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Hegde HV, Joshiraj B, Paul M, Weerasinghe AS, Mulgund KG, Marimuthu SR, Pai AG, Abdullah RM. A Retrospective Study in 12-Year cohort of 216 Parturients with Invasive Placentation in a Tertiary Care Centre in Oman: Clinical Outcomes Indicate Severe Maternal Morbidity. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102341. [PMID: 38176678 DOI: 10.1016/j.jogc.2023.102341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024]
Abstract
Placenta accreta spectrum (PAS) comprising placenta accreta, increta, and percreta, is 1 of the leading causes of peripartum hemorrhage and accounts for up to 50% of all cesarean hysterectomies (CH). We analyzed the data of 216 parturients with PAS who underwent cesarean delivery (CD) and/or CH. Intraoperative surgical complications were noted in 215 (99.5%). The mean estimated blood loss was 2743 (1790) mL, and 105 parturients (48.6%) lost ≥2500 mL. The patients experienced high rates of severe acute maternal morbidity [162 (75%)], hysterectomy [82 (38%)], large volume blood loss, blood transfusion, peripartum anemia, and prolonged hospital stay.
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Affiliation(s)
- Harihar V Hegde
- Department of Anesthesia and Intensive Care, Royal Hospital, Muscat, Sultanate of Oman.
| | - Bandi Joshiraj
- Department of Anesthesia and Intensive Care, Royal Hospital, Muscat, Sultanate of Oman
| | - Manisha Paul
- Department of Anesthesia and Intensive Care, Royal Hospital, Muscat, Sultanate of Oman
| | | | | | | | - Arun G Pai
- Anaesthesia, Intensive Care and Pain Medicine, Aneurin Bevan University Health Board, Newport, Wales, UK
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Liu C, Chu R, Song N, Yang Q, Song X, Li L, Zhang M, Li Y, Xu Y, Li Y, Ma Y. Perinatal outcomes comparison between neuraxial and general anesthesia in pregnant women with placenta accreta spectrum: a multicenter retrospective study. J Anesth 2024; 38:167-178. [PMID: 38345633 DOI: 10.1007/s00540-023-03287-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 11/10/2023] [Indexed: 03/21/2024]
Abstract
PURPOSE We investigated the impact of anesthesia mode on perinatal outcomes in patients with placenta accreta spectrum (PAS) undergoing cesarean delivery and identified factors associated with adverse perinatal events. METHODS The multicenter retrospective analysis was conducted in patients with PAS who delivered at three medical centers. Patients were classified according to whether they received general anesthesia (GA) or neuraxial anesthesia (NA). We compared the basic clinical characteristics of patients in the pre-propensity score matching (PSM) and post-PSM cohorts and identified factors associated with a high risk of adverse maternal outcomes. RESULTS This study included a total of 425 patients, with 307 (72.2%) in the GA group and 118 (27.8%) in the NA group. After PSM, 162 patients were identified for analysis. In the post-matched cohort, the NA group exhibited shorter total operation time (P = 0.030) and postoperative length of hospital stay (P = 0.037). Additionally, the NA group experienced lower intraoperative blood loss (P < 0.001) and received fewer units of transfused packed red blood cells (PRBC) (P < 0.001). Multivariate logistic regression analysis indicated that GA (P < 0.001), emergency cesarean delivery (P = 0.010), vascular lacunae within the placenta (P < 0.001), hypervascularity of uterine-placental margin (P = 0.002), hypervascularity of the cervix (P = 0.014), and balloon placement in the abdominal aorta (P < 0.001) were associated with a high risk of adverse maternal events. CONCLUSION In comparison to GA, cesarean delivery with NA in PAS patients appears to be associated with reduced intraoperative blood loss, PRBC transfusion, operating duration, and postoperative hospital stay.
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Affiliation(s)
- Chenmian Liu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong, People's Republic of China
| | - Ran Chu
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingsi Road, Jinan, Shandong, People's Republic of China
| | - Ningning Song
- Department of Obstetrics and Gynecology, People's Hospital of Rizhao, Rizhao, Shandong, People's Republic of China
| | - Qiuhong Yang
- Department of Obstetrics and Gynecology, Jinan Maternity and Child Care Hospital, Jinan, Shandong, People's Republic of China
| | - Xiao Song
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, Shandong, People's Republic of China
| | - Liang Li
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong, People's Republic of China
| | - Meiling Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong, People's Republic of China
- Department of Obstetrics and Gynecology, Qingdao Women and Children's Hospital, Qingdao, Shandong, People's Republic of China
| | - Yarong Li
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong, People's Republic of China
- Department of Obstetrics and Gynecology, Jinan Maternity and Child Care Hospital, Jinan, Shandong, People's Republic of China
| | - Yintao Xu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong, People's Republic of China
| | - Yanan Li
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong, People's Republic of China.
| | - Yuyan Ma
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong, People's Republic of China.
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Bartels HC, Walsh D, Nieto-Calvache AJ, Lalor J, Terlezzi K, Cooney N, Palacios-Jaraquemada JM, O'Flaherty D, MacColgain S, Ffrench-O'Carroll R, Brennan DJ. Anesthesia and postpartum pain management for placenta accreta spectrum: The healthcare provider perspective. Int J Gynaecol Obstet 2024; 164:964-970. [PMID: 37724823 DOI: 10.1002/ijgo.15096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/08/2023] [Accepted: 08/17/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE To explore the management and experiences of healthcare providers around anesthetic care in placenta accreta spectrum (PAS). METHODS This descriptive survey study was carried out over a 6-week period between January and March 2023. Healthcare providers, both anesthesiologists and those involved in operative care for women with PAS, were invited to participate. Questions invited both quantitative and qualitative responses. Qualitative responses were analyzed using content analysis. RESULTS In all, 171 healthcare providers responded to the survey, the majority of whom were working in tertiary PAS referral centers (153; 89%) and 116 (70%) had more than 10 years of clinical experience. There was variation in the preferred primary mode of anesthesia for PAS cases; 69 (42%) used neuraxial only, but 58 (35%) used a combined approach of neuraxial and general anesthesia, with only 12 (8%) preferring general anesthesia. Ninety-nine (61%) were offering a routine antenatal anesthesia consultation. Content analysis of qualitative data identified three main themes, which were "variation in approach to primary mode of anesthesia", "perspectives of patient preferences", and "importance of multidisciplinary team care". These findings led to the development of a decision aid provided as part of this paper, which may assist clinicians in counseling women on their options for care to come to an informed decision. CONCLUSIONS Approach to anesthesia for PAS varied between healthcare providers. The final decision for anesthesia should take into consideration the clinical care needs as well as the preferences of the patient.
