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Abnormal placental implantation (accreta cases) delivered by Cesarean-Hysterectomy (C-Hyst): a comparison of main operating room versus L&D operating room outcomes.
Abstract Number: S-10
Abstract Type: Original Research
In most institutions, suspected or confirmed cases of abnormal placentation (accreta cases) are scheduled as cesarean-hysterectomy (C-Hyst) in the main operating room (mOR) rather than in L&D OR,1 to facilitate access to massive transfusion, embolization, specialized surgical interventions and technical support if needed.2 However, unsuspected or emergency cases are often safely and effectively managed in the L&D OR, and there is currently no consensus on where these cases should occur, whether urgent or not. We decided to compare the management, outcomes and resources in C-Hyst performed in both locations at our institution, bearing in mind that the Obstetric Anesthesia team manages all accreta cases irrespective of location.
We conducted a retrospective chart review from 2009-2014, based on ICD-9 and CPT codes and analyzed all hysterectomies performed in L&D OR, and all C-Hyst brought to mOR. Maternal and obstetric data (previous cesarean, uterine surgeries or previa), surgical outcomes (procedure, duration, blood loss), anesthetic management (general, neuraxial or combination), intraoperative management (monitoring, vasopressors, fluids & blood products), postoperative outcomes (ICU admission & length of stay) and cost were recorded.
During the 5-year interval, 14 C-Hysts were performed in the L&D ORs and 35 scheduled in mOR, out of which 12 (34%) did not require a hysterectomy (Table). There were no differences in demographic data, except for gestational age at delivery. The likelihood of having a C-Hyst in the mOR was increased with a diagnosis of placenta previa and previous CD. The rate of neuraxial anesthesia converted to GA and GA for the entire case was similar for C-Hyst in mOR and L&D. The length of stay was longer with mOR C-Hyst and so was the total cost (Table).
Overall, maternal management & outcomes were similar irrespective of location and urgency. Of importance, 34% of cases scheduled in the mOR for possible accreta ended up not requiring a hysterectomy. Since the cost is substantially higher (almost double) when a cesarean delivery with or without hysterectomy is performed in the mOR, further evaluations seem indicated to provide a clinical algorithm to help providers decide of best location to reduce unnecessary and unjustifiable higher costs related with main OR utilization.
1. Perez-Delboy, BJOG 2014;121:163-70.
2. Fawcus, Best Pract Res Clin Obstet Gynaecol 2013;27:233-49