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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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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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Loreto M, Pisanti M, Celentani M, Pasta G, Erman A, Santangelo C, Giaccari LG, Sansone P, Villani R. Non invasive hemodynamic monitoring for fluids and blood resuscitation during placenta praevia accreta cesarean delivery: a retrospective observational study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:54. [PMID: 37386677 DOI: 10.1186/s44158-022-00083-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/06/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND We carry out a retrospective observational analysis of clinical records of patients with major placenta praevia who underwent cesarean section surgery over a period of 20 months in our hospital. Out of a total of 40 patients, 20 were subjected to Goal-Directed Therapy (GDT) implemented with non-invasive hemodynamic monitoring using the EV1000 ClearSight system (Group I) and 20 to standard hemodynamic monitoring (Group II). Given the risk of conspicuous blood loss, this study evaluate the impact on maternal and fetal health of GDT relative to standard hemodynamic monitoring. RESULTS Average total infusion of fluids was 1600 +/- 350 ml. Use of blood products occurred in 29 patients (72,5%), of which 11 had a hysterectomy and 8 were treated with Bakri Balloons. For 2 patients > 1000 mL of concentrated red blood cells were used. When stroke volume index SVI dropped below 35 mL/m2/beat, it responded well to the infusion of at least 2 crystalloid boluses (5 ml/kg) in 7 patients. Cardiac index (CI) increased in 8 patients in concomitance with a reduction in medium arterial pressure (MAP), but the use of ephedrine (10 mg iv) re-established acceptable baseline values. Group I means are higher than Group II means for MAP, lower for RBC usage, end-of-surgery maternal lactates and fetal pH, and for LOS. Statistical analysis determines that the null hypotheses of equalities between Groups I and II can be rejected for all measures apart from MAP at baseline and induction. Proportions of serious complications in Groups I and II are respectively 10% and 32% and Boschloo's test rejects the null of equality of proportions against the alternative hypothesis of lower proportion of occurrence in Group I than in Group II. CONCLUSIONS Hypovolemia can lead to vasoconstriction and inadequate perfusion with decreased oxygen delivery to organs and peripheral tissues and ultimately cause organ dysfunction. Despite the small sample size due to the rarity of the pathology, our statistical analysis finds evidence in favor of more favorable clinical outcomes for patients who received GDT implemented with non-invasive hemodynamic monitoring infusion relative to patients who received standard hemodynamic monitoring.
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Affiliation(s)
- Maria Loreto
- Hospital of National Relevance "A. Cardarelli", Naples, Italy
| | - Massimo Pisanti
- Hospital of National Relevance "A. Cardarelli", Naples, Italy
| | - Marco Celentani
- Department of Economics, Universidad Carlos III de Madrid, Madrid, Spain
| | - Gilda Pasta
- National Cancer Institute IRCCS - "G. Pascale" Foundation, Naples, Italy
| | - Alfredo Erman
- Fatebenefratelli "S. Giovanni di Dio" Hospital, Naples, Italy
| | | | | | | | - Romolo Villani
- Hospital of National Relevance "A. Cardarelli", Naples, Italy
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Enste R, Cricchio P, Dewandre PY, Braun T, Leonards CO, Niggemann P, Spies C, Henrich W, Kaufner L. Placenta accreta spectrum part I: anesthesia considerations based on an extended review of the literature. J Perinat Med 2022; 51:439-454. [PMID: 36181730 DOI: 10.1515/jpm-2022-0232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022]
Abstract
"Placenta accreta spectrum" (PAS) describes abnormal placental adherence to the uterine wall without spontaneous separation at delivery. Though relatively rare, PAS presents a particular challenge to anesthesiologists, as it is associated with massive peripartum hemorrhage and high maternal morbidity and mortality. Standardized evidence-based PAS management strategies are currently evolving and emphasize: "PAS centers of excellence", multidisciplinary teams, novel diagnostics/pharmaceuticals (especially regarding hemostasis, hemostatic agents, point-of-care diagnostics), and novel operative/interventional approaches (expectant management, balloon occlusion, embolization). Though available data are heterogeneous, these developments affect anesthetic management and must be considered in planed anesthetic approaches. This two-part review provides a critical overview of the current evidence and offers structured evidence-based recommendations to help anesthesiologists improve outcomes for women with PAS. This first part discusses PAS management in centers of excellence, multidisciplinary care team, anesthetic approach and monitoring, surgical approaches, patient safety checklists, temperature management, interventional radiology, postoperative care and pain therapy. The diagnosis and treatment of hemostatic disturbances and preoperative prepartum anemia, blood loss, transfusion management and postpartum venous thromboembolism will be addressed in the second part of this series.
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Affiliation(s)
- Rick Enste
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Patrick Cricchio
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Pierre-Yves Dewandre
- Department of Anesthesia and Intensive Care Medicine, Université de Liège, Liege, Belgium
| | - Thorsten Braun
- Department of Obstetrics and 'Exp. Obstetrics', Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christopher O Leonards
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Phil Niggemann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics and 'Exp. Obstetrics', Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lutz Kaufner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Abstract
The incidence of placenta accreta spectrum (PAS) is increasing and is now about 3 per 1000 deliveries, largely due to the rising cesarean section rate. Ultrasound is the preferred method for diagnosis of PAS. Ultrasound markers include multiple vascular lacunae, loss of the hypoechoic retroplacental zone, abnormalities of the uterine serosa-bladder interface, retroplacental myometrial thickness less than 1 mm, increased placental vascularity, and observation of bridging vessels linking the placenta and bladder. Patients with PAS should be managed by experienced multidisciplinary teams. Hysterectomy is the accepted management of PAS and conservative or expectant management of PAS should be considered investigational.