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Affiliation(s)
- Helena C Bartels
- Department of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Don Walsh
- Department of Anaesthesiology, National Maternity Hospital, Dublin, Ireland
| | | | - Joan Lalor
- School of Nursing and Midwifery, Trinity College, Dublin, Ireland
| | | | | | | | - Doireann O'Flaherty
- Department of Obstetric Anaesthesiology, Coombe Women's Hospital, Dublin, Ireland
| | - Siaghal MacColgain
- Department of Anaesthesiology, National Maternity Hospital, Dublin, Ireland
| | | | - Donal J Brennan
- University College Dublin Gynaecological Oncology Group, Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland
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Huang YC, Yang CC. Impact of planned versus emergency cesarean delivery on neonatal outcomes in pregnancies complicated by abnormal placentation: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e34498. [PMID: 37565895 PMCID: PMC10419427 DOI: 10.1097/md.0000000000034498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/05/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Although planned cesarean delivery (PCD) is the mainstay of management for abnormal placentation, some patients still require emergency cesarean delivery (ECD). We aimed to systematically analyze the impact of various modes of delivery on neonatal outcomes. METHODS This study was complied with the PRISMA guidelines and was registered in the PROSPERO (code: CRD42022379487). A systematic search was conducted on Ovid MEDLINE and Embase, Web of Science, PubMed, and the Cochrane databases. Data extracted included gestational age at delivery, birth weight, the Apgar scores at 1 and 5 minutes, numbers of newborns with low Apgar score (<7) at 5 minutes, the rates of neonatal intensive care unit admission, and the rates of neonatal mortality. RESULTS Fifteen cohort studies met the inclusion criteria, comprising a total of 2565 women (2567 neonates) who underwent PCD (n = 1483) or ECD (n = 1082) for prenatally diagnosed placenta accreta spectrum (PAS) and/or placenta previa (PP). Compared with the ECD group, neonates in the PCD group had significantly higher gestational ages (standardized mean difference [SMD]: 2.20; 95% confidence interval [CI]: 1.25-3.15; P < .001), birth weights (SMD: 1.64; 95% CI: 1.00-2.27; P < .001), and Apgar scores at 1 minute (SMD: 0.51; 95% CI: 0.29-0.73; P < .001) and 5 minutes (SMD: 0.47; 95% CI: 0.25-0.70; P < .001). Additionally, the PCD group had significantly lower rates of neonatal intensive care unit admission (odds ratio [OR]: 0.21; 95% CI: 0.14-0.29; P < .001), low Apgar score at 5 minutes (OR: 0.27; 95% CI: 0.11-0.69; P = .01), and neonatal mortality (OR: 0.13; 95% CI: 0.05-0.33; P < .001). CONCLUSION When pregnancies are complicated by abnormal placentation, PCD is linked to noticeably better neonatal outcomes than emergent delivery.
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Affiliation(s)
- Yi-Chien Huang
- Division of Neonatology, Department of Pediatrics, Chi Mei Medical Center, Tainan, Taiwan
| | - Cheng-Chun Yang
- Department of Medical Imaging, Chi Mei Medical Center, Tainan, Taiwan
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Warrick CM, Sutton CD, Farber MM, Hess PE, Butwick A, Markley JC. Anesthesia Considerations for Placenta Accreta Spectrum. Am J Perinatol 2023; 40:980-987. [PMID: 37336215 DOI: 10.1055/s-0043-1761637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Anesthesiologists are critical members of the multidisciplinary team managing patients with suspected placenta accreta spectrum (PAS). Preoperatively, anesthesiologists provide predelivery consultation for patients with suspected PAS where anesthetic modality and invasive monitor placement is discussed. Additionally, anesthesiologists carefully assess patient and surgical risk factors to choose an anesthetic plan and to prepare for massive intraoperative hemorrhage. Postoperatively, the obstetric anesthesiologist hold unique skills to assist with postoperative pain management for cesarean hysterectomy. We review the unique aspects of peripartum care for patients with PAS who undergo cesarean hysterectomy and explain why these responsibilities are critical for achieving successful outcomes for patients with PAS. KEY POINTS: · Anesthesiologists are critical members of the multidisciplinary team planning for patients with suspected placenta accreta spectrum.. · Intraoperative preparation for massive hemorrhage is a key component of anesthetic care for patients with PAS.. · Obstetric anesthesiologists have a unique skill set to manage postpartum pain and postoperative disposition for patients with PAS who undergo cesarean hysterectomy..
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Affiliation(s)
- Christine M Warrick
- Department of Anesthesiology, School of Medicine, University of Utah Hospital, Salt Lake City, Utah
| | - Caitlin D Sutton
- Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Michaela M Farber
- Department of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Philip E Hess
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Alexander Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University Medical Center, Palo Alto, California
| | - John C Markley
- Department of Anesthesia and Perioperative Care, University of California San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
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Carusi DA, Duzyj CM, Hecht JL, Butwick AJ, Barrett J, Holt R, O'Rinn SE, Afshar Y, Gilner JB, Newton JM, Shainker SA. Knowledge Gaps in Placenta Accreta Spectrum. Am J Perinatol 2023; 40:962-969. [PMID: 37336213 DOI: 10.1055/s-0043-1761635] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Since its first description early in the 20th Century, placenta accreta and its variants have changed substantially in incidence, risk factor profile, clinical presentation, diagnosis and management. While systematic use of diagnostic tools and a multidisciplinary team care approach has begun to improve patient outcomes, the condition's pathophysiology, epidemiology, and best practices for diagnosis and management remain poorly understood. The use of large databases with broadly accepted terminology and diagnostic criteria should accelerate research in this area. Future work should focus on non-traditional phenotypes, such as those without placenta previa-preventive strategies, and long term medical and emotional support for patients facing this diagnosis. KEY POINTS: · Placenta accreta spectrum research may be improved with standardized terminology and use of large databases.. · Placenta accreta prediction should move beyond ultrasound with the addition of biomarkers, and needs to extend to those without traditional risk factors.. · Future research should identify practices that can prevent future accreta development..
