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Anesthetic management of the "placenta left in situ" followed by post-cesarean hysterectomy
Abstract Number: 223
Abstract Type: Case Report/Case Series
Introduction: Uncontrolled hemorrhage is a major cause of maternal mortality. The use of uterine artery balloons and leaving the placenta in-situ are measures that can decrease obstetric bleeding. Anesthetic management of cases where both of these measures are utilized has not been described.
Materials and Methods: A 31 year old female G3P2 was hospitalized at 29 weeks of gestation for asymptomatic vaginal bleeding. MRI and ultrasound showed placenta previa/percreta. Four weeks later, she was brought to interventional radiology for the placement of uterine artery catheters and then to the operating room for Cesarean section with possible hysterectomy. The anesthesia team placed combined spinal/epidural anesthesia (CSE) prior to the interventional radiology procedure and then bolused the catheter before the Cesarean section. After the midline skin incision and longitudinal incision over the fundus of the uterus, a baby was delivered with APGARS of 3/8. The placenta was left in situ, placenta increta was confirmed and the surgical team proceeded with a hysterectomy. Estimated blood loss was 2000 ml, the patient was given 5000 ml crystalloid, 4 units of PRBC and 3 units of FFP. Due to the surgeons preference, blood loss was controlled without the use of uterine artery catheters. The patient was discharged home on post-operative day 7.
Results and Discussion: (required) Managing the placenta percreta by leaving the placenta inside the uterus, closing the uterus and then proceeding with hysterectomy is a very attractive option for obstetricians. Placental manipulation, the major source of bleeding, will be completely avoided. The presence of uterine artery balloons offers another option for the control of bleeding. Although we did not use them, that would have been our next step if the surgeons had been unable to control the bleeding. With the increasing rate of Cesarean sections, we can expect more cases of abnormal placental implantation, and some of these cases will have a surgical approach similar to ours. The goal of the anesthetic management is to provide for a hemodynamically stable, comfortable, normothermic, and noncoagulopathic patient. Blood bank, interventional radiology and general surgery should be informed and be available, because even unintentional manipulation of the placenta can result in uncontrolled bleeding. All necessary equipment for rapid volume replacement should be immediately available as well.
Conclusion: Based on our experience, CSE anesthesia is a valuable option for Cesarean section in these patients.