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Sindos M, Kalmatis K, Samartzis K, Diakosavvas M, Kalampalikis A, Kalopita K, Stamatakis E, Valsamidis D, Daskalakis G. Peripartum Ηysterectomy: A Four-Year Obstetric and Anesthetic Experience in a Tertiary Referral Hospital in Greece. Cureus 2022; 14:e25062. [PMID: 35719763 PMCID: PMC9201674 DOI: 10.7759/cureus.25062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 11/05/2022] Open
Abstract
Background Although peripartum hysterectomy (PH) is a life-saving procedure in cases of abnormal placentation and postpartum hemorrhage, it can be associated with major obstetric and anesthetic complications. This retrospective study aimed to evaluate the incidence, etiology, perioperative anesthetic and obstetric management, complications, and fetal outcomes in women undergoing PH in a single tertiary referral hospital in Greece. Methodology This was a retrospective analysis of medical records of women who underwent emergency or elective PH in our hospital between January 2015 and December 2018. Results During the study period, 69 women who underwent a PH were identified. The incidence rate of elective and emergency PH was 4 and 1.2 per 1,000 deliveries, respectively. The main indication for PH was abnormal placentation (81.2%), followed by uterine atony (13%). Conversion to general anesthesia (GA) was performed in 21 (30.4%) cases. Conclusions This study showed a high prevalence of PH in our hospital compared to high-income countries. A neuraxial-only technique may be a safe alternative in individual cases of abnormal placentation. Conversion to GA can be reserved for complex surgical cases when massive hemorrhage is anticipated and, if possible, after the neonate has been delivered.
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Fiszer E, Weiniger CF. Placenta accreta. A review of current anesthetic considerations. Best Pract Res Clin Anaesthesiol 2022; 36:157-164. [DOI: 10.1016/j.bpa.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 01/17/2022] [Accepted: 01/20/2022] [Indexed: 10/19/2022]
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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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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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Alves ÁLL, Silva LBD, Costa FDS, Rezende GDC. Management of placenta accreta spectrum. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:713-723. [PMID: 34670307 PMCID: PMC10183858 DOI: 10.1055/s-0041-1736371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
| | | | - Fabrício da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine, Griffith University, Gold Coast, Queensland, Australia
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11
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Riveros-Perez E, Sanchez MG, Odo N, Shukla M, Rungruang B. Supra-massive transfusion and interdisciplinary approach to cesarean hysterectomy due to complex placenta percreta: Case report. SAGE Open Med Case Rep 2021; 9:2050313X211010011. [PMID: 33959282 PMCID: PMC8060747 DOI: 10.1177/2050313x211010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/22/2021] [Indexed: 11/29/2022] Open
Abstract
Placenta accreta spectrum encompasses a group of conditions of abnormal placental infiltration of the uterine wall and surrounding tissues. It is associated with significant blood loss, perioperative morbidity, and risk of death. A coordinated interdisciplinary approach to these complex cases and early resuscitation with blood products are critical factors in the successful management of patients affected by this disease. We describe the successful management of a patient with placenta percreta who required supra-massive transfusion of blood products and interventions by different specialized teams in a tertiary care center.
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Affiliation(s)
- Efrain Riveros-Perez
- Department of Anesthesiology and
Perioperative Medicine, Medical College of Georgia at Augusta University,
Augusta, GA, USA
- Outcomes Research Consortium,
Cleveland Clinic, Cleveland, OH, USA
| | - Maria Gabriela Sanchez
- Department of Anesthesiology and
Perioperative Medicine, Medical College of Georgia at Augusta University,
Augusta, GA, USA
| | - Nadine Odo
- Department of Anesthesiology and
Perioperative Medicine, Medical College of Georgia at Augusta University,
Augusta, GA, USA
| | - Mrinal Shukla
- Vascular Surgery Division,
Department of Surgery, Medical College of Georgia at Augusta University,
Augusta, GA, USA
| | - Bunya Rungruang
- Division of Gynecologic Oncology,
Department of Obstetrics and Gynecology, Medical College of Georgia at
Augusta University, Augusta, GA, USA
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12
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Einerson BD, Weiniger CF. Placenta accreta spectrum disorder: updates on anesthetic and surgical management strategies. Int J Obstet Anesth 2021; 46:102975. [PMID: 33784573 DOI: 10.1016/j.ijoa.2021.102975] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 01/31/2021] [Accepted: 02/24/2021] [Indexed: 12/15/2022]
Abstract
Placenta accreta spectrum (PAS) is a leading contributor to major obstetric hemorrhage and severe maternal morbidity in the developed world. In the United States, PAS has become the most common cause of peripartum hysterectomy. Over the last 40 years, clinicians have also witnessed a dramatic increase in the incidence of PAS. In the 1950s, the incidence of PAS was reported to be 0.03 per 1000 pregnancies. Recent epidemiological studies estimate that the PAS incidence is between 0.79 and 3.11 in 1000 pregnancies. As a consequence, obstetric anesthesiologists are increasingly likely to be called upon to manage women with suspected PAS for delivery. Given the increasing incidence and the morbidity burden associated with PAS, anesthesiologists play a vital role in optimizing maternal outcomes for women with PAS. This review will provide up-to-date information on nomenclature, pathophysiology, risk factors, antenatal detection, systemic preparations (includes timing of delivery, location of surgery, pre-operative evaluation and patient positioning), surgical and anesthetic approach, intra-operative management, invasive radiology and postoperative plans.