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Affiliation(s)
- Daniela A Carusi
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christina M Duzyj
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan L Hecht
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Jon Barrett
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Roxane Holt
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
| | | | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Jennifer B Gilner
- Division of Maternal-Fetal Medicine, Duke University Medical Center, Durham, North Carolina
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Ioscovich A, Weiss A, Shatalin D. The anesthetic approach to a patient with placenta accreta spectrum. Curr Opin Anaesthesiol 2023; 36:263-268. [PMID: 36745077 DOI: 10.1097/aco.0000000000001242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Placenta accreta poses significant risk of morbidity and mortality to a laboring patient. Here we review available treatment options, highlight trends in bleeding prevention and diagnosis that have been shown to improve patient outcome, and provide best practice suggestions. We also discuss the decision-making process for choice of anesthesia, as it is not based on a gold-standard paradigm. RECENT FINDINGS The use of resuscitative endovascular balloon occlusion of the aorta has been gaining popularity around the world. It has been shown to cause an equivocal reduction in perioperative bleeding in placenta accreta spectrum (PAS), reduce the rate of hysterectomies, and is a safe and relatively easy technique. There are other invasive radiology techniques that have also proven to be beneficial in bleeding prevention: balloon occlusion of hypogastric arteries intraoperatively, internal iliac artery embolization, and intraoperative ligation of the hypogastric or uterine arteries. SUMMARY Optimal management of PAS begins with early and definitive diagnosis. A multidisciplinary approach along with preparation of special equipment and the use of a check-list maximize the chance for success. Anesthesia could be done with all types of regional or under general, considering case-by-case factors but most importantly choosing according to the institution's best facility and skill.
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Affiliation(s)
- Alexander Ioscovich
- Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Zedek Medical Center, affiliated with The Hebrew University, Jerusalem, Israel
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Antończyk A, Kiełbowicz Z, Niżański W, Ochota M. Comparison of 2 anesthetic protocols and surgical timing during cesarean section on neonatal vitality and umbilical cord blood parameters. BMC Vet Res 2023; 19:48. [PMID: 36782240 PMCID: PMC9923906 DOI: 10.1186/s12917-023-03607-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 02/06/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND The objective of this study was to evaluate the relationship between the mode of anesthesia, the time form the induction to the extraction of a puppy and the immediate postnatal vitality and umbilical cord blood gases parameters in cesarean section derived-puppies. Two different anesthetic protocols were used: inhalation using isoflurane (ISO) and combined-inhalation and epidural (EPI) with propofol being the induction agent. RESULTS Significant differences were found in ISO group in pH values, pCO2 levels and Apgar scores between puppies at different extraction times (< 30 vs. ≥ 30 min). In ISO group puppies extracted later were more acidic (7.16 vs. 7.22), had higher levels of pCO2 (69 vs. 57 mmHg) and lower Apgar scores at birth (1.2 vs. 2.5). On the contrary, in EPI group no differences were observed between the delivery time, umbilical blood gas parameters and puppies' vitality. Furthermore, the dams from the EPI group required lower concentrations of isoflurane (MAC 1.11 ± 0.19 vs.1.37 ± 0.16, p < 0.001). CONCLUSIONS Multiple pregnancies frequent in dogs lead to significant differences in extraction times between the first and the last puppy during cesarean section. Obtained results showed that the mode of anesthesia and the surgical time would influence the neonatal outcome during cesarean section in dogs. The higher concentration of isoflurane with the longer time of exposure had a negative effect on the initial newborn vitality as well as the umbilical cord blood gas parameters. Therefore, when performing CS in giant dog breeds or expecting many puppies in the litter, it is worth considering epidural component that allow for lower concentrations of inhalant agents, which may contribute to a better clinical condition of newborns.
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Affiliation(s)
- Agnieszka Antończyk
- Faculty of Veterinary Medicine, Department and Clinic of Surgery, Wroclaw University of Environmental and Life Sciences, Pl. Grunwaldzki 51, 50-366, Wrocław, Poland.
| | - Zdzisław Kiełbowicz
- grid.411200.60000 0001 0694 6014Faculty of Veterinary Medicine, Department and Clinic of Surgery, Wroclaw University of Environmental and Life Sciences, Pl. Grunwaldzki 51, 50-366 Wrocław, Poland
| | - Wojciech Niżański
- grid.411200.60000 0001 0694 6014Faculty of Veterinary Medicine, Department of Reproduction and Clinic of Farm Animals, Wroclaw University of Environmental and Life Sciences, Pl. Grunwaldzki 49, 50-366 Wrocław, Poland
| | - Małgorzata Ochota
- grid.411200.60000 0001 0694 6014Faculty of Veterinary Medicine, Department of Reproduction and Clinic of Farm Animals, Wroclaw University of Environmental and Life Sciences, Pl. Grunwaldzki 49, 50-366 Wrocław, Poland
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Red Blood Cell Transfusion in Patients With Placenta Accreta Spectrum: A Systematic Review and Meta-analysis. Obstet Gynecol 2023; 141:49-58. [PMID: 36701609 DOI: 10.1097/aog.0000000000004976] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/18/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate red blood cell use during delivery in patients with placenta accreta spectrum. DATA SOURCES We searched MEDLINE, EMBASE, CINAHL, Cochrane Central, ClinicalTrials.gov, and Scopus for clinical trials and observational studies published between 2000 and 2021 in countries with developed economies. METHODS OF STUDY SELECTION Abstracts (n=4,275) and full-text studies (n=599) were identified and reviewed by two independent reviewers. Data on transfused red blood cells were included from studies reporting means and SDs, medians with interquartile ranges, or individual patient data. The primary outcome was the weighted mean number of units of red blood cells transfused per patient. Between-study heterogeneity was assessed with an I2 statistic. Secondary analyses included red blood cell usage by placenta accreta subtype. TABULATION, INTEGRATION, AND RESULTS Of the 599 full-text studies identified, 20 met criteria for inclusion in the systematic review, comprising 1,091 cases of placenta accreta spectrum. The number of units of red blood cells transfused was inconsistently described across studies, with five studies (25.0%) reporting means, 11 (55.0%) reporting medians, and four (20.0%) reporting individual patient data. The weighted mean number of units transfused was 5.19 (95% CI 4.12-6.26) per patient. Heterogeneity was high across studies (I2=91%). In a sensitivity analysis of five studies reporting mean data, the mean number of units transfused was 6.61 (95% CI 4.73-8.48; n=220 patients). Further quantification of units transfused by placenta accreta subtype was limited due to methodologic inconsistencies between studies and small cohort sizes. CONCLUSION Based on the upper limit of the CI in our main analysis and the high study heterogeneity, we recommend that a minimum of 6 units of red blood cells be available before delivery for patients with placenta accreta spectrum. These findings may inform future guidelines for predelivery blood ordering and transfusion support. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021240993.
