO), tranexamic acid, definitive surgical hemostasis, and timely transfusion of 7 units of cross-matched O Rh(D)-negative packed red blood cells and 600 mL of fresh frozen plasma. ICS was activated after fetal delivery and 900 mL of processed autologous blood was held in reserve; reinfusion was not undertaken after hemorrhage had been controlled through IABO, definitive surgical hemostasis, and same-type allogeneic transfusion, while hemoglobin remained ≥ 80 g/L and no additional red-cell support was considered clinically necessary. This was a case-specific intraoperative judgment rather than a predefined protocol. Postpartum anti-D immunoglobulin was not administered, and no postpartum antibody screening was performed. Although the patient was discharged on postoperative day 5 and was clinically well at 3-month follow-up, this interval was too short to evaluate delayed alloantibody formation. Therefore, her subsequent alloimmunization status and the immunohematologic safety of this management could not be determined. This report describes one context-specific decision to prepare and retain ICS blood without subsequent reinfusion. It does not establish that withholding reinfusion is safe or preferable and does not provide a generalizable strategy or threshold for other Rh(D)-negative patients with PAS.