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Affiliation(s)
- B D Einerson
- University of Utah Health Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Salt Lake City, Utah, USA.
| | - C F Weiniger
- Division of Anesthesia, Critical Care and Pain, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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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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Chandraharan E, Hartopp R, Thilaganathan B, Coutinho CM. How to set up a regional specialist referral service for Placenta Accreta Spectrum (PAS) disorders? Best Pract Res Clin Obstet Gynaecol 2020; 72:92-101. [PMID: 32747327 DOI: 10.1016/j.bpobgyn.2020.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 12/22/2022]
Abstract
There has been an approximately fivefold increase in the incidence of placenta accreta spectrum (PAS) disorders during the last 30 years, believed to be secondary to increasing Caesarean section rates. PAS disorder is associated with significantly increased maternal morbidity and mortality worldwide. Antenatal diagnosis by foetal medicine teams that have a special expertise to diagnose PAS disorder by the use of ultrasound scan, and a dedicated, highly specialised multidisciplinary team (MDT) comprising surgeons who are skilled in complex pelvic surgery and obstetric anaesthetists who have an expertise in high-risk obstetric anaesthesia, supported by haematology, operating theatre, interventional radiology, midwifery, neonatology, high-dependency and intensive care teams have been recommended to improve maternal and perinatal outcomes. Setting up a specialist MDT regional referral service, PAS involves collaboration with all stakeholders, ensuring appropriate funding, developing MDT care pathways, continuously auditing patient outcomes and disseminating knowledge through research, innovation, education and publications.
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Affiliation(s)
- Edwin Chandraharan
- Global Academy of Medical Education & Training, Office 4, 219 Kensington High Street, Kensington, London, England, W8 6BD, UK.
| | - Richard Hartopp
- St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, England, SW 17 0QT, UK.
| | - Baskaran Thilaganathan
- St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, England, SW 17 0QT, UK.
| | - Conrado Milani Coutinho
- Ribeirão Preto Medical School, University of São Paulo, Campus Universitário S/N, Ribeirão Preto, SP, CEP: 14048-900, Brazil.
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Abstract
PURPOSE OF REVIEW The prevalence of cesarean delivery is increasing worldwide despite the advance of Trial of Labor After Cesarean section. In many countries, a history of previous cesarean section is an almost absolute indication for a repeat cesarean section. The purpose of this review was to examine if the perioperative anesthetic management of patients with repeat cesarean section is different from the anesthetic management of patients with primary cesarean section. RECENT FINDINGS This review discusses important topics, such as early diagnosis of cases with a potentially high risk for complications; the need for assessment of patients diagnosed with abnormal placentation; the importance of a multidisciplinary approach that includes interaction of the anesthesiologist, gynaecologist, and invasive radiologist; emphasizing the need for reinforcement of new methods of invasive procedures; management of massive bleeding, use of new technologies, and development of an institutional protocol for management of patients with abnormal placentation. SUMMARY According to this review, we show that the management of patients with repeat cesarean section without abnormal placentation is almost the same as the management of patients for primary cesarean section. Timely diagnosis of patient with abnormal placentation and multidisciplinary approach is crucial for prevention of morbidity or even mortality.
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16
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Clinical outcomes and anesthetic management of pregnancies with placenta previa and suspicion for placenta accreta undergoing intraoperative abdominal aortic balloon occlusion during cesarean section. BMC Anesthesiol 2020; 20:133. [PMID: 32473651 PMCID: PMC7260841 DOI: 10.1186/s12871-020-01040-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/17/2020] [Indexed: 12/12/2022] Open
Abstract
Background This retrospective study aimed to compare the clinical outcomes of parturients with placenta previa (PP) and placenta accreta (PA) according to their severity, when they were managed with intraoperative abdominal aortic balloon occlusion (IAABO) during cesarean section. Methods We retrospectively examined 57 cases of PP and suspicion for PA in which IAABO was performed during cesarean section between April 2014 and June 2016. Based on preoperative examination and clinical risk factors, patients were divided into the low suspicion PA group and the high suspicion PA group. We compared the demographic characteristics, methods of anesthesia, intra- and postoperative parameters, and maternal and neonatal outcomes. Results The two groups showed similar demographic characteristics and intraoperative outcomes. Four women underwent cesarean hysterectomy. Eight neonates were admitted to the neonatal intensive care unit and three did not survive. Neonatal Apgar scores were significantly higher in the low suspicion PA group. Eight patients experienced postoperative femoral artery thrombosis and one patient complicated hematoma in the front wall of the common femoral artery. Patients who received neuraxial anesthesia showed significantly lower intraoperative blood loss, lower intraoperative, postoperative and total blood transfusion and shorter surgery than patients who received general anesthesia. Conclusions Our data suggested that the severity of aberrant placental position does not affect intraoperative blood loss during a cesarean section while the IAABO is performed. We propose that neuraxial anesthesia is preferred for conducting these surgeries without contraindications.
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Sichitiu J, El-Tani Z, Mathevet P, Desseauve D. Conservative Surgical Management of Placenta Accreta Spectrum: A Pragmatic Approach. J INVEST SURG 2019; 34:172-180. [PMID: 31429327 DOI: 10.1080/08941939.2019.1623956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In the last 30 years, with increasing cesarean section rates, the incidence of the placenta accreta spectrum has also increased. It is estimated that by the year 2020 there will be nearly 9000 cases annually in the United States. Currently, no consensus exists regarding optimal management. Conventional treatment by cesarean-hysterectomy is challenging, with a high maternal morbidity due to massive hemorrhage, and surgical complications such as urinary tract, bowel and pelvic nerve injury, in addition to loss of fertility and its accompanying psychological trauma. Innovative approaches seek to preserve the uterus with the adherent placenta in situ, thus maintaining fertility and potentially reducing hemorrhage and adjacent organ injury. This review reports strategies for conservative treatment of such conditions, based on the current literature.