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Antończyk A, Ochota M. Is an epidural component during general anaesthesia for caesarean section beneficial for neonatal puppies' health and vitality? Theriogenology 2022; 187:1-8. [PMID: 35500422 DOI: 10.1016/j.theriogenology.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 10/18/2022]
Abstract
Regional centro-axial block is a recommended technique for uncomplicated caesarean section in human medicine. Since the application of regional anaesthesia as the only technique in veterinary medicine is impractical, the objective of the study was to assess and compare the epidural component of caesarean section (CS) on maternal and fetal outcomes. Bitches (n = 36) undergoing elective CS were enrolled in this study. Females were randomly assigned into two groups: Gr I (Isoflurane, n = 20) and Gr IE (Isoflurane plus Epidural, n = 16). Anaesthesia was induced with propofol, and maintained with isoflurane in oxygen. In the IE group, epidural anaesthesia was also performed using lidocaine. The maternal intraoperative parameters were compared at three time points: T1 - just before the skin incision, T2 - after the last puppy removal, and T3 - at the end of surgery. At least 100 mcl of mixed umbilical cord blood was collected for gas analysis. The modified Apgar scoring system (AS) was used to objectively score newborn health and vitality immediately after birth (0 min), 5 and 20 min after birth. Systolic, diastolic, and mean blood pressure were lower in the IE group at T1, T2, and T3 compared to I group (p < 0.05). In the combined anaesthesia group blood pressure remained stable but low at all time points. Throughout surgery, the IE group required a lower concentration of isoflurane (p < 0.05). The median values of the umbilical blood gas results were found to be similar (p > 0.05) in both investigated groups. The initial results of the Apgar score were comparable in the I and IE groups (p > 0.05). However, subsequent AS measurements revealed significant differences between both groups. Puppies from the IE group received better AS scores at 5 and 20 min compared to the I group (median AS 8 and 9 vs. 5 and 8, respectively). The results obtained demonstrated that epidural anaesthesia administration reduced the requirement for isoflurane in dams undergoing caesarean section and despite episodes of maternal hypotension did not affect the results of neonatal umbilical blood gas. Furthermore, newborns from the epidural anaesthesia group improved more quickly postnatally, developing a satisfactory condition in a shorter time.
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Affiliation(s)
- Agnieszka Antończyk
- Wroclaw University of Environmental and Life Sciences, Faculty of Veterinary Medicine, Department and Clinic of Surgery, pl. Grunwaldzki 51, 50-366, Wrocław, Poland.
| | - Małgorzata Ochota
- Wroclaw University of Environmental and Life Sciences, Faculty of Veterinary Medicine, Department of Reproduction and Clinic of Farm Animals, pl. Grunwaldzki 49, 50-366, Wrocław, Poland.
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Bao Y, Zhang T, Li L, Zhou C, Liang M, Zhou J, Wang C. A retrospective analysis of maternal complications and newborn outcomes of general anesthesia for cesarean delivery in a single tertiary hospital in China. BMC Anesthesiol 2022; 22:208. [PMID: 35794540 PMCID: PMC9258083 DOI: 10.1186/s12871-022-01753-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 06/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background Either neuraxial anesthesia or general anesthesia can be performed for cesarean delivery. Generally, neuraxial anesthesia is the first choice with the risk and benefit balance for both the mother and fetus. However, general anesthesia is also applicable most commonly in the emergent setting. This study analyzed maternal complications associated with general anesthesia for cesarean delivery and suggested lowering pregnancy-related maternal and newborn adverse outcomes. Methods With the approval of the Institutional Ethics Review Board (No: 2017016), data on cesarean delivery and related anesthesia were collected from the Electronic Health Record System from 1/1/2013 to 12/31/2016. Statistical software STATA version 15.1 was used for data analyses. All statistical tests were two-sided, and a level significance of 0.05 was assumed. Results The rate of general anesthesia for cesarean delivery increased steadily during 2013–2016, 3.71% in 2013 to 10.23% in 2016 (p < 0.001). Repeat cesarean delivery among general anesthesia group increased significantly from 16.22% in 2013 to 54.14% in 2016 (p < 0.001). Morbidly adherent placenta (MAP) was the first reason among pregnancy-related complications, which accounted for 33% in total in general anesthesia group (38% in 2013 to 44% in 2016). The laryngeal mask airway (LMA) was used in airway management, and the proportion of LMA increased from 28.38% in 2013 to 92.99% in 2016 (p < 0.001). There were significant differences in newborn outcomes between general anesthesia and neuraxial anesthesia groups, including newborn weight, newborn Apgar score at 1 min and 5 min and newborn admission to the NICU (p < 0.001). Conclusions The growing incidence of general anesthesia was consistent with the trend of rising repeat cesarean delivery and MAP. low newborn Apgar score and high newborn admission to the NICU in general anesthesia group compared with neuraxial anesthesia group. The LMA was performed safely for airway management with enough fasting and careful gastric volume evaluation.
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Touhami O, Allen L, Flores Mendoza H, Murphy MA, Hobson SR. Placenta accreta spectrum: a non-oncologic challenge for gynecologic oncologists. Int J Gynecol Cancer 2022; 32:ijgc-2021-003325. [PMID: 35478092 DOI: 10.1136/ijgc-2021-003325] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Placenta accreta spectrum disorders are a major risk factor for severe postpartum hemorrhage and maternal death worldwide, with a rapidly growing incidence in recent decades due to increasing rates of cesarean section. Placenta accreta spectrum disorders represent a complex surgical challenge, with the primary concern of massive obstetrical hemorrhagic sequelae and organ damage, occurring in the context of potentially significant anatomical and physiological changes of pregnancy. Most international obstetrical organizations have published guidelines on placenta accreta spectrum, embracing the creation of regionalized 'Centers of Excellence' in the diagnosis and management of placenta accreta spectrum, which includes a dedicated multidisciplinary surgical team. One mandatory criterion for these Centers of Excellence is the presence of a surgeon experienced in complex pelvic surgeries. Indeed, many institutions in the United States and worldwide rely on gynecologic oncologists in the surgical management of placenta accreta spectrum due to their experience and skills in complex pelvic surgery. Surgical management of placenta accreta spectrum frequently includes challenging pelvic dissection in regions with distortion of anatomy alongside large aberrant neovascularization. With a goal of definitive management through cesarean hysterectomy, surgeons require a systematic and thoughtful approach to promote prevention of urologic injuries, embrace measures to secure challenging hemostasis and, in selected cases, employ conservative management where indicated or desired. In this review recommendations are made for gynecologic oncologists regarding the management and important considerations in the successful care of placenta accreta spectrum disorders. Where required, gynecologic oncologists are encouraged to be proactively involved in the management of placenta accreta spectrum, not only intra-operatively, but also in the development of clinical protocols, guidelines, and pre-operative counseling of patients, as a 'call if needed' approach is suboptimal for this potentially major and life-threatening condition.
