|Year : 2018 | Volume
| Issue : 2 | Page : 99-101
Perioperative anesthetic management of a pregnant mother with placenta percreta
Roshana Prasad Mallawaarachchi, Ramani Pallemulla
Department of Anesthesia and Critical Care, Castle Street Hospital for Women, Sri Lanka
|Date of Web Publication||3-Oct-2018|
Dr. Roshana Prasad Mallawaarachchi
Department of Anaesthesia and Critical Care, Teaching Hospital, Kandy, Peradeniya 20400, Central Province
Source of Support: None, Conflict of Interest: None
Placenta percreta is a rare condition during pregnancy in which the abnormal presentation of placenta penetrates the uterine wall and invades into the surrounding organs including bowel and bladder. With the increasing rate of cesarean sections, the incidence of placenta percreta has also increased. This is a condition which gives rise to a major obstetric hemorrhage, peripartum hysterectomy, and maternal and fetal morbidity and mortality. This case report presents a successful obstetric and anesthetic management of a patient with preoperatively diagnosed placenta percreta.
Keywords: Hemorrhage, peripartum hysterectomy, placenta percreta
|How to cite this article:|
Mallawaarachchi RP, Pallemulla R. Perioperative anesthetic management of a pregnant mother with placenta percreta. J Obstet Anaesth Crit Care 2018;8:99-101
|How to cite this URL:|
Mallawaarachchi RP, Pallemulla R. Perioperative anesthetic management of a pregnant mother with placenta percreta. J Obstet Anaesth Crit Care [serial online] 2018 [cited 2019 May 20];8:99-101. Available from: http://www.joacc.com/text.asp?2018/8/2/99/242633
| Introduction|| |
Placenta adheres to the decidua basalis layer which allows the separation of the placenta following delivery of the fetus. In some instances, the placenta can invade the decidua basalis layer. Placenta percreta is a rare condition when the placenta is attached deep into the uterine muscles invading into the bladder. Abnormal presentation of placenta including placenta accreta/percreta is one of the two leading causes of peripartum hemorrhage and is the most common indication for peripartum hysterectomy. When not diagnosed early, it can lead to severe maternal morbidity.
Anesthetic strategies are important during the management of a patient with placenta percreta because it is very important to prepare for a major bleeding during the surgery. This includes rapid blood and fluid replacement, which can be guided by an assessment of blood loss along with clinical parameters such as heart rate, urine output, and invasive blood pressure monitoring. Rotational thromboelastography can be used for blood and blood product replacement more objectively. Due to longer operating time and massive bleeding, general anesthesia would be the most preferred option. A multidisciplinary team approach may improve patient outcome. This is a case report of placenta percreta which was successfully managed with planned hysterectomy resulting in decreased morbidity and mortality.
| Case Report|| |
A 36-year-old mother (P3C2) was transferred from a base hospital to a major maternity hospital for elective cesarean section at 33 weeks of amenorrhea due to an abnormal presentation of the placenta. Anesthesia referral was done 1 week prior to the planned date of operation. This was her third elective cesarean section. She had received spinal anesthesia for her previous cesarean sections. She had undergone an ultrasonography during pregnancy to rule out a low-lying or abnormal placenta, and was found to have an anterior lower lying placenta which was completely covering the internal cervical os with some evidence of lacunae pattern and sponge-like cervix. Myometrium was thinned out. Translucent areas were seen between the bladder and the uterus. Hyper vascularity was also noted. All these features confirmed the presence of placenta percreta. A major hemorrhage was anticipated at the time of delivery and all planning was made accordingly.
She was also diagnosed to have Type II diabetes mellitus. Her glycemic control was satisfactory throughout the pregnancy with metformin 250 mg bd and mixtard insulin 5 units bd during the third trimester. There was no history of antepartum hemorrhage. Fetal movements were satisfactory and estimated fetal weight was 2.2 kg. Intramuscular dexamethasone 12 mg, 12 hours apart 2 doses were given for fetal lung maturity. Elective cesarean delivery and hysterectomy was planned at the period of amenorrhea of 34 weeks. Adequate blood and blood products were kept in reserve.