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Affiliation(s)
- Joanna Sichitiu
- Women-Mother-Child Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Zeina El-Tani
- Women-Mother-Child Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Patrice Mathevet
- Women-Mother-Child Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - David Desseauve
- Women-Mother-Child Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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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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Binici O, Büyükfırat E. Anesthesia for Cesarean Section in Parturients with Abnormal Placentation: A Retrospective Study. Cureus 2019; 11:e5033. [PMID: 31501725 PMCID: PMC6721892 DOI: 10.7759/cureus.5033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Placental invasion anomalies are associated with high mortality and may require hysterectomy due to the high risk of massive hemorrhage. The aim of this retrospective study was to evaluate intraoperative anesthetic management, postoperative follow-up, clinical features, and fetal wellbeing in patients undergoing cesarean section due to placental invasion anomalies in a tertiary health center. Methods The retrospective study included patients that underwent cesarean section due to placental invasion anomalies at a tertiary health center over the period between 2013 and 2018. Intraoperative anesthetic management, blood and blood products transfusion, and total volume of blood loss, as well as neonatal Apgar score and postoperative intensive care unit (ICU) follow-up, were reviewed for each patient. Results The study evaluated a total of 92 patients that underwent cesarean section due to placental invasion anomalies, including 49 patients with placenta previa, 42 patients with placenta percreta, and one patient with placenta accreta. Of the 92 patients, 59 (64.1%) patients underwent general anesthesia, 31 (33.7%) underwent spinal anesthesia, and two (2.2%) underwent spinal anesthesia followed by general anesthesia. Hysterectomy was performed in four patients, including three patients who underwent general anesthesia and one patient who started with spinal anesthesia and subsequently switched to general anesthesia prior to a hysterectomy. The Apgar scores at min 1 and min 5 after the induction of anesthesia were significantly lower in patients who underwent general anesthesia as compared to those who underwent spinal anesthesia (p=0.002 and p=0.007, respectively). The duration of surgery and intraoperative blood loss were significantly higher in patients with placenta percreta as compared to other patients (p<0.001 for both). Conclusion In surgical planning for the patients with placental invasion anomalies, care should be taken by anesthesiologists to select the most ideal anesthetic technique, by taking into account the type of anomaly, probable volume of blood loss, and surgical complications, to ensure both maternal and fetal wellbeing. Moreover, the coordination of a team of well-educated and experienced staff is essential.
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Affiliation(s)
- Orhan Binici
- Anesthesiology and Critical Care, University of Harran, Sanliurfa, TUR
| | - Evren Büyükfırat
- Anesthesiology and Critical Care, University of Harran, Sanliurfa, TUR
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Hussein AM, Kamel A, Elbarmelgy RA, Thabet MM, Elbarmelgy RM. Managing Placenta Accreta Spectrum Disorders (PAS) in Middle/Low-Resource Settings. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2019. [DOI: 10.1007/s13669-019-00263-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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21
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Abnormally adherent placenta: Current concepts and anesthetic management. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
The term "morbidly adherent placenta" has recently been introduced to describe the spectrum of disorders including placenta accreta, increta and percreta. Due to excessive invasion of the placenta into the uterus there is associated significant maternal morbidity and mortality. Most significant risk factors for morbidly adherent placenta include history of prior cesarean delivery as well as placenta previa in the current pregnancy. Ultrasound remains the gold standard for antenatal diagnosis, however, in recent years MRI has assisted in identifying complex parametrial involvement. Optimizing maternal and neonatal outcomes involves early prenatal diagnosis, a multi-disciplinary team-based approach, and referral to an experienced center.
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Affiliation(s)
- Whitney Booker
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, United States.
| | - Leslie Moroz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, United States
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Manzano-Nunez R, Escobar-Vidarte MF, Orlas CP, Herrera-Escobar JP, Galvagno SM, Melendez JJ, Padilla N, McCarty JC, Nieto AJ, Ordoñez CA. Resuscitative endovascular balloon occlusion of the aorta deployed by acute care surgeons in patients with morbidly adherent placenta: a feasible solution for two lives in peril. World J Emerg Surg 2018; 13:44. [PMID: 30258488 PMCID: PMC6154816 DOI: 10.1186/s13017-018-0205-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 09/11/2018] [Indexed: 02/04/2023] Open
Abstract
Morbidly adherent placenta (MAP), which includes accreta, increta, and percreta, is a condition characterized by the invasion of the uterine wall by placental tissue. The condition is associated with higher odds of massive post-partum hemorrhage. Several interventions have been developed to improve hemorrhage-related outcomes in these patients; however, there is no evidence to prefer any intervention over another. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular intervention that may be useful and effective to reduce hemorrhage and transfusions in MAP patients. The objective of this narrative review is to summarize the evidence for REBOA in patients with MAP. We posit that acute care surgeons can perform REBOA for patients with MAP.
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Affiliation(s)
- Ramiro Manzano-Nunez
- 1Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia.,2Center for Surgery and Public Health - Brigham and Women's Hospital, Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, MA USA
| | - Maria F Escobar-Vidarte
- 6Critical Care Obstetrics, Department of Gynecology and Obstetrics, Fundacion Valle del Lili, Cali, Colombia
| | - Claudia P Orlas
- 1Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia.,3Trauma and Acute Care Surgery Division, Department of Surgery, Fundacion Valle del Lili, Cali, Colombia
| | - Juan P Herrera-Escobar
- 2Center for Surgery and Public Health - Brigham and Women's Hospital, Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, MA USA
| | | | - Juan J Melendez
- 5Trauma Division and Trauma and Emergency Surgery Fellowship, Universidad del Valle, Cali, Colombia
| | | | - Justin C McCarty
- 2Center for Surgery and Public Health - Brigham and Women's Hospital, Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, MA USA
| | - Albaro J Nieto
- 6Critical Care Obstetrics, Department of Gynecology and Obstetrics, Fundacion Valle del Lili, Cali, Colombia
| | - Carlos A Ordoñez
- 3Trauma and Acute Care Surgery Division, Department of Surgery, Fundacion Valle del Lili, Cali, Colombia.,5Trauma Division and Trauma and Emergency Surgery Fellowship, Universidad del Valle, Cali, Colombia
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Grant T, Ellinas E, Kula A, Muravyeva M. Risk-stratification, resource availability, and choice of surgical location for the management of parturients with abnormal placentation: a survey of United States-based obstetric anesthesiologists. Int J Obstet Anesth 2018. [DOI: 10.1016/j.ijoa.2018.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Purwosunu Y, Haloho AH. Placenta accreta complicated with peripartum cardiomyopathy. BMJ Case Rep 2018; 2018:bcr-2017-223009. [PMID: 29574429 DOI: 10.1136/bcr-2017-223009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 33-year-old G2P1 was referred to our hospital due to placenta accreta. During perioperative preparations, the patient was diagnosed with having a peripartum cardiomyopathy. The patient underwent caesarean hysterectomy at 36 weeks with an associated 2 L blood loss. Haemodynamic maintenance and stabilisation during the operation were challenging, with the combinations of fluid therapy, blood transfusions as well as vasoactive, antifibrinolytic and haemostatic drug. Postoperatively, the patient was managed in the intensive care unit and was subsequently transferred to intermediate care after less than 24 hours' observation. She was stable enough to be moved to the obstetrics ward the next day.
