The anaesthetic management of Caesarean section for placenta praevia: a questionnaire survey

Management of massive hemorrhage in pregnant women with placenta previa

Patients with placenta previa are at risk for intra- and postpartum massive blood loss as well as increased risk of placenta accreta, a type of abnormal placental implantation. This condition can lead to serious obstetric complications, including maternal mortality and morbidity. The risk factors for previa include prior cesarean section, multiparity, advanced maternal age, prior placenta previa history, prior uterine surgery, and smoking. The prevalence of previa parturients has increased due to the rising rates of cesarean section and advanced maternal age. For these reasons, we need to identify the risk factors for previa and identify adequate management strategies to respond to blood loss during surgery. This review evaluated the diagnosis of placenta previa and placenta accreta and assessed the risk factors for previa-associated bleeding prior to cesarean section. We then presented intraoperative anesthetic management and other interventions to control bleeding in patients with previa expected to experience massive hemorrhage and require transfusion.

A retrospective review of 10-year trends in general anesthesia for cesarean delivery at a university hospital: the impact of a newly launched team on obstetric anesthesia practice

BACKGROUND

The indications for general anesthesia (GA) in obstetric settings, which are determined in consideration of maternal and fetal outcome, could be affected by local patterns of clinical practice grounded in unique situations and circumstances that vary among medical institutions. Although the use of GA for cesarean delivery has become less common with more frequent adoption of neuraxial anesthesia, GA was previously chosen for pregnancy with placenta previa at our institution in case of unexpected massive hemorrhage. However, the situation has been gradually changing since formation of a team dedicated to obstetric anesthesia practice. Here, we report the results of a review of all cesarean deliveries performed under GA, and assess the impact of our newly launched team on trends in clinical obstetric anesthesia practice at our institution.

METHODS

Our original database for obstetric GA during the period of 2010 to 2019 was analyzed. The medical records of all parturients who received GA for cesarean delivery were reviewed to collect detailed information. Interrupted time series analysis was used to evaluate the impact of the launch of our obstetric anesthesia team.

RESULTS

As recently as 2014, more than 10% of cesarean deliveries were performed under GA, with placenta previa accounting for the main indication in elective and emergent cases. Our obstetric anesthesia team was formed in 2015 to serve as a communication bridge between the department of anesthesiology and the department of obstetrics. Since then, there has been a steady decline in the percentage of cesarean deliveries performed under GA, decreasing to a low of less than 5% in the latest 2 years. Interrupted time series analysis revealed a significant reduction in obstetric GA after 2015 (P = 0.04), which was associated with decreased use of GA for pregnancy with placenta previa. On the other hand, every year has seen a number of urgent cesarean deliveries requiring GA.

CONCLUSIONS

There has been a trend towards fewer obstetric GA since 2015. The optimized use of GA for cesarean delivery was made possible mainly through strengthened partnerships between anesthesiologists and obstetricians with the support of our obstetric anesthesia team.

Anesthesia for Cesarean Section in Parturients with Abnormal Placentation: A Retrospective Study

Introduction Placental invasion anomalies are associated with high mortality and may require hysterectomy due to the high risk of massive hemorrhage. The aim of this retrospective study was to evaluate intraoperative anesthetic management, postoperative follow-up, clinical features, and fetal wellbeing in patients undergoing cesarean section due to placental invasion anomalies in a tertiary health center. Methods The retrospective study included patients that underwent cesarean section due to placental invasion anomalies at a tertiary health center over the period between 2013 and 2018. Intraoperative anesthetic management, blood and blood products transfusion, and total volume of blood loss, as well as neonatal Apgar score and postoperative intensive care unit (ICU) follow-up, were reviewed for each patient. Results The study evaluated a total of 92 patients that underwent cesarean section due to placental invasion anomalies, including 49 patients with placenta previa, 42 patients with placenta percreta, and one patient with placenta accreta. Of the 92 patients, 59 (64.1%) patients underwent general anesthesia, 31 (33.7%) underwent spinal anesthesia, and two (2.2%) underwent spinal anesthesia followed by general anesthesia. Hysterectomy was performed in four patients, including three patients who underwent general anesthesia and one patient who started with spinal anesthesia and subsequently switched to general anesthesia prior to a hysterectomy. The Apgar scores at min 1 and min 5 after the induction of anesthesia were significantly lower in patients who underwent general anesthesia as compared to those who underwent spinal anesthesia (p=0.002 and p=0.007, respectively). The duration of surgery and intraoperative blood loss were significantly higher in patients with placenta percreta as compared to other patients (p<0.001 for both). Conclusion In surgical planning for the patients with placental invasion anomalies, care should be taken by anesthesiologists to select the most ideal anesthetic technique, by taking into account the type of anomaly, probable volume of blood loss, and surgical complications, to ensure both maternal and fetal wellbeing. Moreover, the coordination of a team of well-educated and experienced staff is essential.

