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Abnormally Adherent Placentation: A Report of Cases from 2011-2016 at Froedtert Hospital in Milwaukee, WI
Abstract Number: T-49
Abstract Type: Original Research
Abnormally Adherent Placentation: A Report of Cases from 2011-2016 at Froedtert Hospital
Tamila Grant, MD, Ayse Kula, MD, & Elizabeth Ellinas MD
Parturients with abnormally adherent placentation are a population that necessitates a multidisciplinary plan to manage their care. At our institution, there has been desire from the obstetricians to perform these deliveries in the Labor and Delivery (L&D) operating rooms and to utilize neuraxial anesthesia as possible. Our goal was to examine our anesthetic management of these patients over the last five years, identify characteristics that may allow neuraxial anesthesia and assess a way to stratify cases to see which could be safely managed on L&D.
A total of 14 patients were identified: 3 with placenta percreta, 3 had increta and 8 had accreta. 13/14 patients required a hysterectomy. 11 /14 patients had a general endotracheal anesthetic(GETA), 3 had continuous neuraxial anesthetics and 1 had a spinal that was converted to a GETA.
The average estimated blood loss(EBL) for all cases was 5.5 L(range 1.5 L-24 L) and the average RBC transfusion requirement was 7 units(range 0-24 units), with 2 patients receiving no blood products. A total of 5 patients required recovery in an ICU.
For the 6 patients in whom the pre-operative diagnosis is “possible” adherent placentas, all went on to have operative findings of accreta or increta, with EBL of 2 or more liters. Our data also show that even the operative findings of “merely” an accreta does not seem indicate a low blood loss surgery with average EBL 3.1 L(range 1.3-7.5L) with an average transfusion of 4.8 units of PRBCS(range 0-12 units).
We have performed a majority of these cases under GETA – therefore we were unable to assess outcomes/risk factors surrounding this parameter. When attempting to stratify which cases could be performed in the L&D ORs, we did not find the predicted type of placental abnormality based on imaging to be a reliable clinical outcomes predictor.
Fortunately, the expert coordination of care allowed for none of the patients in our study to experience mortality or long term morbidity. Our next steps would be to further delineate whether a change of our practices away from GETA may be warranted, how other physicians risk stratify these parturients, and what factors can be optimized to allow for delivery of some of these patients on L&D. To this effect, we have created an online survey that was sent to the heads of the obstetric anesthesia departments of all ACGME accredited programs to learn more about how these patients are cared for nationwide.
Kuczkowski, K. M. (2006). Anesthesia for the repeat cesarean section in the parturient with abnormal placentation: What does an obstetrician need to know?
Ioscovich, A., (2013). Anesthetic considerations for high order cesarean sections: A protective
Lilker, S., (2011). Anesthetic Considerations for placenta accreta.