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Affiliation(s)
- Yuditiya Purwosunu
- Department of Obstetrics and Gynaecology, University of Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Agrifa Hasiholan Haloho
- Department of Obstetrics and Gynaecology, University of Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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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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Riveros-Perez E, Wood C. Retrospective analysis of obstetric and anesthetic management of patients with placenta accreta spectrum disorders. Int J Gynaecol Obstet 2017; 140:370-374. [DOI: 10.1002/ijgo.12366] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/10/2017] [Accepted: 10/27/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Efrain Riveros-Perez
- Department of Anesthesiology and Perioperative Medicine; Medical College of Georgia at Augusta University; Augusta GA USA
| | - Cristina Wood
- Department of Anesthesiology; University of Colorado School of Medicine; Aurora CO USA
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Davies MH, Brunning T, Kerr J, Cullis K. Anaesthesia for abnormally invasive placenta: a single-institution case series. Int J Obstet Anesth 2017; 32:95-96. [PMID: 28882415 DOI: 10.1016/j.ijoa.2017.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 07/03/2017] [Accepted: 07/17/2017] [Indexed: 10/19/2022]
Affiliation(s)
- M H Davies
- The Selwyn Crawford Department of Anaesthesia, Birmingham Women's Hospital, Birmingham, UK.
| | - T Brunning
- The Selwyn Crawford Department of Anaesthesia, Birmingham Women's Hospital, Birmingham, UK
| | - J Kerr
- The Selwyn Crawford Department of Anaesthesia, Birmingham Women's Hospital, Birmingham, UK
| | - K Cullis
- The Selwyn Crawford Department of Anaesthesia, Birmingham Women's Hospital, Birmingham, UK
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Lee PS, Kempner S, Miller M, Dominguez J, Grotegut C, Ehrisman J, Previs R, Havrilesky LJ, Broadwater G, Ellestad SC, Secord AA. Multidisciplinary approach to manage antenatally suspected placenta percreta: updated algorithm and patient outcomes. GYNECOLOGIC ONCOLOGY RESEARCH AND PRACTICE 2017; 4:11. [PMID: 28852530 PMCID: PMC5567476 DOI: 10.1186/s40661-017-0049-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 08/10/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Due to the significant morbidity and mortality associated with placenta percreta, alternative management options are needed. Beginning in 2005, our institution implemented a multidisciplinary strategy to patients with suspected placenta percreta. The purpose of this study is to present our current strategy, maternal morbidity and outcomes of patients treated by our approach. METHODS From 2005 to 2014, a retrospective cohort study of patients with suspected placenta percreta at an academic tertiary care institution was performed. Treatment modalities included immediate hysterectomy at the time of cesarean section (CHYS), planned delayed hysterectomy (interval hysterectomy 6 weeks after delivery) (DH), and fertility sparing (uterine conservation) (FS). Prognostic factors of maternal morbidity were identified from medical records. Complications directly related to interventional procedures and DH was recorded. Descriptive statistics were utilized. RESULTS Of the 21 patients with suspected placenta percreta, 7 underwent CHYS, 13 underwent DH, and 1 had FS with uterine preservation. Of the 20 cases that underwent hysterectomy, final pathology showed 11 increta, 7 percreta, and 2 inconclusive. 19/20 cases underwent interventional radiology (IR) procedures. Selective embolization was utilized in 14 cases (2/7 CHYS; 12/13 DH). The median time from cesarean section (CS) to DH was 41 [26-68] days. There were no cases of emergent hysterectomy, delayed hemorrhage, or sepsis in the DH group. Both estimated blood loss and number of packed red blood cell transfusions were significantly higher in the CHYS group. 3/21 cases required massive transfusion (2 CHYS, 1 FS) with median total blood product transfusion of 13 units [12-15]. The four IR-related complications occurred in the DH group. Incidence of postoperative complications was similar between both groups. Median hospital length of stay (LOS) after CHYS was 4 days [3-8] compared to DH cohort: 7 days [3-33] after CS and 4 days [1 -10] after DH. The DH cohort had a higher rate of hospital readmission of 54% (7/13) compared to 14% (1/7) CHYS, most commonly due to pain. There were no maternal deaths. CONCLUSION This multidisciplinary strategy may appear feasible; however, further investigation is warranted to evaluate the effectiveness of alternative approaches to cesarean hysterectomy in cases of morbidly adherent placenta.