Anesthesia management of complete versus incomplete placenta previa: a retrospective cohort study

PURPOSE

Placenta previa (PP) is a major cause of obstetric hemorrhage. Clinical diagnosis of complete versus incomplete PP has a significant impact on the peripartum outcome. Our study objective is to examine whether distinction between PP classifications effect anesthetic management.

METHODS AND MATERIALS

This multi-center, retrospective, cohort study was performed in two tertiary university-affiliated medical centers between the years 2005 and 2013. Electronic delivery databases were reviewed for demographic, anesthetic, obstetric hemorrhage, and postoperative outcomes for all cases.

RESULTS

Throughout the study period 452 cases of PP were documented. We found 134 women (29.6%) had a complete PP and 318 (70.4%) had incomplete PP. Our main findings were that women with complete PP intraoperatively had higher incidence of general anesthesia (p = .017), higher mean estimated blood loss (p < .001), increased blood components transfusions (p < .001), and significant increase in cesarean hysterectomy rate (p < .001) than women with incomplete PP. Additionally, complete PP was associated with more postoperative complications: higher incidence of admission to the intensive care unit (ICU) (p < .001), more mechanical ventilation (p = .02), a longer median postoperative care unit (PACU) (p = .02), ICU (p = .002), and overall length of stay in the hospital (p < .001).

CONCLUSIONS

Complete PP is associated with increased risk of hemorrhage compared with incomplete PP. Therefore distinction between classifications should be factored into anesthetic management protocols.

Brief communication (Original). Anesthesia for cesarean section in parturients diagnosed with placenta previa in a Thai university hospital: a retrospective analysis of 562 consecutive cases

Background: Anesthesia for cesarean delivery in parturients diagnosed with placenta previa remains controversial.

Objectives: To investigate factors correlated with choice of anesthesia in these parturients and their outcomes.

Methods: Retrospective analysis of patients with placenta previa and cesarean delivery at King Chulalongkorn Memorial Hospital. Peri operative anesthetic and complication data were collected using a structured collection form. Univariate analysis and multivariate logistic regression were used. P < 0.05 was considered significant.

Results: Among 50,237 deliveries from July 1, 2005 to June 30, 2011, there were 562 cesarean sections in diagnosed cases of placenta previa. Cesarean deliveries (479) were performed under spinal anesthesia (81%), epidural anesthesia (1.8%), and if the effects spinal anesthesia dissipated, general anesthesia (2.3%). Among 46 cases of cesarean hysterectomy, 27 patients (58.7%) received regional anesthesia. However, 6 of 10 patients with planned cesarean hysterectomy underwent general anesthesia, while 1 of 4 of a group with regional anesthesia needed conversion to general anesthesia. There was no serious anesthesia-related complication. Factors related to general anesthesia were: a higher American Society of Anesthesiologists (ASA) physical status OR 2.7 (95% CI 1.7-4.3) P < 0.001; presentation with bleeding OR 1.8(95% CI 1.0-3.1) P = 0.033; anterior site of placenta OR 1.8 (95% CI 1.1-3.2) P = 0.025; heart rate >125 bpm OR 5.6 (95% CI 1.5-214) P = 0.01; and pack red cell transfusion OR 3.4 (95% CI 2.0-5.7) P < 0.001.

Conclusions: Most parturients received regional anesthesia. Neuroaxial anesthesia and general anesthesia are safe.

