|Year : 2015 | Volume
| Issue : 2 | Page : 95-96
Placenta accreta diagnosed 15 days following primary cesarean section
Krutika Parasar, Shruti Shah, Shaul Cohen, Adil Mohiuddin
Department of Anaesthesiology, Rutgers-Robert Wood Johnson University Hospital, 1 Robert Wood Johnson Place, New Brunswick, NJ 08901, USA
|Date of Web Publication||11-Sep-2015|
Department of Anaesthesiology, CAB 3100, 1 Robert Wood Johnson Pl, New Brunswick, NJ 08901
Source of Support: None, Conflict of Interest: None
Placenta accreta is a life-threatening obstetric complication with an ever-increasing incidence. Between 1982 and 2002, the reported incidence of placenta accreta was 1/533 pregnancies, nearly 4 times its incidence in the 1980s and 8 times its incidence in the 1970s. As Cesarean sections (C/S) become more common, so does placenta accreta, as prior C/S is a risk factor. Placenta accreta requires emergent treatment and unique anesthetic considerations. However, little research discusses the anesthetic protocol to treat this condition. This report details the anesthetic procedure used to successfully treat a patient with placenta accrete diagnosed 15 days post-C/S.
Keywords: Cesarean section, obstetric hemorrhage, placenta accreta
|How to cite this article:|
Parasar K, Shah S, Cohen S, Mohiuddin A. Placenta accreta diagnosed 15 days following primary cesarean section. J Obstet Anaesth Crit Care 2015;5:95-6
|How to cite this URL:|
Parasar K, Shah S, Cohen S, Mohiuddin A. Placenta accreta diagnosed 15 days following primary cesarean section. J Obstet Anaesth Crit Care [serial online] 2015 [cited 2020 Nov 24];5:95-6. Available from: https://www.joacc.com/text.asp?2015/5/2/95/165140
| Case Report|| |
A 27-year-old healthy gravida 1 para 1 parturient received appropriate prenatal care and underwent an uncomplicated primary C/S at 39 weeks gestation for failure to progress under epidural anesthesia. She presented to the Emergency Department 15 days postoperatively with complaints of continued vaginal bleeding that had increased since the day prior to the presentation. She noted passing up to 1000 mL of clotted blood. She also had complaints of weakness which began the night prior to the presentation. She denied loss of consciousness, altered mental status, and pelvic pain. The patient had no uterine surgery prior to C/S. She presented with the following vital signs: Heart rate of 105 beats/min, blood pressure of 115/66 mmHg, respiratory rate of 18/min, and oxygen saturation of 100% on room air. Her hemoglobin on arrival to emergency department was 9.1 g/dL (baseline 10-11 g/dL). Prothrombin time, partial thromboplastin time, and international normalized ratio were within normal limits. She was suspected to have retained placental fragments and preparations for dilation and curettage/evacuation of placental products. Preoperatively, type and screen was performed, and the patient received 1 L of normal saline. In holding, she received 2 mg intravenous (IV) midazolam and then brought to the operating room for emergency dilation and curettage. Two large-bore peripheral IV catheters were placed prior to induction of general anesthesia. Invasive hemodynamic monitors were not placed due to stable vital signs. Discussion with patient, obstetric team, and anesthesia team regarding the potential for hemorrhage, the possible need for blood transfusion and the possible need for hysterectomy was carried out prior to induction of anesthesia.
In the OR, the patient received IV fentanyl 100 mcg, IV lidocaine 40 mg, and IV propofol 150 mg. Intra-operatively, the patient was positioned and rapid sequence induction with cricoid pressure was induced with succinylcholine 100 mg and rocuronium 30 mg. Endotracheal intubation was successful on first attempt. Relaxation was maintained with oxygen and the inhalation agent sevoflurane. The obstetric team found polypoid-like material protruding through a 1-2 cm dilated cervix that was densely adherent to the left lower uterine segment. A surgical plane could not be identified between the polypoid material and uterine wall. The polypoid material was extracted piecemeal under ultrasound guidance, and vaginal packing was used to control blood loss. Twenty units pitocin via IV infusion was initiated to increase uterine tone. Frozen section of extracted material revealed placental tissue. Estimated blood loss was 500 mL. The patient was extubated at the conclusion of procedure without complications and was transferred to the recovery room. Given her clinical presentation and operative and pathologic findings, the diagnosis of placenta accreta was made.
| Discussion|| |
Placenta accreta is the invasion of the placenta into the uterine wall. Between 1982 and 2002, the reported incidence of placenta accreta was 1/533 pregnancies,  nearly 4 times its incidence in the 1980s and 8 times its incidence in the 1970s. , Risk factors for placenta accreta include prior C/S,  placenta previa, other uterine surgery or thermal ablation, uterine artery embolization, advanced maternal age, and multiparity. Diagnosis of placenta accreta is usually made before birth with use of ultrasound and magnetic resonance imaging. Diagnosis prior to birth can allow appropriate planning of delivery as there is a risk of life-threatening hemorrhage associated with placenta accreta.  Diagnosis following vaginal delivery should be considered if persistent postpartum bleeding is present.
Placenta accreta diagnosis following primary C/S in a patient with no other risk factors for placenta accreta is rare. Anesthetic considerations for a patient presenting with vaginal bleeding 15 days following C/S include the risk of obstetric hemorrhage, potential need for invasive hemodynamic monitoring, and the possibility of massive blood transfusion.
In this report, we described successful anesthetic management of a rare case of placenta accreta 2 weeks following C/S delivery. Anesthetic techniques and agents were applied in concordance with guidelines for the management of more typical cases of placenta accreta, but modifications were made to account for the unique considerations of this case. Prior to induction of anesthesia, two large-bore IV catheters were placed, as this measure has been regarded a minimum requirement of anesthetic management of placenta accreta.  Succinylcholine was selected as the agent for rapid sequence induction since the patient's vital signs were stable. General anesthesia was administered; this was deemed the most appropriate choice in consideration of the risk of massive blood loss, hypotension, and possible need for hysterectomy in our patient. This report highlights the importance of vigilance for cases of placenta accrete post-C/S delivery and provides an anesthetic management plan that resulted in a successful outcome for our patient.
| References|| |
Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: Twenty-year analysis. Am J Obstet Gynecol 2005;192:1458-61.
Read JA, Cotton DB, Miller FC. Placenta accreta: Changing clinical aspects and outcome. Obstet Gynecol 1980;56:31-4.
Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol 1997;177:210-4.
Snegovskikh D, Clebone A, Norwitz E. Anesthetic management of patients with placenta accreta and resuscitation strategies for associated massive hemorrhage. Curr Opin Anaesthesiol 2011;24:274-81.
Kato R, Terui K, Yokota K, Watanabe M, Uokawa R, Miyao H. Anesthetic management for cases of placenta accreta presented for cesarean section: A 7-year single-center experience. Masui 2008;57:1421-6.