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A Review of 48 Cesarean Hysterectomies for Abnormal Placentation at One Institution
Abstract Number: T-79
Abstract Type: Original Research
OBJECTIVES: The aim of this retrospective study was to review abnormal placentation cases and determine the prognostic factors effective on morbidity and mortality and to evaluate the strategy of anesthetic management. We will also review our multidisciplinary management protocol, including preadmission of patients at 32 weeks gestation, involvement of obstetrics, gyn-oncology, urology, neonatology, blood bank, interventional radiology, anesthesiology.
MATERIAL AND METHODS: 48 women with abnormal placentation scheduled for elective or emergency cesarean deliveries from 2010 to 2014 were examined. Patient demographic data, surgery and obstetric characteristics, anesthetic techniques, blood transfusions, and complications were recorded.
RESULTS: The total number of accreta, increta, and percreta deliveries has increased every year since 2010, with a 2.6 fold increase from 2013 to 2014. Notably, 42% of patients had one prior cesarean delivery and 10% of patients had no previous cesarean deliveries. Out of the 48, thirty-six deliveries were elective, 11 were emergency, and there was one urgent delivery. Five patients had an unknown diagnosis of abnormal placentation prior to surgery. Two patients had preoperative internal iliac artery balloon placements. 83% of cases were done with general anesthesia exclusively, 2 cases with combined-spinal epidural exclusively, 4 cases that began with CSE then converted to GA for hemodynamic instability, and 2 cases in which spinal anesthesia was performed for cystoscopy and ureteral stent placement, then converted to general anesthesia prior to incision and delivery. 45% of our patients had less than 1500 ml blood loss and did not require blood transfusion and 29% required massive blood transfusion. Aortic cross clamping was required for three patients. Of the patients who underwent GA; 91% were extubated in the OR, and 43% required postoperative SICU care. Four patients have returned to the operating room, two
planned and two unplanned. Two intraoperative maternal mortalities occurred, for one emergency delivery and one elective delivery.
CONCLUSIONS: Anesthetic management is critical for parturients with abnormal placentation undergoing cesarean hysterectomy; this includes a multidisciplinary approach. We found that general anesthesia was our method of preference. The majority of patients did not require postoperative ICU care or reoperation. However massive hemorrhage can be unpredictable and rapid; necessitating thorough preparation for massive transfusion and advanced surgical hemostasis. This includes adequate large bore I.V access, invasive blood pressure monitoring, blood bank notification and readily available Trauma or Vascular surgeon.