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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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3
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Bartels HC, Lalor JG, Walsh D, Nieto-Calvache AJ, Terlizzi 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 patient perspective and recommendations for care. Int J Gynaecol Obstet 2024; 164:992-1000. [PMID: 37724833 DOI: 10.1002/ijgo.15125] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/25/2023] [Accepted: 08/27/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) is a high-risk complication of pregnancy, which often requires complex surgical intervention. There is limited literature on the patient experience during the perioperative period and postpartum pain management for PAS. Therefore, this study aims to explore the patient perspective of anesthesia care. METHODS Ethical approval was granted by the hospital ethics committee (EC02.2023). This was a descriptive survey study, including women with a history of pregnancy complicated by PAS who were members of two patient advocacy groups. The survey, consisting of both open and closed questions, was performed over a 6-week period between January and March 2023. Content analysis was performed on qualitative data to identify themes, and recommendations for care are suggested. RESULTS A total of 347 participants responded to the survey; 76% (n = 252) had a cesarean hysterectomy (n = 252), and general anesthesia was the most common primary mode of anesthesia (39%, n = 130). We identified two overarching themes: experiences of anesthesia and experience of postpartum pain management. Under experiences of anesthesia, three subthemes were identified, namely "communication with the anesthesiologist", "deferring to the expertise of the team", and "consequences of decision around the mode of anesthesia." Under postpartum pain management, two subthemes emerged: "support of specialist PAS team" and "poor pain management following PAS surgery". CONCLUSIONS Women want to be involved in decisions around their care, but do not always understand the consequences of their decision-making, such as missing the birth of their child. An antenatal anesthesiology consultation is important to provide women with information, explore preferences, and develop a plan of care for the birth.
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Affiliation(s)
- Helena C Bartels
- Department of Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Dublin 2, Ireland
| | - Joan G Lalor
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Don Walsh
- Department of Anaesthesiology, National Maternity Hospital, Dublin 2, Ireland
| | | | | | | | | | - Doireann O'Flaherty
- Department of Obstetric Anaesthesiology, Coombe Women's Hospital, Dublin, Ireland
| | - Siaghal MacColgain
- Department of Anaesthesiology, National Maternity Hospital, Dublin 2, Ireland
| | | | - Donal J Brennan
- University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland
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4
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Zabida A, Zahavi G, Bartoszko J, Otálora-Esteban M, Weinstein J, Frogel J, Miller L, Sivan E, Orkin D, Dolgoker I, Berkenstadt H. Improving blood product management in placenta accreta patients with severe bleeding: institutional experience. Int J Obstet Anesth 2023; 56:103904. [PMID: 37364347 DOI: 10.1016/j.ijoa.2023.103904] [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: 02/06/2022] [Revised: 04/10/2023] [Accepted: 05/31/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Placenta accrete spectrum (PAS) is a significant risk factor for postpartum hemorrhage and effective blood product management is critical in ensuring patient safety. In PAS patients undergoing cesarean section (CS) blood transfusion management guided by the combined clinical experience of the anesthesiologist and surgeon with point-of-care coagulation testing appears safe and effective. We describe and evaluate our experience and identify potential areas for improvement with blood product management in this patient population. METHODS A retrospective chart review of peri-operative demographic, anesthetic, and obstetric data was conducted for all patients with PAS undergoing CS between 2012 and 2018 at our center. To facilitate a practical evaluation of blood product management, we divided patients into two groups based on the severity of bleeding. RESULTS A total of 221 parturients with PAS underwent CS, with 133 in group 1 requiring excessive amounts of transfusion and 88 in group 2 requiring management similar to other uncomplicated CS cases. There were no deaths or instances of disseminated intravascular coagulation, and intensive care unit admission occurred in five cases (2.2%). Patients in group 1 had higher mean nadir values of intra-operative hemoglobin and platelet count. We observed a high rate of missing data for peri-operative measurement of lactate and fibrinogen, PAS grade documentation, and temperature monitoring. CONCLUSION Given no significant morbidity or mortality, clinical judgment in experienced centers appears safe for the management of PAS patients undergoing CS. The adoption of an institutional protocol and point-of-care coagulation testing could decrease over-transfusion and associated complications.
