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Anesthetic Management of Cesarean Hysterectomies for Morbidly Adherent Placenta
Abstract Number: T5B-3
Abstract Type: Original Research
Morbidly adherent placenta (MAP) is an important contributor to maternal morbidity and mortality.1 We present the anesthetic management of cesarean hysterectomy for MAP performed over a 7 year period.
IRB approval was obtained for this retrospective case series. All patients with MAP diagnosed on ultrasound, MRI, or intraoperatively from July 2010 to January 2018 were identified and retrospectively reviewed. Results are presented as median [IQR].
A total of 104 cases of MAP were identified. Patient demographics are summarized in Table 1. Placenta accreta accounted for 21 cases (21%), placenta increta 47 (46%), placenta percreta 29 (28%) and placenta previa 5 (5%). General anesthesia (GA) alone was administered in 87 (84%) cases. Neuraxial anesthesia was chosen as primary anesthetic in 13 (13%), with 9 (8%) cases requiring conversion to GA. Only 3 (3%) cases used both neuraxial and GA as a combined anesthetic technique. Hemorrhage was common: 1500ml [1000-3000ml], with 24% having an estimated blood loss of >3000ml. All cases utilized intraoperative cell salvage. Transfusion of blood products was required in 70 (67%) cases, with 46 (44%) patients receiving transfusion obtained from cell salvage alone or in combination with allogenic products. Central venous catheters were placed in 77 (74%) cases and invasive arterial blood pressure monitoring was used in 93 (89%) cases. Twenty one (20%) patients required intensive care unit monitoring post operatively and 2 (2%) patients died intraoperatively.
To our knowledge, this is the largest case series reporting anesthetic management for MAP. In contrast to a previous publication, the majority of our cases are done with general anesthesia as the primary anesthetic. 2 Reasons for variation in practice include a high degree of placental invasion with 74% of cases being percreta and increta pathologies and nearly a quarter of our patients having an EBL of >3000ml. Also, our patients tend to have a high BMI (30 [26-33]) adding to the overall complexity in these high risk cases. Multidisciplinary team discussion in all MAP cases is vital to assure optimal anesthetic management that is tailored to each patient’s needs.
1. Shamshirsaaz, Alireza A. et al. American Journal of Obstetrics and Gynecology. 2015; 212:218.e1-9
2. Tylor, N. J., Russel, R. International Journal of Obstetric Anesthesia (2017) 30, 10-15.