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Affiliation(s)
- Omar Touhami
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Centre Intégré Universitaire de Santé et Services Sociaux CIUSSS du Saguenay-Lac-Saint-Jean, Sherbrooke University, Sherbrooke, Quebec, Canada
| | - Lisa Allen
- Department of Obstetrics and Gynecology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Homero Flores Mendoza
- Department of Obstetrics and Gynecology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - M Alix Murphy
- Department of Obstetrics and Gynecology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Sebastian Rupert Hobson
- Department of Obstetrics and Gynecology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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Swanson K, Liang L, Grobman WA, Higgins N, Roy A, Son M. Duration of Exposure to General Endotracheal Anesthesia during Cesarean Deliveries at Term and Perinatal Complications. Am J Perinatol 2022; 39:232-237. [PMID: 34844279 DOI: 10.1055/s-0041-1739355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To examine whether the duration of time from initiation of general endotracheal anesthesia (GETA) to delivery for cesarean deliveries (CDs) performed is related to perinatal outcomes. STUDY DESIGN This is a retrospective study of patients with singleton nonanomalous gestations undergoing CD ≥37 weeks of gestation under GETA with reassuring fetal status at a single tertiary care center from 2000 to 2016. Duration from GETA initiation until delivery was calculated as the time interval from GETA induction to delivery (I-D), categorized into tertiles. Outcomes for those in the tertile with the shortest I-D were compared with those in the other two tertiles. The primary perinatal outcome was a composite of complications (continuous positive airway pressure or high-flow nasal cannula for ≥2 consecutive hours, inspired oxygen ≥30% for ≥4 consecutive hours, mechanical ventilation, stillbirth, or neonatal death ≤72 hours after birth). Secondary outcomes were 5-minute Apgar score <7 and a composite of maternal morbidity (bladder injury, bowel injury, and extension of hysterotomy). Bivariable and multivariable analyses were used to compare outcomes. RESULTS Two hundred eighteen maternal-perinatal dyads were analyzed. They were dichotomized based on I-D ≤4 minutes (those in the tertile with the shortest duration) or >4 minutes. Women with I-D >4 minutes were more likely to have prior abdominal surgery and less likely to have labored prior to CD. I-D >4 minutes was associated with significantly increased frequency of the primary perinatal outcome. This persisted after multivariable adjustment. In bivariable analysis, 5-minute Apgar <7 was more common in the group with I-D >4 minutes, but this did not persist in multivariable analysis. Frequency of maternal morbidity did not differ. CONCLUSION When CD is performed at term using GETA without evidence of nonreassuring fetal status prior to delivery, I-D interval >4 minutes is associated with increased frequency of perinatal complications. KEY POINTS · Cesarean delivery under general anesthesia is associated with increased perinatal complications.. · Perinatal complications are increased with increasing duration of exposure to general anesthetics.. · Maternal complications were not increased with shorter duration of exposure to general anesthesia..
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Affiliation(s)
- Kate Swanson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, California.,Division of Medical Genetics, Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Luzhou Liang
- Section of Obstetric Anesthesiology, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William A Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nicole Higgins
- Section of Obstetric Anesthesiology, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Archana Roy
- Department of Obstetrics & Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Moeun Son
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University, New Haven, Connecticut
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Warrick CM, Markley JC, Farber MK, Balki M, Katz D, Hess PE, Padilla C, Waters JH, Weiniger CF, Butwick AJ. Placenta Accreta Spectrum Disorders: Knowledge Gaps in Anesthesia Care. Anesth Analg 2022; 135:191-197. [DOI: 10.1213/ane.0000000000005862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Effect of Different Anesthesia Methods on Emergence Agitation and Related Complications in Postoperative Patients with Osteosarcoma. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:7120035. [PMID: 34950442 PMCID: PMC8692017 DOI: 10.1155/2021/7120035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/11/2021] [Accepted: 11/20/2021] [Indexed: 11/17/2022]
Abstract
Purpose To explore the effect of different anesthesia methods on emergence agitation (EA) and related complications in postoperative patients with osteosarcoma. Methods According to the order of admission, 115 patients requiring osteosarcoma surgery treated in our hospital from January 2018 to December 2020 were selected as the research object and randomly divided into the control group (n = 57, accepted the general anesthesia with tracheal intubation) and the experimental group (n = 58, accepted the combined spinal-epidural anesthesia) to compare their anesthesia effect, incidence rates of agitation and complications, and other indexes. Results In terms of the hemodynamic indexes (MAP, HR, and CVP values), both groups had lower ones at T1 than at T0, but the decline of the experimental group was generally lesser than that of the control group; at T2, no statistical difference was shown within the experimental group's indexes when comparing with those at T1, but the control group obtained a significant increase; at T3 and T4, both groups had their hemodynamic indexes increased, but such increase within the experimental group showed no statistical difference when comparing with those at T0, while the control group achieved obviously higher values at T4 than at T0 (before the anesthesia); and the between-group difference in the hemodynamic indexes at T1 and T4 was significant. Compared with the control group, the experimental group achieved better VAS scores and anesthesia indexes and lower incidence rates of EA and complications such as the hypoxemia, cardiovascular response, delayed recovery, and headache. In addition, the differences in the incidence rates of hypotension and cognitive dysfunction between the two groups were not statistically significant. Conclusion When comparing with tracheal intubation general anesthesia, the combined spinal-epidural anesthesia has a better effect in osteosarcoma surgery, with less hemodynamics influence on patients, reduced postoperative pain and stress reaction, and lowered incidence rates of postoperative EA and complications, which is worthy of wide application in clinical treatment.
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Herbert KA, Gatta LA, Fuller M, Grotegut CA, Gilner J, Habib AS. Anesthetic management of placenta accreta spectrum at an academic center and a comparison of the combined spinal epidural with the double catheter technique: A retrospective study. J Clin Anesth 2021; 77:110573. [PMID: 34883414 DOI: 10.1016/j.jclinane.2021.110573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVES To describe the anesthetic management and outcomes of placenta accreta spectrum (PAS) cases at our institution over a 19 year period and to compare outcomes associated with the lumbar combined spinal epidural (CSE) technique versus the double catheter technique (lumbar CSE with thoracic epidural catheter). DESIGN Retrospective cohort study. SETTING Labor and delivery unit at a tertiary care center. PATIENTS 113 female patients who had histologically confirmed PAS on the final pathology report after cesarean delivery or cesarean hysterectomy. INTERVENTION Neuraxial anesthesia, including CSE and the double catheter technique, and general anesthesia for PAS cases (including scheduled and unscheduled cases and those known or unknown as PAS preoperatively). MEASUREMENTS The medical records were reviewed for demographic information, intraoperative management, anesthetic technique, and outcomes. We describe anesthetic management and outcomes of cases classified as scheduled vs. unscheduled and known vs. unknown PAS. We also compare the CSE and double catheter techniques with the primary outcome being conversion to general anesthesia (GA). MAIN RESULTS We included 113 cases: 60 (53.1%) scheduled/known cases, 12 (10.6%), scheduled/unknown cases, 22 (19.5%) unscheduled/known, and 19 (16.8%) unscheduled/unknown cases. All scheduled cases except two were started with a neuraxial technique. General anesthesia (GA) was used to start 18/41 (44%) of unscheduled cases. The double catheter technique (n = 35) was associated with a lower GA conversion rate (5.7% vs. 29.7%, P = 0.036) compared to the CSE technique (n = 37). CONCLUSIONS Neuraxial anesthesia is the most commonly used technique for PAS cases in our practice. The double catheter technique was associated with lower GA conversion rates compared to the CSE technique in our cohort.