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Affiliation(s)
- Paula S. Lee
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
- Duke Cancer Institute, Durham, USA
| | - Samantha Kempner
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
| | - Michael Miller
- Department of Interventional Radiology, Duke University Hospital, Durham, USA
| | | | - Chad Grotegut
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
| | - Jessie Ehrisman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
| | - Rebecca Previs
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
- Duke Cancer Institute, Durham, USA
| | - Laura J. Havrilesky
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
- Duke Cancer Institute, Durham, USA
| | | | - Sarah C. Ellestad
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
| | - Angeles Alvarez Secord
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
- Duke Cancer Institute, Durham, USA
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[Recent standards in management of obstetric anesthesia]. Wien Med Wochenschr 2017; 167:374-389. [PMID: 28744777 DOI: 10.1007/s10354-017-0584-0] [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: 02/06/2017] [Accepted: 07/04/2017] [Indexed: 10/19/2022]
Abstract
The following article contains information not only for the clinical working anaesthesiologist, but also for other specialists involved in obstetric affairs. Besides a synopsis of a German translation of the current "Practice Guidelines for Obstetric Anaesthesia 2016" [1], written by the American Society of Anesthesiologists, the authors provide personal information regarding major topics of obstetric anaesthesia including pre-anaesthesia patient evaluation, equipment and staff at the delivery room, use of general anaesthesia, peridural analgesia, spinal anaesthesia, combined spinal-epidural anaesthesia, single shot spinal anaesthesia, and programmed intermittent epidural bolus.
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Taylor N, Russell R. Anaesthesia for abnormally invasive placenta: a single-institution case series. Int J Obstet Anesth 2017; 30:10-15. [DOI: 10.1016/j.ijoa.2017.01.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/04/2017] [Accepted: 01/13/2017] [Indexed: 11/28/2022]
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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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A Novel and Multidisciplinary Strategy for Cesarean Delivery With Placenta Percreta: Intraoperative Embolization in a Hybrid Suite. ACTA ACUST UNITED AC 2017; 7:135-8. [PMID: 27464941 DOI: 10.1213/xaa.0000000000000375] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cesarean deliveries in patients with placenta accreta often are accompanied by life-threatening bleeding and sometimes death. A novel, multidisciplinary approach that uses uterine embolization after cesarean delivery recently has been advocated; however, embolization in the radiology department requires transfer of postoperative patients, which could increase maternal mortality and morbidity. In a case of severe placenta accreta, we planned a stepwise treatment, including cesarean delivery without separation of the placenta followed by intraoperative uterine arterial embolization in a hybrid operating room, followed by hysterectomy a few weeks after cesarean delivery. With no postpartum bleeding, complete hysterectomy was performed uneventfully 25 days later.
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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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Lim G, Horowitz JM, Berggruen S, Ernst LM, Linn RL, Hewlett B, Kim J, Chalifoux LA, McCarthy RJ. Correlation of probability scores of placenta accreta on magnetic resonance imaging with hemorrhagic morbidity. J Clin Anesth 2016; 34:261-9. [DOI: 10.1016/j.jclinane.2016.04.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 03/28/2016] [Accepted: 04/24/2016] [Indexed: 11/25/2022]
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Nguyen-Lu N, Carvalho JCA, Kingdom J, Windrim R, Allen L, Balki M. Mode of anesthesia and clinical outcomes of patients undergoing Cesarean delivery for invasive placentation: a retrospective cohort study of 50 consecutive cases. Can J Anaesth 2016; 63:1233-44. [DOI: 10.1007/s12630-016-0695-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/23/2016] [Accepted: 07/04/2016] [Indexed: 12/22/2022] Open
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Günaydın B, Kurdoğlu M, Güler İ, Bashiri M, Büyüktaşkın F, Keleşoğlu MD, İnan G. Management of Neuraxial Anaesthesia for Emergent Caesarean Section for Placenta Previa. Turk J Anaesthesiol Reanim 2016; 44:40-3. [PMID: 27366554 DOI: 10.5152/tjar.2016.52385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/04/2015] [Indexed: 11/22/2022] Open
Abstract
Abnormal placental attachments, such as placenta accreta, increta or percrata, can result in increased morbidity and mortality because of the risk of severe postpartum haemorrhage. We aimed to present the management of spinal anaesthesia and surgical approach for emergent caesarean section because of vaginal bleeding in a multiparous pregnant woman with placenta previa at 36 weeks' gestation. Hyperbaric bupivacaine 12 mg, fentanyl 10 μg and morphine 150 μg were intrathecally administered for spinal anaesthesia. Oxytocin, methyl ergonovin and tranexamic acid were administered after umbilical cord clamping. Breech delivery of the baby was provided by a vertical incision to the uterus for avoiding placental harm. Subtotal hysterectomy was performed leaving the placenta in situ. Two units of red blood cells were transfused during the operation, lasting approximately 40 min. The patient was uneventfully discharged on the postoperative fourth day. In conclusion, a single-shot spinal anaesthesia was successfully maintained without conversion to general anaesthesia until the end of the hysterectomy in the patient in whom placenta increta was observed during caesarean delivery.