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Affiliation(s)
- A Zabida
- Department of Anesthesiology, Chaim Sheba Medical Centre, Tel-Hashomer, Israel.
| | - G Zahavi
- Department of Anesthesiology, Chaim Sheba Medical Centre, Tel-Hashomer, Israel
| | - J Bartoszko
- Department of Anaesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, Ontario, Canada
| | - M Otálora-Esteban
- Department of Anesthesiology, Hospital Universitario San Ignacio, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - J Weinstein
- Department of Anesthesiology, Chaim Sheba Medical Centre, Tel-Hashomer, Israel
| | - J Frogel
- Department of Anesthesiology, Chaim Sheba Medical Centre, Tel-Hashomer, Israel
| | - L Miller
- Blood Bank, Sheba Medical Centre, Tel-Hashomer, Israel
| | - E Sivan
- Josef Buchman Gynecology and Maternity Centre, Sheba Medical Centre, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - D Orkin
- Department of Anesthesiology, Chaim Sheba Medical Centre, Tel-Hashomer, Israel
| | - I Dolgoker
- Department of Anesthesiology, Chaim Sheba Medical Centre, Tel-Hashomer, Israel
| | - H Berkenstadt
- Department of Anesthesiology, Chaim Sheba Medical Centre, Tel-Hashomer, Israel
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Munoz JL, Blankenship LM, Ramsey PS, McCann GA. Implementation and outcomes of a uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Am J Obstet Gynecol 2023; 229:61.e1-61.e7. [PMID: 36965865 DOI: 10.1016/j.ajog.2023.03.028] [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: 12/09/2022] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall degree of placental adherence, and thus patients with placenta increta or percreta represent a high-risk category of patients. Hemorrhage and transfusion of blood products represent 90% of placenta accreta spectrum morbidity. Both tranexamic acid and uterine artery embolization independently decrease obstetrical hemorrhage. OBJECTIVE This study aimed to provide an evidence-based intraoperative protocol for placenta accreta spectrum management. STUDY DESIGN This study was a pre- and postimplementation analysis of concomitant uterine artery embolization and tranexamic acid in cases of patients with antenatally suspected placenta increta and percreta over a 5-year period (2018-2022). For comparison, a 5-year (2013-2017) preimplementation group was used to assess the impact of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Patient demographics and clinically relevant outcomes were obtained from electronic medical records. RESULTS A total of 126 cases were managed by the placenta accreta spectrum team, of which 66 had suspected placenta increta/percreta over the 10-year time period. Two patients were excluded from the postimplementation cohort because they did not undergo both interventions. Thus, 30 (30/64; 47%) were treated after implementation of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum, and 34 (34/64; 53%) preimplementation patients did not undergo uterine artery embolization or tranexamic acid infusion. With the uterine artery embolization and tranexamic acid protocol, operative times were longer (416 vs 187 minutes; P<.01), and patients were more likely to receive general anesthesia (80% vs 47%; P<.01). However, blood loss was reduced by 33% (2000 vs 3000 cc; P=.03), overall blood transfusion rates decreased by 51% (odds ratio, 0.05 [95% confidence interval, 0.001-0.20]; P<.01), and massive blood transfusion (>10 units transfused) was reduced 5-fold (odds ratio, 0.17 [95% confidence interval, 0.02-0.17]; P=.02). Postoperative complication rates remained unchanged (4 vs 10 events; P=.14). Neonatal outcomes were equivalent. CONCLUSION The uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum is an effective approach to the standardization of complex placenta accreta spectrum cases that results in optimal perioperative outcomes and reduced maternal morbidity.
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Affiliation(s)
- Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Logan M Blankenship
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Patrick S Ramsey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Georgia A McCann
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
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6
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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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8
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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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Enste R, Cricchio P, Dewandre PY, Braun T, Leonards CO, Niggemann P, Spies C, Henrich W, Kaufner L. Placenta Accreta Spectrum Part II: hemostatic considerations based on an extended review of the literature. J Perinat Med 2022; 51:455-467. [PMID: 36181735 DOI: 10.1515/jpm-2022-0233] [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: 05/13/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022]
Abstract
"Placenta accreta spectrum" (PAS) is a rare but serious pregnancy condition where the placenta abnormally adheres to the uterine wall and fails to spontaneously release after delivery. When it occurs, PAS is associated with high maternal morbidity and mortality-as PAS management can be particularly challenging. This two-part review summarizes current evidence in PAS management, identifies its most challenging aspects, and offers evidence-based recommendations to improve management strategies and PAS outcomes. The first part of this two-part review highlighted the general anesthetic approach, surgical and interventional management strategies, specialized "centers of excellence," and multidisciplinary PAS treatment teams. The high rates of PAS morbidity and mortality are often provoked by PAS-associated coagulopathies and peripartal hemorrhage (PPH). Anesthesiologists need to be prepared for massive blood loss, transfusion, and to manage potential coagulopathies. In this second part of this two-part review, we specifically reviewed the current literature pertaining to hemostatic changes, blood loss, transfusion management, and postpartum venous thromboembolism prophylaxis in PAS patients. Taken together, the two parts of this review provide a comprehensive survey of challenging aspects in PAS management for anesthesiologists.
