|LETTERS TO EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 147-148
Multidisciplinary approach with favorable outcome in management of placenta accreta
Saurabh Sud1, Deepak Dwivedi1, Shalendra Singh2, Alok Raj Gautam1
1 Department of Anaesthesia and Critical Care, Command Hospital (SC), Pune, Maharashtra, India
2 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||01-Jul-2019|
|Date of Acceptance||14-Mar-2020|
|Date of Web Publication||20-Aug-2020|
Dr. Deepak Dwivedi
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command) Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sud S, Dwivedi D, Singh S, Gautam AR. Multidisciplinary approach with favorable outcome in management of placenta accreta. J Obstet Anaesth Crit Care 2020;10:147-8
|How to cite this URL:|
Sud S, Dwivedi D, Singh S, Gautam AR. Multidisciplinary approach with favorable outcome in management of placenta accreta. J Obstet Anaesth Crit Care [serial online] 2020 [cited 2020 Sep 19];10:147-8. Available from: http://www.joacc.com/text.asp?2020/10/2/147/292735
Placenta accreta has an incidence of 0.04% and is one of the leading causes of peripartum hemorrhage and accounts for 50% of all peripartum hysterectomy. Risk factors include placenta praevia, submucous myoma, previous cesarean section, multiparity, prior curettage, smoking, chronic hypertension, advance maternal age, prior placenta accreta, and asherman syndrome. Management of placenta accreta requires multispecialty coordination with increased risk of maternal and fetal morbidity and mortality including a large volume of blood transfusion, peripartum hysterectomy, intensive care unit (ICU) admission and prolonged hospitalization.
We present a 26 years old female weighing 60 kg, G3P2L0 at 35 weeks of gestation, a case of placenta accreta planned for lower uterine caesarian section (LSCS) with previous two LSCS under spinal anesthesia. Preoperative investigations were within normal limits. Written informed consent and nil per oral (NPO) status were confirmed. Standard monitoring ensued. Operation theater (OT) preparation included invasive arterial monitoring setup, confirmation of the availability of blood products and C Arm in the OT. Under local anesthesia right radial artery was cannulated for invasive blood pressure (IBP) monitoring followed by bilateral femoral artery cannulation and insertion of the Atlas More Details percutaneous transluminal angioplasty (PTA) balloon catheter 12 × 40 mm into bilateral internal iliac arteries using Seldinger' s technique under fluoroscopic guidance by the interventional radiologist. Rapid sequence induction with intubation was done with propofol 100 mg and 100 mg succinylcholine I.V and the airway was secured with a cuffed endotracheal tube. Internal iliac arteries were occluded temporarily on delivery of the neonate and the balloons were deflated 45 min after the completion of hysterectomy. The intraoperative period was uneventful with a blood loss of 1500 mL.
Average blood loss during vaginal delivery is around 500 mL, 1000 mL in LSCS and 2.5–5.0 L in placenta accreta patients. Postpartum hemorrhage (PPH) is seen in 50% of placenta accreta patients with 22.6% exhibiting a severe form of PPH. Management strategy in such high-risk cases includes the timing of LSCS, choice of anesthesia, preoperative availability of massive transfusion packs in OT and cannulation of the internal iliac artery with balloon catheter under fluoroscopic guidance. Occlusion of internal iliac arteries reduces the pressure distal to the balloon, thus limiting the blood loss through the uterine vessels without compromising the blood flow to lower extremities.
In view of previous pregnancy with placenta accreta and history of previous fetal losses, LSCS was conducted in our case at 35 weeks. Literature shows an increased incidence of spontaneous bleeding after 34 weeks of gestation in patients of placenta accreta leading to increased incidence of emergency LSCS thereby affecting both, mother and fetus adversely. Massive transfusion pack which includes four units of crossmatched/O negative blood, four units of fresh frozen plasma, and one unit of apheretic platelet was arranged preoperatively to tide over the crisis in the situation of massive life-threatening hemorrhage which was in accordance to the massive transfusion protocol for delivery areas. GA technique was chosen in anticipation of hemodynamic changes and in view of heparinization done during preoperative insertion of the bilateral internal iliac artery cannulation. Literature exhibits conversion rates of 8–45% from regional anesthesia to general anesthesia in patients of placenta accreta.
The availability of C Arm in OT saved precious time and prevented the intrahospital transfer of the patient to the interventional radiology lab and back. Use of balloon occlusion of both the internal iliac arteries limited the blood loss reduced the transfusion requirements and improved the visualization of the operative fields, which was also observed by Carnevale et al. in their study.
Multidisciplinary approach and the closed-loop functioning between the anesthesiologist, interventional radiologist and obstetrician is a cornerstone in the management of such cases which may cause an 80% decrease in morbidity related to placenta accreta.
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.
| References|| |
Weiniger CF, Elram T, Ginosar Y, Mankuta D, Weissman C, Ezra Y. Anaesthetic management of placenta accreta: Use of a pre-operative high and low suspicion classification. Anaesthesia 2005;60:1079-84.
Eller A, Porter T, Soisson P, Silver R. Optimal management strategies for placenta accreta. BJOG 2009;116:648–54.
McLintock C, James AH. Obstetric hemorrhage. J Thromb Haemost 2011;9:1441-51.
Knuttinen MG, Jani A, Gaba RC, Bui JT, Carrillo TC. Balloon occlusion of the hypogastric arteries in the management of placenta accreta: A case report and review of the literature. Semin Intervent Radiol 2012;29:161-8.
Trikha A, Singh PM. Management of major obstetric haemorrhage. Indian J Anaesth 2018;62:698-703.
] [Full text]
Allen L, Jauniaux E, Hobson S, Smith JP, Belfort MA. FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management. Int J Gynecol Obstet 2018;140:281-90.