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Affiliation(s)
- Berrin Günaydın
- Department of Anaesthesiology, Gazi University School of Medicine, Ankara, Turkey
| | - Mertihan Kurdoğlu
- Department of Gynecology and Obstetrics, Gazi University School of Medicine, Ankara, Turkey
| | - İsmail Güler
- Department of Gynecology and Obstetrics, Gazi University School of Medicine, Ankara, Turkey
| | - Mehrnoosh Bashiri
- Department of Anaesthesiology, Gazi University School of Medicine, Ankara, Turkey
| | - Fırat Büyüktaşkın
- Department of Gynecology and Obstetrics, Gazi University School of Medicine, Ankara, Turkey
| | - Mine Dağgez Keleşoğlu
- Department of Gynecology and Obstetrics, Gazi University School of Medicine, Ankara, Turkey
| | - Gözde İnan
- Department of Anaesthesiology, Gazi University School of Medicine, Ankara, Turkey
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Ioscovich A, Shatalin D, Butwick AJ, Ginosar Y, Orbach-Zinger S, Weiniger CF. Israeli survey of anesthesia practice related to placenta previa and accreta. Acta Anaesthesiol Scand 2016; 60:457-64. [PMID: 26597396 DOI: 10.1111/aas.12656] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 07/12/2015] [Accepted: 09/24/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anesthesia practices for placenta previa (PP) and accreta (PA) impact hemorrhage management and other supportive strategies. We conducted a survey to assess reported management of PP and PA in all Israeli labor and delivery units. METHODS After Institutional Review Board waiver, we surveyed all 26 Israeli hospitals with a labor and delivery unit by directly contacting the representatives of obstetric anesthesiology services in every department (unit director or department chair). Each director surveyed provided information about the anesthetic and transfusion management in their labor and delivery units for three types of abnormal placentation based on antenatal placental imaging: PP, low suspicion for PA, and high suspicion for PA. The primary outcome was use of neuraxial or general anesthesia for PP and PA Cesarean delivery. Univariate statistics were used for survey responses using counts and percentages. RESULTS The response rate was 100%. Spinal anesthesia is the preferred anesthetic mode for PP cases, used in 17/26 (65.4%) of labor and delivery units. By comparison, most representatives reported that they perform general anesthesia for patients with PA: 18/26 (69.2%) for all low suspicion cases of PA and 25/26 (96.2%) for all high suspicion cases of PA. Although a massive transfusion protocol was available in the majority of hospitals (84.6%), the availability of thromboelastography and cell salvage was much lower (53.8% and 19.2% hospitals respectively). CONCLUSIONS In our survey, representatives of anesthesia labor and delivery services in Israel are almost exclusively using general anesthesia for women with high suspicion for PA; however, almost two-thirds use spinal anesthesia for PP without suspicion of PA. Among representatives, we found wide variations in anesthesia practice patterns with regard to anesthesia mode, multidisciplinary management, and hemorrhage anticipation strategies.
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Affiliation(s)
- A. Ioscovich
- Department of Anesthesiology; Perioperative Medicine and Pain Treatment; Shaare Zedek Medical Center; Hebrew University; Jerusalem Israel
| | - D. Shatalin
- Department of Anesthesiology; Perioperative Medicine and Pain Treatment; Shaare Zedek Medical Center; Hebrew University; Jerusalem Israel
| | - A. J. Butwick
- Department of Anesthesia; Stanford University School of Medicine; Stanford California USA
| | - Y. Ginosar
- Department of Anesthesiology and Critical Care Medicine; Hadassah-Hebrew University Medical Center; Ein Kerem Jerusalem Israel
| | - S. Orbach-Zinger
- Department of Anesthesia; Rabin Medical Center (Beilinson Campus); Petah Tikvah; Tel Aviv University; Tel Aviv Israel
| | - C. F. Weiniger
- Department of Anesthesiology and Critical Care Medicine; Hadassah-Hebrew University Medical Center; Ein Kerem Jerusalem Israel
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Abstract
Abstract
The American Society of Anesthesiologists Committee on Standards and Practice Parameters and the Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology present an updated report of the Practice Guidelines for Obstetric Anesthesia.
Supplemental Digital Content is available in the text.
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Shaylor R, Ginosar Y, Avidan A, Eventov-Friedman S, Amison N, Weiniger CF. Pre-delivery remifentanil infusion for placenta accreta cesarean delivery under general anesthesia: an observational study. J Matern Fetal Neonatal Med 2015; 29:2793-7. [PMID: 26527226 DOI: 10.3109/14767058.2015.1104297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE General anesthesia may be required for placenta accreta cesarean delivery. Intrauterine fetal anesthetic exposure should be minimized to avoid neonatal respiratory depression; opioids are often delayed until post-delivery. METHODS In this observational study, we compared neonatal outcome using pre-delivery remifentanil versus post-delivery (deferred) opioids for placenta accreta cesarean delivery. Choice of anesthesia was discretionary. The primary outcome was Apgar score at 5 min comparing women who received pre-delivery remifentanil versus deferred opioid administration. We recorded maternal/obstetric characteristics, surgical characteristics, maternal hemodynamic data, neonatal outcomes: Apgar scores, umbilical vein pH and respiratory interventions at birth. RESULTS Between February 2007 and April 2014 we identified 40 general anesthesia placenta accreta cesarean deliveries. The remifentanil dose rate ranged from 0.06 to 0.46 mcg kg(-1 )min(-1). Obstetric and maternal characteristics were similar. Neonatal Apgar, umbilical pH and respiratory intervention outcomes were similar in both groups; Apgar scores median (interquartile range IQR [range]) at 5 min were 9 (8-10) for pre-delivery remifentanil versus 9 (9-10) for deferred opioid administration, p = 0.18. CONCLUSIONS We did not observe a significant effect on neonatal Apgar scores at 1 and 5 min, or respiratory interventions at birth when remifentanil infusion was administered pre-delivery.