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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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10
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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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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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12
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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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13
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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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14
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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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15
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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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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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O'Flaherty D, Enright S, Ainle FN, Hayes N. Intraoperative cell salvage as part of a blood conservation strategy in an obstetric population with abnormal placentation at a large Irish tertiary referral centre: an observational study. Ir J Med Sci 2020; 189:1053-1060. [PMID: 32002738 DOI: 10.1007/s11845-020-02182-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 01/23/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Haemorrhagic morbidity is more common in women with abnormal placentation, that is placenta praevia or morbidly adherent placenta. The incidence of abnormal placentation is increasing due to rising caesarean section rates. Concerns regarding blood safety, blood shortages and soaring costs of blood processing have generated growing enthusiasm for blood conservation strategies. The aim of our study was to look at intraoperative cell salvage (IOCS) use and allogeneic transfusion patterns in patients with abnormal placentation. METHODS Patients with abnormal placentation were identified from the hospital database over a 2-year period between 2015 and 2016. Information collected for those that had IOCS setup included estimated blood loss, volume of blood collected and returned, pre- and postoperative haemoglobin levels and use of allogeneic blood. RESULTS A total of 139 cases of abnormal placentation were identified. Abnormal placentation accounted for 62% of all cases of IOCS usage and was established for 53 patients with abnormal placentation. The re-transfusion rate was 18.5%. Five patients received IOCS blood only. The allogeneic transfusion rate was 7.5% in patients who had IOCS setup compared with 6.9% in those who did not (p = 1.00). Median blood loss was greater for patients who had IOCS blood returned compared with patients who had not (p = 0.004). The median volume of blood returned was 520 (114-608) mL. Preoperative haemoglobin levels were lower for patients who received a combination of cell salvage and allogeneic blood (p = 0.006). CONCLUSIONS IOCS contributed to a reduction or elimination of allogeneic transfusion for a proportion of this high-risk cohort and should be an integral component of a hospitals' blood conservation strategy.
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Affiliation(s)
- Doireann O'Flaherty
- Department of Anaesthesia, The Rotunda Hospital, Parnell Square, Dublin, Ireland.
| | - Siobhan Enright
- Department of Haemovigilence, The Rotunda Hospital, Dublin, Ireland
| | - Fionnuala Ní Ainle
- Department of Haematology, The Rotunda Hospital, Dublin, Ireland.,Mater Misericordiae University Hospital, Eccles St, Dublin, Ireland
| | - Niamh Hayes
- Department of Anaesthesia, The Rotunda Hospital, Parnell Square, Dublin, Ireland.,Mater Misericordiae University Hospital, Eccles St, Dublin, Ireland
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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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21
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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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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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Abstract
As major stakeholders in the labor and delivery suite, obstetric anesthesiologists are frequently called upon to provide their unique skill sets and expertise to the management of postpartum hemorrhage, whether anticipated or not. Essential contributions of the anesthesia team ideally begin in the antenatal period with referral of women at high risk of postpartum hemorrhage to an outpatient obstetric anesthesia clinic where a tailored plan for both urgent or scheduled delivery for women with an anticipated complex delivery can be formulated. Maternal safety can be greatly improved if comorbidities are identified early and strategies to address these issues are proposed and known by the obstetric anesthesia team. Participation of the obstetric anesthesiology team is crucial in the development of systematic approaches that are customized to each institution and should comprise the creation and dissemination of algorithms and guidelines that are anesthesia specific, including detailed protocols for the labor and delivery unit and operating rooms, at large. Because management of postpartum hemorrhage requires a coordinated team effort, and may not always be planned, the anesthesia team should be prepared at all times to provide the appropriate anesthetic management and advanced cardiovascular support. The involvement of the anesthesia team should not only be limited to the immediate intrapartum period, but should also extend to the postpartum period where adequate anesthetic/analgesic plans will enhance maternal safety and recovery.
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Affiliation(s)
- Laurence Ring
- Department of Anesthesiology, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, 630 West 168th St PH-5, New York, NY 10032, United States
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, 630 West 168th St PH-5, New York, NY 10032, United States.
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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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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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28
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Is the grass on the other side greener? Int J Obstet Anesth 2017; 33:90. [PMID: 29126861 DOI: 10.1016/j.ijoa.2017.07.012] [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: 07/14/2017] [Accepted: 07/25/2017] [Indexed: 11/20/2022]
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29
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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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30
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Neely D, Elnour S. Anaesthesia for abnormally invasive placenta: cell salvage and tranexamic acid. Int J Obstet Anesth 2017; 32:94-95. [PMID: 28801163 DOI: 10.1016/j.ijoa.2017.07.001] [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: 05/24/2017] [Revised: 06/29/2017] [Accepted: 07/02/2017] [Indexed: 12/01/2022]
Affiliation(s)
- D Neely
- Department of Anaesthesia, King's College Hospital, London, UK.
| | - S Elnour
- Department of Anaesthesia, King's College Hospital, London, UK
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