General anesthesia was performed on obstetrician's request and also to improve patient comfort. Two 14G wide bore intravenous cannulae and a left side radial arterial line were established. Rapid blood warmer infuser was primed with Ringer's lactate and kept ready. Two packs of blood were available in the operating theater prior to induction. The patient was intubated with a 7-mm endotracheal tube with modified rapid sequence induction using intra venous (IV) fentanyl, thiopental sodium 250 mg, and IV suxamethonium 100 mg. Right side internal jugular central venous catheter was inserted just after the induction.
Upper segment cesarean section was performed. Placenta had penetrated the lower segment of the uterus and firmly adhered to the bladder base. Bladder and placenta were separated carefully. A 0.5-cm size bladder injury was noted which was repaired and the hysterectomy performed. A drain was placed inside.
During surgery, the patient lost 2000 mL of blood. The obstetrician placed a Panicker's suction within the uterine cavity which minimized the collection of blood within the uterus during hysterectomy. This helped us to accurately assess the blood loss during the intraoperative period. There was no hemodynamic instability as we have started rapid blood transfusion from the time of delivery of the baby. All the fluid was given via fluid warmers and patient warmer was kept at 38°C. Her body temperature remained at 97-98°F. She received 3 packs of blood and rotational thromboelastography-guided coagulopathy correction was done with 10 units of cryoprecipitate. Her calcium level was 0.2 mmol/l and was treated with IV 10% calcium chloride 10 ml. At the end of the surgery, the patient's trachea was extubated and transferred to the intensive care unit for monitoring.
She was given an IV infusion of morphine 1-1.5 mg/hr for postoperative pain relief. Her postoperative hemoglobin was 10.2 g/dl. Repeated thromboelastometry revealed the corrected coagulopathy. She was treated with prophylactic dose of IV antibiotics. Subcutaneous enoxaparin was started after 12 hours. There were no significant complications during the postoperative period.
| Discussion|| |
Normal placenta attaches to the fundus of the uterus. Abnormal presentation occurs in some women due to various reasons. Once the placenta is attached over the previous scar, it tends to grow through the scar. With the repeated number of cesarean sections, the risk of abnormal presentation of the placenta increases. Abnormal placenta presentation includes low-lying placenta previa, placenta accreta, and placenta percreta.
Our patient had undergone two previous cesarean sections. In abnormal placenta there is a defect in the decidua basalis which causes the placenta to adhere to the uterine wall. In this situation, there is no clear margin between the uterus and the placenta. The incidence rate of abnormal placenta is gradually increasing from 1980 to 2000, from one in 25,000 to one in 500. Increasing cesarean section rate is considered as one of the reasons for increasing incidence.
Placenta percreta can lead to bladder injury, bowel injury, major bleeding with severe coagulopathy, and peripartum hysterectomy. Maternal death rate due to placenta percreta is 9.5%. Incidence of placenta percreta is about 3 per 100,000 births, while the incidence rate of placenta accreta is 0.1-2.3 per 1000 births. Abnormal placental presentation as a major indication for peripartum hysterectomy has risen from 5.4% to 46.5% over the last four decades. We could have been able to successfully complete the cesarean section without any complications such as organ injuries and we could also have preserved the fertility.
Ultrasonography and/or magnetic resonance imaging (MGI) are used to diagnose placenta percreta. Myometrial interface, retroplacental clear space, reduced myometrial thickness, turbulent placental lacunar flow, intraplacental lacunae, and irregular bladder wall which are findings of ultrasound of placenta accreta and percreta. There can be a placental bulging into the bladder. More accurate investigation is magnetic resonance imaging to diagnose posterior placenta and placenta percreta, and it is the preferred imaging technique in morbidly obese patients. Our patient had undergone an ultrasonography which revealed an anterior low-lying placenta with placenta percreta. MRI had not been done in our patient.