Maternal haemorrhage

Maternal haemorrhage is the leading cause of preventable maternal death worldwide and encompasses antepartum, intrapartum, and postpartum bleeding. This review highlights factors that predispose to severe bleeding, its management, and the most recent treatment and guidelines. Advances in obstetric care have provided physicians with the diagnostic tools to detect, anticipate, and prevent severe life-threatening maternal haemorrhage in most patients who have had prenatal care. In an optimal setting, patients at high risk for haemorrhage are referred to tertiary care centres where multidisciplinary teams are prepared to care for and deal with known potential complications. However, even with the best prenatal care, unexpected haemorrhage occurs. The first step in management is stabilization of haemodynamic status, which involves securing large bore i.v. access, invasive monitoring, and aggressive fluid management and transfusion therapy. Care for the patient with maternal bleeding should follow an algorithm that goes through a rapid and successive sequence of medical and surgical approaches to stem bleeding and decrease morbidity and mortality. With the addition of potent uterotonic agents and the advent of minimally invasive interventional radiological techniques such as angiographic embolization and arterial ligation, definitive yet conservative management is now possible in an attempt to avoid hysterectomy in patients with severe peripartum bleeding. If these interventions are inadequate to control the bleeding, the decision to proceed to hysterectomy must be made expeditiously. Recombinant factor VIIa is a relatively new treatment that could prove useful for severe coagulopathy and intractable bleeding.

Anaesthetic issues related to postpartum haemorrhage (excluding antishock garments)

The obstetric anaesthetist is a key member of the multidisciplinary team required to manage postpartum haemorrhage, having been trained in resuscitation and being experienced in managing haemorrhage and in monitoring and caring for the critically ill patient. The diagnosis of shock, initial resuscitation controversies surrounding fluid replacement, cell salvage in obstetrics and monitoring are discussed.

Contraindications to regional anaesthesia in obstetrics: a survey of German practice

BACKGROUND

We assessed current practice regarding indications and contraindications to regional analgesia and anaesthesia for labour and delivery in Germany.

METHODS

Questionnaires were mailed to the directors of 918 German departments of anaesthesiology.

RESULTS

A total of 397 completed replies were received representing 41.3% of all deliveries in Germany. More than half of the respondents never perform spinal or epidural anaesthesia when the platelet count falls below 65x10(9)/L. Preeclampsia, which was not graded for severity, was considered an absolute contraindication to regional block by 15% and placenta praevia by 30% of respondents. If a woman had taken aspirin three days before, the numbers of respondents considering epidural anaesthesia contraindicated (40.2%) were nearly double those considering spinal anaesthesia contraindicated (21.7%) (P<0.001). For a platelet count of 79x10(9)/L, epidural anaesthesia was thought to be contraindicated by 37% and spinal anaesthesia by 22.2% (P=0.001). In departments with <500 deliveries/year, reluctance to use regional blockade was more pronounced than in departments with >1000 deliveries/year.

CONCLUSION

Clinical practice varies considerably in Germany. Concerns regarding the use of regional blockade were more prevalent in hospitals with small delivery units. Indications and contraindications are not consistent in Germany and some recommendations or guidelines are needed.

Anesthesia for cesarean section in a patient with placenta previa and methylenetetrahydrofolate reductase deficiency

We describe the anesthetic management of a patient with placenta previa presenting for a cesarean section, who had methylenetetrahydrofolate reductase (MTHFR) deficiency. Methylenetetrahydrofolate reductase deficiency increases homocysteine levels in the body and, therefore, predisposes to thrombosis. After a cerebrovascular accident at 8 weeks of gestational age, the patient received anticoagulants throughout the course of her pregnancy. Bleeding from the placenta previa occurred at 30 weeks of gestational age. Although general anesthesia was indicated for this patient because of her hemodynamic instability and an anticoagulated state, nitrous oxide is contraindicated in such patients. Thus, we chose a subarachnoid block because the patient remained hemodynamically stable, and anticoagulation had been stopped 8 hours before surgery. To our knowledge, there is no reported case of a parturient with MTHFR deficiency complicated with a cerebrovascular accident and associated with placenta previa presenting for a cesarean section. Anesthetic considerations are discussed in patients presenting with placenta previa associated with MTHFR deficiency.

