|Year : 2022 | Volume
| Issue : 2 | Page : 94-96
A challenging case of placenta accreta spectrum with known seizure disorder planned for cesarean hysterectomy
Rashmi Singh Kuntia, Michell Gulabani, Swati Bharti, Medha Mohta
Department of Anaesthesia and Critical Care, UCMS and GTBH, New Delhi, India
|Date of Submission||02-Nov-2022|
|Date of Acceptance||08-Nov-2022|
|Date of Web Publication||02-Dec-2022|
Dr. Michell Gulabani
Department of Anaesthesia and Critical Care, UCMS and GTBH, New Delhi, 19/245,246, Second Floor Malviya Nagar, New Delhi - 110 017
Source of Support: None, Conflict of Interest: None
A 28-year-old female with amenorrhea of 25 weeks G2P1L1, diagnosed case of placenta previa and placenta accreta with previous lower-segment cesarean section and ventriculomegaly in the fetus was planned for hysterotomy ± hysterectomy. Optimization of anticipated bleeding during surgical procedure was done with prior uterine artery embolization and a multidisciplinary care team for the management of the placenta accreta spectrum keeping general anesthesia as the choice. The role of strictly monitoring blood pressure invasively is critical in ensuring hemodynamic stability. In addition, quick access to a blood bank capable of employing massive transfusion protocols is essential. This approach allowed the maintenance of stable hemodynamics with an uneventful surgical course.
Keywords: General anesthesia, hemodynamics, multidisciplinary approach, placenta accreta spectrum
|How to cite this article:|
Kuntia RS, Gulabani M, Bharti S, Mohta M. A challenging case of placenta accreta spectrum with known seizure disorder planned for cesarean hysterectomy. J Ind Coll Anesth 2022;1:94-6
|How to cite this URL:|
Kuntia RS, Gulabani M, Bharti S, Mohta M. A challenging case of placenta accreta spectrum with known seizure disorder planned for cesarean hysterectomy. J Ind Coll Anesth [serial online] 2022 [cited 2023 Feb 3];1:94-6. Available from: https://www.jicajournal.in//text.asp?2022/1/2/94/362618
| Introduction|| |
Placenta accreta spectrum (PAS), formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. An important risk factor governing the presence of placenta accreta is a history of a prior cesarean delivery. One of the two leading causes of peripartum hemorrhage is placenta accreta and is also the most common indication for peripartum hysterectomy. Therefore, a planned delivery with a multidisciplinary approach optimizes the outcome. The present case is of PAS which was successfully managed with planned anesthesia, resulting in a favorable intraoperative and postoperative course.
| Case Report|| |
A 28-year-old female was scheduled for cesarean hysterotomy and hysterectomy if required at 25 weeks of amenorrhea in view of severe congenital malformation of the fetus. An ultrasonography during the pregnancy revealed placenta previa with accreta and increta. In addition, prominent cisterna magna of the fetus was noted. She had received subarachnoid block for her previous cesarean section 2 years ago.
Historically, she was a known case of seizure disorder with the last episode being 5 years back and was receiving the tablet levetiracetam 250 mg BD since then. The hematological investigations were in normal limits with hemoglobin was 10.4 gm/dl. Anticipating major hemorrhage at the time of surgery, all the essential planning was ensured. Uterine artery embolization by interventional radiological procedure was performed before definite surgery, and adequate blood and blood products were kept in reserve.
In the operating room, all standard monitors including noninvasive blood pressure, 5-lead electrocardiogram, and an oxygen saturation probe were placed. Two 16 G wide bore intravenous cannulae (IV) and a right radial arterial line were established before general anesthesia induction. One unit of packed red blood cells was available in the operating room. Trachea was intubated with 7 mm ID endotracheal tube using modified rapid sequence intubation accomplished with an injection of ketamine 30 mg IV, propofol 80 mg, and IV suxamethonium 100 mg IV. Maintenance with a volatile anesthetic agent isoflurane with air, around a minimum alveolar concentration of 0.5%–0.75% followed.