Multidisciplinary team with an obstetrician, anesthetists, radiologists, neonatologists, hematologists, transfusion physicians, urologists, and sometimes gynecological oncology surgeon involvement is needed in placenta percreta patients. This requires early detection and an elective cesarean delivery and peripartum hysterectomy. Sometimes placenta may be left in situ. Cesarean section is usually done early at a period of amenorrhea (POA) of 34-36 weeks. Our patient underwent surgery at POA of 34 weeks. Oxygen carrying capacity of blood can be optimized with oral iron therapy. In some instances, simultaneous intravenous iron therapy would be beneficial. A mother with abnormal placenta should be managed in a hospital with all facilities to manage a massive obstetric hemorrhage. National safety agency UK has recommended a care bundle to be used with every placenta previa after cesarean section.
Preoperative optimization and planning is important. Main management strategies are optimizing the hemoglobin, good intravenous access, availability of rapid infusers, invasive monitoring including central venous pressure monitoring, and invasive blood pressure measurement. Availability of cell salvager will be an added advantage. Keeping the cross-matched blood products, compression stockings, padding for position the patient to prevent nerve compression, fluid warmers, and patient warmers to prevent hypothermia are necessary for better outcome.
Mode of anesthesia could be general anesthesia or regional anesthesia. Advantages of regional anesthesia would be optimal postoperative pain relief, reducing the risk of aspiration, minimizing blood loss, allowing the mother and baby bonding, and reducing the fetal exposure to anesthetic drugs. The main disadvantage is the risk of hemodynamic instability and potentially difficult airway during surgery in an emergency situation. Hemodynamic instability could be managed easily when rapid warmer infuser is used.
General anesthesia is preferred if a major bleeding is anticipated as it allows better control of ventilation and better hemodynamic stability during a massive hemorrhage. Most anesthetists and obstetricians still prefer general anesthesia for placenta percreta.
Duration is usually much longer than a cesarean section which can lead to patient restlessness, pain, nausea, and vomiting. Hypervascular pelvic viscera requires a careful surgical dissection with good muscle relaxation.
Placenta accreta and increta are most of the time supplied by uterine arteries, so clamping of uterine artery can stop further bleeding. In contrast, placenta percreta may be supplied by extrauterine arteries, with formation of neoblood vessels, so there is a high risk of massive hemorrhage during the intraoperative period. Such bleeding cannot be controlled by ligation of uterine vessels alone. This, together with the need for prolonged surgery and muscle relaxation, makes general anesthesia a better option than regional anesthesia. Our mother underwent general anesthesia with both invasive monitoring.
Immediate availability of blood products in the operating room is compulsory while performing the surgery on a patient with placenta percreta. Prompt communication with the blood bank is very important.
Activation of massive transfusion protocol ensures prompt availability of blood and other products until the bleeding can be stopped surgically. This can be a lifesaving in a situation of massive hemorrhage. In our case, we were ready with 2 packs of blood and initiated the blood transfusion early via rapid warmer infuser. Early use of ROTEM-guided blood product replacement can have minimized the unnecessary blood product transfusion.
Intraoperative cell salvaging has been advocated by the American College of Obstetrics and Gynecology for mothers in whom massive bleeding is anticipated, such as those with placenta accreta. A theoretical concern about cell salvage is the possibility of amniotic fluid embolism. We have not used cell salvage because it was not an available option in our institute.
Recombinant factor VIIa has been used off-label to treat major postpartum hemorrhages with positive results. But it should be cautiously used because of risk of thrombosis. It should be used with caution because of the potential risk of vascular thrombosis.
| Conclusion|| |
Patients with placenta percreta are at a high risk for major intraoperative hemorrhage. Main successful outcome in these cases is early diagnosis despite of negative ultrasonography results, multidisciplinary team approach, and early planning. With a rising rate of cesarean deliveries, the incidence of accreta and percreta is high as well.
Management of placenta percreta by a multidisciplinary team in a tertiary specialized care hospital that is able to handle a massive transfusion is more important in minimizing the morbidity and mortality with these conditions.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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