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Affiliation(s)
- Katherine A Herbert
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States.
| | - Luke A Gatta
- Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC, United States.
| | - Matthew Fuller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States.
| | - Chad A Grotegut
- Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC, United States.
| | - Jennifer Gilner
- Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC, United States.
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States.
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Panjeton GD, Reynolds PS, Saleem D, Mehkri Y, Samra R, Wendling A. Neuraxial anesthesia and postoperative opioid administration for cesarean delivery in patients with placenta accreta spectrum disorder: a retrospective cohort study. Int J Obstet Anesth 2021; 49:103220. [PMID: 34598859 DOI: 10.1016/j.ijoa.2021.103220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 08/17/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is no consensus on optimal anesthetic and analgesic management of patients presenting for cesarean delivery with suspected placenta accreta spectrum disorder. Neuraxial anesthesia is preferred for uncomplicated procedures, but general anesthesia may be indicated for those at risk of hemorrhage and hysterectomy. We compared the effect of anesthesia techniques on postoperative maternal opioid administration and neonatal respiratory distress. METHODS A single-center retrospective study from 2016 to 2019 using electronic records to identify singleton pregnancies with a high index of suspicion of placenta accreta spectrum disorder. Patients were categorized by the anesthetic technique they received: general, neuraxial, or neuraxial with conversion to general anesthesia following delivery. Postoperative maternal opioid administration (oral morphine in mg equivalents) and risk of neonatal respiratory distress were compared using linear mixed models. RESULTS Thirty-nine records were analyzed. Mean-adjusted oral morphine mg equivalents were 192 for patients receiving general anesthesia vs. 90 for neuraxial anesthesia only (P=0.009) and 104 for neuraxial with conversion to general anesthesia (P=0.052). Neonates delivered under general anesthesia had a 3.5 times relative risk (95% CI 1.3 to 9.8, P=0.017) of respiratory distress compared with those exposed to neuraxial anesthesia alone. CONCLUSION Patients receiving general anesthesia alone were administered more opioids than those undergoing neuraxial anesthesia or neuraxial with conversion to general anesthesia. This finding was maintained when accounting for whether or not the patient underwent hysterectomy. Deciding on anesthetic management requires consideration of patient comorbidities, severity of placenta accreta spectrum pathology, and surgical requirements.
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Affiliation(s)
- G D Panjeton
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA.
| | - P S Reynolds
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA; Statistics in Anesthesiology Research (STAR) Core, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - D Saleem
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Y Mehkri
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - R Samra
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - A Wendling
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
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Jain V, Bos H, Bujold E. Guideline No. 402: Diagnosis and Management of Placenta Previa. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 42:906-917.e1. [PMID: 32591150 DOI: 10.1016/j.jogc.2019.07.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 07/24/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To summarize the current evidence and to make recommendations for diagnosis and classification of placenta previa and for managing the care of women with this diagnosis. OPTIONS To manage in hospital or as an outpatient and to perform a cesarean delivery preterm or at term or to allow a trial of labour when a diagnosis of placenta previa or a low-lying placenta is suspected or confirmed. OUTCOMES Prolonged hospitalization, preterm birth, rate of cesarean delivery, maternal morbidity and mortality, and postnatal morbidity and mortality. INTENDED USERS Family physicians, obstetricians, midwives, and other maternal care providers. TARGET POPULATION Pregnant women with placenta previa or low-lying placenta. EVIDENCE Medline, PubMed, Embase, and the Cochrane Library were searched from inception to October 2018. Medical Subject Heading (MeSH) terms and key words related to pregnancy, placenta previa, low-lying placenta, antepartum hemorrhage, short cervical length, preterm labour, and cesarean. This document represents an abstraction of the evidence rather than a methodological review. VALIDATION METHODS This guideline has been reviewed by the Maternal-Fetal Medicine and Diagnostic Imaging committees of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and approved by the SOGC Board of Directors. BENEFITS, HARMS, AND/OR COSTS Women with placenta previa or low-lying placenta are at increased risk of maternal, fetal and postnatal adverse outcomes that include a potentially incorrect diagnosis and possibly unnecessary hospitalization, restriction of activities, early delivery, or cesarean delivery. Optimization of diagnosis and management protocols has potential to improve maternal, fetal and postnatal outcomes. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES) RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
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Advances in anesthetic and obstetric management of patients with placenta accreta spectrum. Curr Opin Anaesthesiol 2021; 34:260-268. [PMID: 33935172 DOI: 10.1097/aco.0000000000000985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The incidence of placenta accreta spectrum is increasing and it is a leading cause of peripartum hysterectomy and massive postpartum hemorrhage. The purpose of the present article is to provide a contemporary overview of placenta accreta spectrum pertinent to the obstetric anesthesiologist. RECENT FINDINGS Recent changes in the terminology used to report invasive placentation were proposed to clarify diagnostic criteria and guidelines for use in clinical practice. Reduced morbidity is associated with scheduled preterm delivery in a center of excellence using a multidisciplinary team approach. Neuraxial anesthesia as a primary technique is increasingly being used despite the known risk of major bleeding. The use of viscoelastic testing and endovascular interventions may aid hemostatic resuscitation and improve outcomes. SUMMARY Accurate diagnosis and early antenatal planning among team members are essential. Obstetric anesthesiologists should be prepared to manage a massive hemorrhage, transfusion, and associated coagulopathy. Increasingly, viscoelastic tests are being used to assess coagulation status and the ability to interpret these results is required to guide the transfusion regimen. Balloon occlusion of the abdominal aorta has been proposed as an intervention that could improve outcomes in women with placenta accreta spectrum, but high-quality safety and efficacy data are lacking.
