Title: Anesthesia%20Management%20for%20A%20Patient%20with%20Placenta%20Accreta%20Undergoing%20Cesarean%20Section
1Anesthesia Management for A Patient with Placenta
Accreta Undergoing Cesarean Section
2Brief History(1)
- This 34 y/o woman, G4P1AA2, AP 32wks, was
admitted for elective Cesarean Section on 91-10-7
due to highly-suspected placenta accreta. - She was rather well before. C/S was performed 11
years ago due to giant baby and post-op course
was smooth.
3Brief History(2)
- During this time of pregnancy, she was suffered
from several times of APH and uterine contraction
and hospitalized for tocolysis. Ultrasonography
showed placenta previa and placenta accreta was
highly suspected.
4Brief History(3)
- After admission, two 5 French (8mmID) RCI balloon
catheters were placed at bilateral internal iliac
artery under fluoroscopy by radiologist on 10/8. - Before operation, Hb is 9.9, no thrombycytopenia
and PT, PTT are WNL.
5Anesthesia and Operation Management(1)
- Combined spinal-epidural (CSE) anesthesia was
performed initially for bilateral double J
insertion by urologist before C/S and post-op
pain control. Arterial line was set up. - After obstetrician were prepared, general
endotracheal anesthesia was induced with
thiopental, ketamine and succinylcholine. N2O
(50) and Isoflurane (0.5) were used to maintain
general anesthesia. 14x14 CVP was inserted via
rt IJV.
6Anesthesia and Operation Management(2)
- After the delivery of the baby (Ag 58),
bilateral internal iliac artery catheter balloons
were dilated. Placenta accreta in anterior low
segment of uterus and severe adhesion were noted
followed by Cesarean hysterectomy. - Peri-op vital signs were stable under aggressive
fluid replacement. Hb has ever drop from 10.4 to
8.3
7Anesthesia and Operation Management(3)
- Input Blood transfusion with whole blood 6u,
HAES 500ml, crystalloid 2500ml - Output Estimated blood loss 3500ml, U/O 1200ml
- After the operation, she was extubated and then
transferred to SICU for post-op care.
8Post-op Care
- She stayed at SICU for 1 day. Hb 8.0 was noted
and PRBC 4u was transfused. The catheter balloons
were kept inflated for 1 day and removed after
achieving hemostasis. Double J were left for 2
days. - The post-op course was smooth and she was
discharged on the 6th post-op day.
9Obstetric Hemorrhage
- Obstetric hemorrhage remains a leading cause of
maternal mortality and morbidity, followed by
embolism and pregnancy-induced hypertension. - Understanding maternal adaptations to pregnancy
and response to blood loss, pathophysiology, and
management of massive hemorrhage can improve
outcome.
10Placenta Accreta(1)
- ?????
- Incidence 1 per 2500 deliveries.
- Placenta is unusually adherent to implantation
site, with absent decidua. - The physiologic line of cleavage through the
decidual spongy layer is lacking. - Placenta accreta/increta/percreta
???/???/???
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12Placenta Accreta(2)
- Risk Factors
- Previous C/S or other previous uterine incisions
- Repeated uterine curettage.
- Placenta previa.
- A history of manual extraction of placenta.
- High parity and increasing maternal age.
13Placenta Accreta(3)
- Placenta accreta is noted at the time of delivery
or C/S with difficulty in separating the placenta
from uterine wall. - Ultrasonography can diagnose 78 to 100 of
cases. - Antenatal recognition of placenta accreta and
careful planning by obstetrician and
anethesiologist can decrease blood loss and
reduce serious complications.
14Obstetric Management
- Elective cesarean section.
- Anticipation of significant blood loss (sewing
the placenta implantation site, uterine artery or
internal iliac artery ligation) and high
probability of cesarean hysterectomy. - Better preparation before op (autologous blood
transfusion, pre-op catheterization for
subsequent uterine artery balloon occlusion).
15Prophylactic Internal Iliac Artery Balloon
Occlusion in Abnormal Placentation(1)
- Purposes
1. to stop hemorrhage so
that hysterectomy is avoided and fertility is
reserved. 2. to decrease obstetric
hemorrhage prior to hysterectomy, so that
bleeding vessels are better identified and
intraoperative blood loss is decreased.
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17Prophylactic Internal Iliac Artery Balloon
Occlusion in Abnormal Placentation(2)
- Occlusion of internal iliac arteries does not
halt blood flow to uterus because there is a rich
blood supply of collaterals. However this
technique dose reduce pulse pressure distal to
the occlusion site, thus minimizing blood loss
during hysterectomy.
18Anesthetic Management Elective cesarean
hysterectomy(1)
- Chestnut and Redick 7/25 of epidural anesthesia
required intra-op general anesthesia. The causes
were patient discomfort and inadequate operative
conditions longer operative time, excessive
intraperitoneal manipulation (pain, vomiting),
and engorged edematous vasculature requires
careful dissection.
19Anesthetic Management Elective cesarean
hysterectomy(2)
- Chestnut et al after trying to overcome the
problem above, the authors concluded that
continuous epidural anesthesia is not
contraindicated. - There is always a possibility that immediate
conversion from regional anesthesia to general
anesthesia will be required during acute
hemorrhagic crisis.
