Anesthesia%20Management%20for%20A%20Patient%20with%20Placenta%20Accreta%20Undergoing%20Cesarean%20Section

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Anesthesia Management for A Patient with Placenta
Accreta Undergoing Cesarean Section

• By R2 ???

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Brief 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.

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Brief 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.

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Brief 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.

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Anesthesia 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.

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Anesthesia 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

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Anesthesia 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.

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Post-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.

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Obstetric 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.

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Placenta 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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Placenta 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.

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Placenta 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.

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Obstetric 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).

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Prophylactic 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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Prophylactic 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.

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Anesthetic 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.

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Anesthetic 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.

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Anesthetic 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.

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Anesthetic 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.

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Anesthetic 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.

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Anesthetic 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.

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Management 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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Management 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.

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Management 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.

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Management 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.

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Management 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.

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Blood 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.

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Blood 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.

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Other 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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Other 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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Other 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 ????

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Summary(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.

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Summary(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.

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Thank You