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Minimally Invasive Hemodynamic Assessment during Obstetric Hysterectomy for Invasive Placentation with Epidural Anesthesia. Anesthesiol Res Pract 2020; 2020:1968354. [PMID: 33193758 PMCID: PMC7641720 DOI: 10.1155/2020/1968354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/18/2020] [Accepted: 10/14/2020] [Indexed: 11/18/2022] Open
Abstract
Background The present study aimed to describe the evolution of hemodynamic parameters over time of patients with invasive placentation during their third trimester who were delivered via cesarean section and subsequently underwent obstetric hysterectomy under epidural anesthesia. Methods A prospective, descriptive, longitudinal, 11-month cohort study of 43 patients aged between 18 and 37 years who presented with invasive placentation. Minimal invasive monitoring was placed before the administration of epidural anesthesia for hemodynamic parameter tracking during the cesarean section. After delivery, the patients underwent an obstetric hysterectomy. Blood loss, hemodynamic parameters, and coagulation were managed via goal-directed therapy. Parameters were compared via repeated measures ANOVA and effect size estimation (Cohen's d). Results The mean age of the patients was 29.2 ± 3.4 years and was moderately overweight. They had minor cardiac index variance (P=NS, no significance), vascular systemic resistance index (NS), heart rate (P=NS), and median arterial pressure (P=NS). Differences were observed in the stroke volume index (P=0.015) due to moderately higher values (d = 0.3, P=0.016) in the middle of the surgery. Patients had lower cardiac index (d = -0.36, NS) and cardiac workload requirements (d = -0.29, P=0.034) toward the completion of surgery. Conclusion Patients who are in their third trimester and who subsequently underwent obstetric hysterectomy under epidural anesthesia had modest surgical hemodynamic variance and reduced cardiac workload requirements toward the end of the surgery.
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Hawkins R, Evans M, Hammond S, Hartopp R, Evans E. Placenta accreta spectrum disorders - Peri-operative management: The role of the anaesthetist. Best Pract Res Clin Obstet Gynaecol 2020; 72:38-51. [PMID: 32888811 DOI: 10.1016/j.bpobgyn.2020.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 12/20/2022]
Abstract
The incidence of placenta accreta spectrum (PAS) is increasing and will become more commonly encountered by obstetric anaesthetists in the elective and emergency settings. Significant maternal and neonatal morbidity is associated with these disorders, and hence it is important for anaesthetists to have early involvement in perioperative planning. Major haemorrhage should be anticipated and requires robust perioperative preparation including Patient Blood Management (PBM) and use of intraoperative strategies for haemorrhage management wherever possible. Several institutions have demonstrated good outcomes with regional anaesthesia alone, but the choice of anaesthetic technique requires individualised planning considering patient, anaesthetic and surgical factors. Optimisation of postoperative analgesia needs additional consideration; it is key to good recovery, minimising the impact on quality of life and reducing the risk of persistent post-surgical pain. Further research is required to ascertain the optimal multi-modal analgesic regime including the role of peripheral nerve blockade.
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Affiliation(s)
- Richard Hawkins
- Department of Anaesthesia, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, Tooting, London, SW17 0QT, United Kingdom.
| | - Matthew Evans
- Department of Anaesthesia, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, Tooting, London, SW17 0QT, United Kingdom
| | - Sarah Hammond
- Department of Anaesthesia, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, Tooting, London, SW17 0QT, United Kingdom
| | - Richard Hartopp
- Department of Anaesthesia, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, Tooting, London, SW17 0QT, United Kingdom
| | - Emma Evans
- Department of Anaesthesia, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, Tooting, London, SW17 0QT, United Kingdom
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Management of abnormal invasive placenta in a low- and medium-resource setting. Best Pract Res Clin Obstet Gynaecol 2020; 72:117-128. [PMID: 32900599 DOI: 10.1016/j.bpobgyn.2020.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 12/22/2022]
Abstract
The purpose of this review is to describe the panorama of placenta accreta spectrum (PAS) disorder management in low- and middle-income countries, providing information that allows for the improvement of maternal and perinatal outcomes in the management of this pathology. This spectrum of disorders is associated with implications of high morbidity and mortality, both maternal and perinatal, which is why clinical practice guidelines based on management are produced in settings where there is a wide range of available resources. This situation often contrasts with what the reality is in low-resource countries. Prenatal diagnosis of placental accreta is essential to carry out adequate surgical planning in centres where multidisciplinary teams are in place, which improve results and reduce complications. These ideal scenarios should be developed in countries with more significant difficulties in the availability of human and technological resources, through teamwork in the different hospital centres and the adequate transfer of patients at higher risk to centres with the best interdisciplinary management skills.
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Jain V, Bos H, Bujold E. Directive clinique no 402 : Placenta prævia : Diagnostic et prise en charge. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:918-930.e1. [DOI: 10.1016/j.jogc.2020.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
PURPOSE OF REVIEW Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality in the United States, and worldwide. Recognition of PPH is challenging, but once hemorrhage is recognized, management needs to focus on achieving adequate uterine tone and maintaining maternal hemodynamic stability. There have been several advances in the management of postpartum hemorrhage, many of which can be implemented at the labor and delivery unit level. RECENT FINDINGS There have been many advances in the understanding of at-risk parturients, and the use of hemorrhage protocols and safety bundles have been shown to improve patient outcomes. There are many new advances in transfusion management (e.g. fibrinogen concentrate, prothrombin complex concentrate, tranexamic acid) that can compliment traditional component therapy. Consideration should be given to transferring women at high risk for complications (e.g. invasive placentation) to a higher level facility for delivery. SUMMARY Although postpartum hemorrhage itself may not be preventable, early identification of blood loss, and mobilization of resources may prevent adverse outcomes. Multidisciplinary planning at the system level, ensuring that hemorrhage protocols exist, as well as for management of high-risk patients is important for improving patient outcomes.
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Markley JC, Farber MK, Perlman NC, Carusi DA. Neuraxial Anesthesia During Cesarean Delivery for Placenta Previa With Suspected Morbidly Adherent Placenta: A Retrospective Analysis. Anesth Analg 2019; 127:930-938. [PMID: 29481427 DOI: 10.1213/ane.0000000000003314] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND General anesthesia (GA) is often selected for cesarean deliveries (CD) with placenta previa and suspected morbidly adherent placenta (MAP) due to increased risk of hemorrhage and hysterectomy. We reviewed maternal outcomes and risk factors for conversion to GA in a cohort of patients undergoing CD and hysterectomy under neuraxial anesthesia (NA). METHODS We performed a single-center, retrospective cohort study of parturients undergoing nonemergent CD for placenta previa with suspected MAP from 1997 to 2015. Patients were classified according to whether they received GA, NA, or intraoperative conversion from NA to GA. The primary outcome measure was postoperative acuity, defined as the need for intensive care unit admission, arterial embolization, reoperation, or ongoing transfusion with ≥3 units packed red blood cells. We additionally identified variables positively associated with intraoperative conversion from NA to GA during hysterectomy. Confounding was controlled with logistic regression models. RESULTS Of 129 patients undergoing nonemergent CD for placenta previa with suspected MAP, 122 (95%) received NA as the primary anesthetic. NA was selected in the majority of patients with a body mass index ≥40 kg/m (9 of 10, 90%), a history of ≥3 prior CDs (18 of 20, 90%), suspected placenta increta or percreta (29 of 35, 83%), and Mallampati classification ≥3 (19 of 21, 90%). Of 72 patients with NA at the time of delivery who required hysterectomy, 15 (21%) required conversion to GA intraoperatively. Converted patients had a higher rate of major packed red blood cell transfusion (60% vs 25%; P = .01), with similar rates of massive transfusion (9% vs 7%; P = 1.0). Converted patients also had a higher incidence of postoperative acuity (47% vs 4%; P < .0001), including 5 intensive care unit admissions for airway management after large-volume resuscitation. After adjusting for multiple confounders, the only independent predictors of conversion among hysterectomy patients were longer surgical duration (adjusted odds ratio 1.54, 95% CI, 1.01-2.42) and a history of ≥3 prior CDs (adjusted odds ratio, 6.45; 95% CI, 1.12-45.03). CONCLUSIONS NA was applied to and successfully used in the majority of patients with suspected MAP. Our findings support selective conversion to GA during hysterectomy in these patients, focusing on those with the highest levels of surgical complexity.
