Anesthesia management of complete versus incomplete placenta previa: a retrospective cohort study

Anesthetic management in cesarean delivery of women with placenta previa: a retrospective cohort study

Background

The incidence of placenta preiva is rising. Cesarean delivery is identified as the only safe and appropriate mode of delivery for pregnancies with placenta previa. Anesthesia is important during the cesarean delivery. The aim of this study is to assess maternal and neonatal outcomes of patients with placenta previa managed with neuraxial anesthesia as compared to those who underwent general anesthesia during cesarean delivery.

Methods

A retrospective cohort study was performed of all patients with placenta preiva at our large academic institution from January 1, 2014 to June 30, 2019. Patients were managed neuraxial anesthesia and general anesthesia during cesarean delivery.

Results

We identified 1234 patients with placenta previa who underwent cesarean delivery at our institution. Neuraxial anesthesia was performed in 737 (59.7%), and general anesthesia was completed in 497 (40.3%) patients. The mean estimated blood loss at neuraxial anesthesia of 558.96 ± 42.77 ml were significantly lower than the estimated blood loss at general anesthesia of 1952.51 ± 180 ml (p < 0.001). One hundred and forty-six of 737 (19.8%) patients required blood transfusion at neuraxial anesthesia, whereas 381 out of 497 (76.7%) patients required blood transfusion at general anesthesia. The rate neonatal asphyxia and admission to NICU at neuraxial anesthesia was significantly lower than general anesthesia (2.7% vs. 19.5 and 18.2% vs. 44.1%, respectively). After adjusting confounding factors, blood loss was less, Apgar score at 1- and 5-min were higher, and the rate of blood transfusion, neonatal asphyxia, and admission to NICU were lower in the neuraxial group.

Conclusions

Our data demonstrated that neuraxial anesthesia is associated with better maternal and neonatal outcomes during cesarean delivery in women with placenta previa.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01472-w.

Systematic Identification of Hub Genes in Placenta Accreta Spectrum Based on Integrated Transcriptomic and Proteomic Analysis

Placenta accreta spectrum (PAS) is a pathological condition of the placenta with abnormal adhesion or invasion of the placental villi to the uterine wall, which is associated with a variety of adverse maternal and fetal outcomes. Although some PAS-related molecules have been reported, the underlying regulatory mechanism is still unclear. Compared with the study of single gene or pathway, omics study, using advanced sequencing technology and bioinformatics methods, can increase our systematic understanding of diseases. In this study, placenta tissues from 5 patients with PAS and 5 healthy pregnant women were collected for transcriptomic and proteomic sequencing and integrated analysis. A total of 728 messenger RNAs and 439 proteins were found to be significantly different between PAS group and non-PAS group, in which 23 hub genes were differentially expressed in both transcriptome and proteome. Functional enrichment analysis showed that the differentially expressed genes were mainly related to cell proliferation, migration and vascular development. Totally 18 long non-coding RNA were found that might regulate the expression of hub genes. Many kinds of single nucleotide polymorphism, alternative splicing and gene fusion of hub genes were detected. This is the first time to systematically explore the hub genes and gene structure variations of PAS through integrated omics analysis, which provided a genetic basis for further in-depth study on the underlying regulatory mechanism of PAS.

Nomogram to predict postpartum hemorrhage in cesarean delivery for women with scarred uterus: A retrospective cohort study in China

AIM

To develop nomograms predicting the risk of postpartum hemorrhage (PPH) in cesarean delivery for singleton pregnant women with a scarred uterus in the north of China.

METHODS

A retrospective cohort study was conducted. Totally 3722 singleton pregnant women with a scarred uterus who underwent a cesarean delivery in a large teaching hospital of north China between January 2013 and December 2017 were enrolled. Nomograms, a kind of user-friendly tool, were developed to predict PPH (blood loss ≥1000 mL or accompanied by signs or symptoms of hypovolemia within 24 h after the birth process) based on the model generated by logistic regression analysis. The discrimination and calibration of models were evaluated, and decision curve analysis was developed.

RESULTS

Among 3722 enrolled women, 243 (6.53%) had PPH. There are six identified factors associated with PPH: maternal age, placental location, placenta previa, hypertensive disorders of pregnancy, fetal position and placenta accreta spectrum (PAS). The model achieved a good calibration (Hosmer-Lemeshow test P value 0.77) and discrimination (area under curve c-statistics 0.90, 95% confidence interval 0.86-0.93). Decision curve analysis showed the threshold probability by using our model is between 1.0% and 85.7%. A nomogram was developed accordingly. And another nomogram for women without placenta previa and PAS was also developed.

CONCLUSION

Two nomograms were first generated to predict PPH, respectively, for women with a scarred uterus and for women with a scarred uterus who do not have placenta previa or PAS. Placental location and fetal position were found to be closely related to PPH.

Anesthetic considerations for repeat cesarean section

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.

Random placenta margin incision for control hemorrhage during cesarean delivery complicated by complete placenta previa: a prospective cohort study

Introduction: Complete placenta previa (CPP) is one of the most problematic types of abnormal placenta, which is further complicated by placenta accreta or percreta that can unexpectedly lead to catastrophic blood loss, infection, multiple complications, emergency hysterectomy, and even death. The present study aimed to assess the efficacy of random placenta margin incision in controlling intraoperative and total blood loss during cesarean section for CPP women. Methods: A prospective cohort study, including a total of 100 consecutive pregnant women with CPP, was performed at a tertiary university-affiliated medical center between March 2016 and July 2017. All of them underwent random placenta margin incision, and intraoperative and total blood loss were analyzed. Through antenatal diagnosis using color Doppler, women were further divided into abnormally invasive placenta (AIP) and non-AIP groups, and anterior and posterior placenta groups. The protocol was registered with the Clinical Trial Registry under registration number NCT02695069. Results: Mean maternal age and gestational age at delivery were 32.26 ± 5.03 years old and 36.21 ± 2.07 weeks, respectively. Total duration of the surgical procedure time was 52.50 (42.43-64.00) min. Median estimated intraoperation blood loss was 746.43 (544.44-1092.86) ml. Total blood loss was 875.00 (604.50-1196.67) ml, and 38 (38.0%) had post-partum hemorrhage. The change from baseline in the median hemoglobin level was -0.33 (6.00-13.20). No women underwent hysterectomy due to massive hemorrhage during the study period. No women had an intraoperative urinary bladder injury, postoperative wound infection, and required relaparotomy, owing to intra-abdominal bleeding. The median hospitalization time was 5.41 (4.18-7.58) d. Conclusion: The random placenta margin incision may be a potentially valuable surgical procedure to control the volumes of intraoperative and postoperative blood loss and reduce the incidence of postpartum hemorrhage among women with complete placenta previa.