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Affiliation(s)
- R Shaylor
- a Department of Anesthesiology and Critical Care Medicine , Hadassah Hebrew University Medical Center , Jerusalem , Israel and
| | - Y Ginosar
- a Department of Anesthesiology and Critical Care Medicine , Hadassah Hebrew University Medical Center , Jerusalem , Israel and
| | - A Avidan
- a Department of Anesthesiology and Critical Care Medicine , Hadassah Hebrew University Medical Center , Jerusalem , Israel and
| | - S Eventov-Friedman
- b Department of Neonatology , Hadassah Hebrew University Medical Center , Jerusalem , Israel
| | - N Amison
- a Department of Anesthesiology and Critical Care Medicine , Hadassah Hebrew University Medical Center , Jerusalem , Israel and
| | - C F Weiniger
- a Department of Anesthesiology and Critical Care Medicine , Hadassah Hebrew University Medical Center , Jerusalem , Israel and
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Muñoz LA, Mendoza GJ, Gomez M, Reyes LE, Arevalo JJ. Anesthetic management of placenta accreta in a low-resource setting: a case series. Int J Obstet Anesth 2015; 24:329-34. [PMID: 26343175 DOI: 10.1016/j.ijoa.2015.05.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 05/04/2015] [Accepted: 05/31/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Current recommendations for the anesthetic management of placenta accreta support a conservative approach with neuraxial anesthesia and uterine artery embolization. These are based on case series from experienced centers in developed countries. The aim of this study was to describe the anesthetic management of placenta accreta in a low-resource setting. METHODS A retrospective case note review was performed. From 1 August 2006 to 31 July 2011 placentas from cases of suspected placenta accreta were reassessed histologically to confirm the diagnosis. Patient charts were reviewed and information on anesthetic technique, monitoring, blood transfusion, maternal and fetal outcomes was extracted. RESULTS Thirty-nine cases were identified. Mean (± SD) maternal age was 33 ± 5.4 years. Hysterectomy was performed at the time of cesarean section in all cases. Thirty-four patients received neuraxial anesthesia, of whom 15 required conversion to general anesthesia. Invasive blood pressure monitoring was used in all patients and a central venous catheter was inserted in 33 cases. Complications associated with monitoring occurred in five patients. Median [IQR] blood loss was 2000 [1100-2700] mL and the median [IQR] number of units of red blood cell transfused was 2 [0-6]. Vasoactive medication was used in 14 patients and 15 patients were transferred to the intensive care unit postoperatively. No maternal or newborn deaths occurred. CONCLUSION A multidisciplinary approach can prove valuable when placenta accreta is suspected before delivery. In low-resource settings, lack of interventional radiology services and prenatal diagnostic capability may have an impact on anesthetic management in patients with placenta accreta. However, other than greater blood loss, our study demonstrated that good maternal and neonatal outcomes are possible in spite of limited resources.
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Affiliation(s)
- L A Muñoz
- Department of Anesthesiology, Fundación Universitaria de Ciencias de la Salud, Hospital de San Jose, Bogota, Colombia.
| | - G J Mendoza
- Department of Anesthesiology, Fundación Universitaria de Ciencias de la Salud, Hospital de San Jose, Bogota, Colombia
| | - M Gomez
- Department of Critical Care, Hospital de San Jose, Bogota, Colombia
| | - L E Reyes
- Department of Anesthesiology, Fundación Universitaria de Ciencias de la Salud, Hospital de San Jose, Bogota, Colombia
| | - J J Arevalo
- Department of Anesthesiology, Fundación Universitaria de Ciencias de la Salud, Hospital de San Jose, Bogota, Colombia
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Seyhan TÖ, Sungur MO, Edipoğlu İ, Baştu E. Combined Spinal Epidural Anaesthesia for Caesarean Section and Hysterectomy in a Parturient with Placenta Accreta. Turk J Anaesthesiol Reanim 2014; 42:148-50. [PMID: 27366410 DOI: 10.5152/tjar.2014.59389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 04/08/2013] [Indexed: 11/22/2022] Open
Abstract
Placenta accreta complicates the anaesthetic and surgical approach in caesarean section. In this report, a parturient with placenta accreta and multiple drug allergies who was managed using combined spinal epidural anaesthesia for caesarean hysterectomy is discussed.
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Affiliation(s)
- Tülay Özkan Seyhan
- Department of Anaesthesiology, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Mukadder Orhan Sungur
- Department of Anaesthesiology, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - İpek Edipoğlu
- Department of Anaesthesiology, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Ercan Baştu
- Department of Gynaecology and Obstetrics, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
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Schiraldi R, Calderón L, Maggi G, Brogly N, Guasch E, Gilsanz F. Transoesophageal Doppler-guided fluid management in massive obstetric haemorrhage. Int J Obstet Anesth 2014; 23:71-4. [DOI: 10.1016/j.ijoa.2013.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 07/02/2013] [Accepted: 07/06/2013] [Indexed: 01/18/2023]
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Perez-Delboy A, Wright JD. Surgical management of placenta accreta: to leave or remove the placenta? BJOG 2013; 121:163-9; discussion 169-70. [DOI: 10.1111/1471-0528.12524] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2013] [Indexed: 11/29/2022]
Affiliation(s)
- A Perez-Delboy
- Department of Obstetrics and Gynecology; Columbia University College of Physicians and Surgeons; New York NY USA
| | - JD Wright
- Department of Obstetrics and Gynecology; Columbia University College of Physicians and Surgeons; New York NY USA
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Abstract
Placenta accreta is an abnormal adherence of the placenta to the uterine wall that can lead to significant maternal morbidity and mortality. The incidence of placenta accreta has increased 13-fold since the early 1900s and directly correlates with the increasing cesarean delivery rate. The prenatal diagnosis of placenta accreta by ultrasound along with risk factors including placenta previa and prior cesarean delivery can aid in delivery planning and improved outcomes. Referral to a tertiary care center and the use of a multidisciplinary care team is recommended.
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Affiliation(s)
- Alison C Wortman
- Department of Maternal Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
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Beilin Y, Halpern SH. Placenta accreta: successful outcome is all in the planning. Int J Obstet Anesth 2013; 22:269-71. [PMID: 24012039 DOI: 10.1016/j.ijoa.2013.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 08/02/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Yaakov Beilin
- Professor of Anesthesiology, Obstetrics, Gynecology and Reproductive Sciences, Vice-chair for Quality and Co-Director, Obstetric Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Su WH, Ho CM, Chen CY, Chuang CM, Wang PH. Strategy for those pregnant women with placenta accreta who plan delivery. Taiwan J Obstet Gynecol 2012; 51:493-4. [DOI: 10.1016/j.tjog.2012.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2012] [Indexed: 10/27/2022] Open
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Williamson R. Anaesthetic considerations for placenta accreta. Int J Obstet Anesth 2012; 21:380-1; author reply 381. [DOI: 10.1016/j.ijoa.2012.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Accepted: 05/31/2012] [Indexed: 10/28/2022]
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