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Affiliation(s)
- John C Markley
- From the Department of Anesthesia and Perioperative Care, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, California
| | - Michaela K Farber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Daniela A Carusi
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Hobson SR, Kingdom JC, Murji A, Windrim RC, Carvalho JC, Singh SS, Ziegler C, Birch C, Frecker E, Lim K, Cargill Y, Allen LM. No 383 – Dépistage, diagnostic et prise en charge des troubles du spectre du placenta accreta. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1050-1066. [DOI: 10.1016/j.jogc.2019.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hobson SR, Kingdom JC, Murji A, Windrim RC, Carvalho JC, Singh SS, Ziegler C, Birch C, Frecker E, Lim K, Cargill Y, Allen LM. No. 383-Screening, Diagnosis, and Management of Placenta Accreta Spectrum Disorders. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1035-1049. [DOI: 10.1016/j.jogc.2018.12.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Bourgioti C, Zafeiropoulou K, Fotopoulos S, Nikolaidou ME, Theodora M, Daskalakis G, Tzavara C, Chatoupis K, Panourgias E, Antoniou A, Konstantinidou A, Moulopoulos LA. MRI prognosticators for adverse maternal and neonatal clinical outcome in patients at high risk for placenta accreta spectrum (PAS) disorders. J Magn Reson Imaging 2018; 50:602-618. [PMID: 30578609 DOI: 10.1002/jmri.26592] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/14/2018] [Accepted: 11/14/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Placenta accreta spectrum (PAS) disorders may be associated with significant mortality and morbidity for both mother and fetus. PURPOSE/HYPOTHESIS To identify MRI risk factors for poor peripartum outcome in gravid patients at risk for PAS. STUDY TYPE Prospective. POPULATION One hundred gravid women (mean age: 34.9 years) at third trimester, with placenta previa. FIELD STRENGTH/SEQUENCE T2 -SSTSE (single-shot turbo spin echo), T2 -TSE, T1 -TSEFS (TSE images with fat-suppression) at 1.5T. ASSESSMENT Fifteen MRI features considered indicative of PAS were recorded by three radiologists and were tested for any association with the following adverse peripartum maternal and neonatal events: increased operation time, profound blood loss, hysterectomy, bladder repair, ICU admission, prematurity, low birthweight, and 5-minute APGAR score <7. STATISTICAL TESTS Kappa (K) coefficients were computed as a measure of agreement between intraoperative information/histology and MRI results as well as for interobserver agreement; chi-square and Fisher's exact tests were used to explore the association of the MRI signs with clinical complications. A score was calculated by adding all recorded MRI signs and its predictive ability was tested using receiver operating characteristic (ROC) analysis, against all complications, separately; odds ratios (ORs) for optimal cutoffs were determined with logistic regression analysis. RESULTS There was excellent agreement (K >0.75, P < 0.001) between MRI and intraoperative findings for invasive placenta, bladder and parametrial involvement. Intraplacental T2 dark bands, myometrial disruption, uterine bulge, and hypervascularity at the utero-placental interface or parametrium, showed significant association (P < 0.005) with poor clinical outcome for both mother and fetus. The MRI score showed significant predictive ability for each adverse maternal event (area under the curve [AUC]: 0.85-0.97, P < 0.001). The presence of ≥3 MRI signs was the cutoff point for a complicated delivery (OR: 19.08, 95% confidence interval [CI]: 6.05-60.13) and ≥6 MRI signs was the cutoff point for massive bleeding (OR: 90.93, 95% CI: 11.3-729.23), hysterectomy (OR: 72.5, 95% CI: 17.9-293.7), or extensive bladder repair (OR: 58.74, 95% CI: 7.35-469.32). The MRI score was not significant for predicting adverse neonatal events including preterm delivery (P = 0.558), low birthweight (P = 0.097), and 5-minute Apgar score (P = 0.078). DATA CONCLUSION Preoperative identification of specific MRI features may predict peripartum course in high-risk patients for PAS. LEVEL OF EVIDENCE 1 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2019;50:602-618.
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Affiliation(s)
- Charis Bourgioti
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece
| | - Konstantina Zafeiropoulou
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece
| | - Stavros Fotopoulos
- Department of Gynaecology and Obstetrics, IASO Maternity Hospital, Athens, Greece
| | | | - Marianna Theodora
- Department of Fetal and Maternal Medicine, First Department of Gynaecology and Obstetrics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - George Daskalakis
- Department of Fetal and Maternal Medicine, First Department of Gynaecology and Obstetrics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Chara Tzavara
- Department of Health, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Chatoupis
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece
| | - Evangelia Panourgias
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece
| | - Aristeidis Antoniou
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece
| | - Anastasia Konstantinidou
- First Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Lia Angela Moulopoulos
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece
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Allen L, Jauniaux E, Hobson S, Papillon-Smith J, Belfort MA. FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management. Int J Gynaecol Obstet 2018; 140:281-290. [PMID: 29405317 DOI: 10.1002/ijgo.12409] [Citation(s) in RCA: 171] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Lisa Allen
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Sebastian Hobson
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | | | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Pavilion for Women, Texas Medical Center, Houston, TX, USA
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Toledano RD, Leffert LR. Anesthetic and Obstetric Management of Placenta Accreta: Clinical Experience and Available Evidence. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0200-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Walker MG, Pollard L, Talati C, Carvalho JC, Allen LM, Kachura J, Murji A, Kingdom JC, Windrim R. Obstetric and Anaesthesia Checklists for the Management of Morbidly Adherent Placenta. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:1015-1023. [DOI: 10.1016/j.jogc.2016.08.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 07/07/2016] [Indexed: 12/15/2022]
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