Comparison of cell salvage with one and two suction devices during cesarean section in patients with placenta previa and/or accrete: a randomized controlled trial

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Comparison of cell salvage with one and two suction devices during cesarean section in patients with placenta previa and/or accrete: a randomized controlled trial

Obstetric hemorrhage remains one of the leading causes of maternal death worldwide, making blood conservation during high-risk cesarean sections (CS) critical. Intraoperative cell salvage (IOCS)—a technique that collects and reuses a patient’s own blood—has become a standard tool in many surgeries to reduce reliance on donated blood and its associated risks, like infections or allergic reactions. But in obstetrics, IOCS raises unique concerns: could amniotic fluid (AF) or fetal blood cells contaminate the salvaged blood, putting mothers at risk?

For women with placenta previa (where the placenta covers the cervix) or placenta accreta (where the placenta invades the uterine wall), CS often involves massive bleeding before the placenta is delivered. Traditionally, two suction devices are used to separate AF from blood—but does using just one device work just as well, while capturing more red blood cells (RBCs) to reuse? That’s what a team from Zhejiang University School of Medicine set out to test in a randomized controlled trial.

How the Study Worked

The study included 30 pregnant women (35–38 weeks gestation) with placenta previa and/or accreta who underwent elective CS at the Women’s Hospital of Zhejiang University School of Medicine between November 2017 and December 2018. Patients were randomly assigned to one of two groups:

  • Group 1 (15 patients): Used a single suction device to collect all blood and AF.
  • Group 2 (15 patients): Used two suction devices—one mainly for AF before the placenta was delivered.

Researchers took three blood samples from each patient:

  1. Pre-wash: Blood from the cell salvage reservoir (unprocessed).
  2. Post-wash: Blood after being cleaned by a continuous autotransfusion system.
  3. Post-filtration: Blood after passing through a leucocyte depletion filter (to remove unwanted cells/particles).

They measured AF components (like squamous cells, lamellar bodies, fat, and biochemical markers such as insulin-like growth factor binding protein 1 (IGFBP1) and alpha-fetoprotein (AFP)) and recorded the volume of salvaged RBCs. Statistical tests (t-tests, Mann-Whitney U, ANOVA) compared results between groups and sample types.

Key Findings

The team’s results, published in the Chinese Medical Journal, were clear:

  1. More Salvaged RBCs with One Device: Group 1 (single device) recovered significantly more RBCs than Group 2 (two devices)—401.6 ± 77.2 mL vs. 330.1 ± 53.3 mL (P < 0.001). This means less blood waste when bleeding is severe.
  2. AF Contaminants Were Effectively Removed: Both devices drastically reduced AF components. Washing the blood cut levels of squamous cells, lamellar bodies, fat, IGFBP1, AFP, albumin, lactate dehydrogenase (LDH), and potassium (all P < 0.001 or P < 0.01). Filtration further lowered squamous cells (only 6 of 30 post-filtration samples had any) and completely eliminated lamellar bodies and fat—key risks for complications like fat embolism.
  3. Fetal RBCs Were Present but Harmless: Fetal RBCs were found in all post-filtration samples, but there was no difference between groups (1.8% in Group 1 vs. 1.9% in Group 2, P = 0.651). Routine Anti-D immune globulin prevents Rh factor incompatibilities (the biggest risk for maternal alloimmunization).
  4. No Adverse Events: Nineteen patients (10 in Group 1, 9 in Group 2) received their salvaged blood. No allergic reactions, hypotension, or other complications were reported.

What the Results Mean

The study’s biggest takeaway? Using a single suction device for cell salvage is safe and more effective for high-risk CS. Here’s why:

  • Better Blood Recovery: When bleeding starts before the placenta is delivered (common in placenta previa/accreta), one device captures more blood—critical for avoiding donated blood transfusion. Previous research (like a 2008 study by Sullivan et al.) hinted at this, but the larger sample size here made the difference statistically significant.
  • AF Contaminants Are Not a Major Risk: Advanced filters and washing nearly eliminate harmful particles. Squamous cells, once a concern, were nearly gone post-filtration. And because AF embolism is now thought to be an anaphylactoid reaction (triggered by an unknown fetal antigen) rather than physical blockage from cells, even trace contaminants are unlikely to cause harm.
  • Fetal RBCs Are Manageable: Routine Anti-D prevents Rh incompatibilities (the main risk for alloimmunization). For other blood group antibodies (like anti-K or anti-c), more long-term research is needed—but this study found no evidence of harm in the patients who received autologous blood.

Conclusion

For women undergoing cesarean section with placenta previa or accreta—where massive bleeding is likely—using a single suction device for cell salvage is a safe, effective choice. It captures more red blood cells to reuse, reducing the need for donated blood, while washing and filtration eliminate most amniotic fluid contaminants. The results should give clinicians confidence to use one device in these high-risk cases, helping to save lives without compromising safety.

Hong Chen, Hua Tan, Pei-Xin Luo, Yi-Fang Shen, Chang-Cheng Lyu, Xiao-Wei Qian, Xin-Zhong Chen. Comparison of cell salvage with one and two suction devices during cesarean section in patients with placenta previa and/or accrete: a randomized controlled trial. Chinese Medical Journal 2020;133(6):638–643. doi.org/10.1097/CM9.0000000000000699

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