Midline vertical incision was given in the lower abdomen and an abortus baby was delivered, after which injection of oxytocin 20 units IV, fentanyl 80ug IV, and midazolam 1mg IV were administered. The placenta had penetrated the lower segment of the uterus and the whole of the cervix and was invading the uterine serosa (percreta), therefore, a decision for cesarean hysterectomy was taken. During surgery, the patient lost around 1700 ml of blood which was replaced with a total of 3 liters of crystalloids and 1 unit of packed red blood cells. In addition, injection of tranexamic acid was also given 1gm IV over 10 min as its role in preventing blood loss has been established. Invasive blood pressure was monitoring throughout the procedure, and no hemodynamic instability was encountered. All the fluid was given through fluid warmers, and the patient's body temperature was maintained by monitoring with the nasopharyngeal temperature probe. Additional monitoring included bispectral index along with neuromuscular monitoring which allowed the maintenance of adequate anesthesia depth. Intraoperatively, the arterial blood gas picture was normal.
A multidisciplinary approach was followed for analgesia, including nonsteroidal anti-inflammatory drugs, paracetamol, opioids, and local anesthesia (0.25% bupivacaine) infiltration at the surgical site. At the end of the surgery, the patient's trachea was extubated and transferred to the intensive care unit for observation. There was no significant complication during the postoperative period.
| Discussion|| |
Placenta accreta is defined as abnormal trophoblast invasion of a part or the entire placenta into the myometrium of the uterine wall. PAS, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta.
PAS disorders have become a significant life-threatening obstetrical issue due to its increased incidence from 0.12% to 0.31% in the last 30 years and the reported mortality rate of approximately 7.0%. The increasing rate of placenta accreta over the past four decades is likely due to a change in risk factors, most notably the increased rate of cesarean delivery.,
Once PAS has been diagnosed, the patient should be reviewed by the surgical team to develop a comprehensive management plan and to determine the timing of delivery., The preoperative assessment focuses on factors that would influence the anesthetic technique and anticipate possible complications, such as comorbidities, increased risk of hemorrhage, indicators of a possible difficult airway or venous access, and contraindications to regional anesthesia (RA).
General anesthesia (GA) is the technique of choice in PAS patients, as it ensures controlled hemodynamics during the surgery and also prevents transfusion-related pulmonary edema. Optimal surgical anesthesia depth is ensured, and additionally, it negates the risk of immediate conversion to GA if RA is chosen primarily for this subgroup., Neuraxial block may not be the technique of choice because of the possibility of hypotension and coagulopathy due to significant blood loss and subsequent massive transfusion. However, in a study by Lopez-Erazo et al., a specific PAS team was introduced, who established that RA is the safe choice and is better than GA, by the presence of an experienced surgical team and the availability of necessary technological resources and interdisciplinary groups but this study was limited with small sample size. Similarly, in a case series by Markley et al, 129 patients with preoperatively suspected PAS were administered RA as a primary modality, out of which 122 were able to be safely maintained with RA alone.
Further, in a review article by Delgado et al, GA has been suggested to not be considered a “requirement” in patients scheduled for operative deliveries, in which there is an increased risk of massive hemorrhage. Hence, case selection, an optimal scenario, and the availability of resources are critical to choose RA in PAS patients.
Extensive dissection and surgical manipulation much more than an uncomplicated cesarean delivery are often required in PAS surgery, therefore, there remains a likelihood of conversion to GA if adequate anesthesia cannot be achieved, which is the case in about 8%–45%. of the patients. Complexities with administering general anesthesia in the event of massive hemorrhage or hemodynamic instability need to be ascertained before planning RA for PAS patients.
In our case, GA was preferred, allowing better control of ventilation, and better hemodynamic stability during a massive hemorrhage. Close monitoring of volume status, urine output, ongoing blood loss, and overall hemodynamics was adequately done with the use of invasive BP monitoring. We followed a multimodal approach for perioperative pain including paracetamol, nonsteroidal anti-inflammatory drugs, opioids, and local anesthesia infiltration (0.25% bupivacaine) at the incision site. Our patient received tranexamic acid, whose role has also been established in the WOMAN Trial, and is a routine practice in this surgery for preventing postpartum hemorrhage. Closed-loop communication with the blood bank ensured the prompt availability of blood and blood products preventing any critical event.
| Conclusion|| |
Successful perioperative management of PAS requires multidisciplinary input. Obstetric anesthetists are key members of the team and should be involved at every stage. With an increasing incidence of PAS, anesthetists should be aware of the pros and cons of the anesthetic options in PAS surgery, the likelihood of massive hemorrhage, and how to manage it.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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