20Anesthetic Management Elective cesarean
hysterectomy(3)
- To have the airway secured might make
anesthesiologist focus on hemodynamic management. - It is important to have adequate personnel
available when one proceeds with continuous
epidural anesthesia. - In this case, regional anesthesia may be suitable.
21Anesthetic Management Elective cesarean
hysterectomy(4)
- Possibility of perioperative coagulation
disorders such as DIC must be concerned although
DIC is more often during emergent hysterectomy. - If possible, the epidural catheter should be
removed after the patients coagulation status is
normal or back to baseline.
22Anesthetic Management Emergency cesarean
hysterectomy(1)
- Placenta accreta was the most frequent indication
for emergency peripartum hysterectomy (more than
half). - The estimated blood in emergency cesarean
hysterectomy was 2526?1240ml, which is
significantly more than in elective cesarean
hysterectomy (1319?396ml). The blood loss among
patients varies significantly.
23Anesthetic Management Emergency cesarean
hysterectomy(2)
- When uncontrolled hemorrhage happened,
hysterectomy becomes necessary. - Anesthetic management starts with the evaluation
of airway and oxygenation, and establishment of
large-bore IV access. - Conversion from regional to general anesthesia is
not always necessary but appropriate when the
ongoing blood loss is significant.
24Management of Massive Hemorrhage(1)
- Assessment of blood loss is somewhat difficult in
parturients because of the increased blood volume
(increase 45) during pregnancy and concomitant
use of vasoactive drugs. - Hypotension is usually a late sign of blood loss,
as heart rate increases in parturients to
compensate blood loss.
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26Management of Massive Hemorrhage(2)
- Hb or Hct are not very helpful in determining the
degree of blood loss in acute phase and they are
not immediately decrease during acute blood loss. - At least two large-bore IV lines in upper trunk
is necessary (compression of IVC). - Colloid solution is more efficacious in fluid
resuscitation.
27Management of Massive Hemorrhage(3)
- The amount of crystalloid necessary to replace
the blood loss is approximately three times of
the amount lost. - ASA Practice Guidelines for Blood Component
Therapy stated that RBC transfusion is usually
indicated when the Hb level is less than 6.
28Management of Massive Hemorrhage(4)
- A parturient with Hb of 3 g/dL due to abruptio
placentae and DIC has been reported. Both mother
and the baby survived without sequelae. - Maintenance of normovolemia is very important for
parturients to compensate for anemia.
29Management of Massive Hemorrhage(5)
- Massive transfusion can cause dilutional
thrombocytopenia and coagulopathy, which can be
treated with appropriate blood component (FFP,
Plt). - Other complications as hyperkalemia, citrate
intoxication (resultant hypocalcemia), and
hypothermia may need special treatment.
30Blood Conservation Technique(1)
- To protect parturients from the risks of
homologous blood transfusion. - Autologous blood donation (5001000ml pre-op) can
decrease blood transfusion rate in high risk of
paturients. Erythropoietion may be administered
to pregnant patients to compensate for loss of
blood by autologous blood donation.
31Blood Conservation Technique(2)
- Acute normovolemic hemodilution 750 to 1000ml of
blood collection was replaced by an equal amount
of 10 pentastarch just before the operation. All
the blood was reinfused at the end of operation
or before. - Intraoperative blood salvage may not cause
amniotic fluid embolism or DIC in a recent
report. Cell savers can effectively separate
amniotic fluid from blood.
32Other Causes of Obstetric Hemorrhage(1)
- Abruptio placentae ?????? premature separation
of the normally implanted placenta. Concealed
hemorrhage can cause DIC and the extent of
hemorrhage is underestimated. Normal blood
pressure can be misleading, as pregnancy-induced
or chronic hypertension is associated with
abruption. It is important to detect coagulopathy
before operation and it may make general
anesthesia indicated.
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34Other Causes of Obstetric Hemorrhage(2)
- Placenta previa ???? abnormal location of
placenta over or very near the internal os. The
incidence is around 1 in 200 deliveries. The
progression of pregnancy results in a shearing
force between uterine wall the nonelastic
placenta and bleeding is inevitable with cervical
dilation. Anesthetic management of such patients
depends on the urgency and the severity of
hemorrhage.
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36Other Causes of Obstetric Hemorrhage(3)
- Uterine rupture ???? a full thickness defect of
the uterine wall. It may be spontaneous,
secondary to trauma or previous uterine scar. - Uterine atony ????
- Retained placenta ?????
- Inversion of the uterus ????
- Vasa previa ????
37Summary(1)
- Obstetric hemorrhage remains a leading cause of
maternal death. - Owing to the increase is circulating blood
volume, parturients do not demonstrate blood
pressure changes, even after moderate blood loss.
Visual assessment of blood loss is often
misleading and hypotension is often a late sign.
38Summary(2)
- Antenatal diagnosis (ultrasonography for placenta
accreta), preoperative preparation (autologous
blood transfusion), prophylactic method to reduce
blood loss (balloon occlusion), aggressive
intervention for massive blood loss (ligation and
fluid replacement), and a close team work to
patient care can reduce maternal mortality and
morbiditly.
39Thank You