Placenta Previa, Placenta Accreta, and Vasa Previa

Placenta previa, placenta accreta, and vasa previa are important causes of bleeding in the second half of pregnancy and in labor. Risk factors for placenta previa include prior cesarean delivery, pregnancy termination, intrauterine surgery, smoking, multifetal gestation, increasing parity, and maternal age. The diagnostic modality of choice for placenta previa is transvaginal ultrasonography, and women with a complete placenta previa should be delivered by cesarean. Small studies suggest that, when the placenta to cervical os distance is greater than 2 cm, women may safely have a vaginal delivery. Regional anesthesia for cesarean delivery in women with placenta previa is safe. Delivery should take place at an institution with adequate blood banking facilities. The incidence of placenta accreta is rising, primarily because of the rise in cesarean delivery rates. This condition can be associated with massive blood loss at delivery. Prenatal diagnosis by imaging, followed by planning of peripartum management by a multidisciplinary team, may help reduce morbidity and mortality. Women known to have placenta accreta should be delivered by cesarean, and no attempt should be made to separate the placenta at the time of delivery. The majority of women with significant degrees of placenta accreta will require a hysterectomy. Although successful conservative management has been described, there are currently insufficient data to recommend this approach to management routinely. Vasa previa carries a risk of fetal exsanguination and death when the membranes rupture. The condition can be diagnosed prenatally by ultrasound examination. Good outcomes depend on prenatal diagnosis and cesarean delivery before the membranes rupture.

General anesthesia for cesarean section in a Singapore maternity hospital: a retrospective survey

We conducted a retrospective study of all cases of cesarean section at the KK Women's and Children's Hospital over a one-year period from September 1, 2002 to August 31, 2003, with the aim of evaluating current anesthetic practice. These cases were identified using hospital databases and relevant data was extracted from clinical notes. There were 14244 deliveries during the study period with a cesarean section rate of 25.2% (3583 cases). Of these, 20.4% (732 cases) were performed under general anesthesia. Maternal request was the chief reason for general anesthesia, especially among elective cases. Regional block failure accounted for 16% of the general anesthesia cases performed or 4.0% of the total regional techniques attempted. Regional block failure rate was highest for emergency cases in which an indwelling labor epidural catheter was used to provide surgical anesthesia via a bolus top-up. General anesthesia still has a definite place for cesarean delivery despite the predominant use of regional techniques in our institution.

Anaesthesia for emergency caesarean section in a parturient with bleeding placenta praevia and a potentially malignant hyperthermia-susceptible fetus

A parturient who was 35 weeks' pregnant by her husband who was known to be susceptible to malignant hyperthermia, required anaesthesia for caesarean section for bleeding placenta praevia. The patient was considered to be haemodynamically stable and the procedure was carried out uneventfully under subarachnoid block. Anaesthesia was conducted as for an individual who is susceptible to malignant hyperthermia. The combination of the potential susceptibility to malignant hyperthermia of the fetus, and the problems of bleeding placenta praevia, produced an unusual clinical situation with potential conflict of interests when choosing the anaesthetic technique.

Planning for hemorrhage. Steps an anesthesiologist can take to limit and treat hemorrhage in the obstetric patient

Obstetric hemorrhage continues to be a significant cause of maternal mortality and morbidity. Blood transfusion in such circumstances may be life saving but involves exposing the patient to additional risks. Limiting blood transfusion and using autologous blood when possible may reduce some of these risks. This article outlines the techniques that may be used to limit and more effectively treat hemorrhage in the obstetric patient, with particular attention paid to reducing the use of allogeneic blood transfusion.

Comparison of general and epidural anesthesia in elective cesarean section for placenta previa totalis: maternal hemodynamics, blood loss and neonatal outcome

There are few consistent guidelines in choosing anesthesia for cesarean section for a parturient with placenta previa. This prospective randomized trial was organized to compare the maternal hemodynamics, blood loss and neonatal outcome of general versus epidural anesthesia for cesarean section with the diagnosis of grade 4 placenta previa. After giving informed consent, 12 patients received general anesthesia and 13 received epidural. Intraoperative blood pressures demonstrated a more stable course in the epidural group than in the general group. Blood loss did not differ significantly between the groups (1622 +/- 775 mL vs. 1418 +/- 996 mL). General anesthesia resulted in lower immediate postoperative hematocrit level (28.1 +/- 3.5% vs. 32.5 +/- 5.0%, P < 0.05). The patients in the general group received a significantly larger transfusion than the epidural group (1.08 +/- 1.6 vs. 0.38 +/- 0.9 units, P < 0.05). The Apgar scores at 1 and 5 min were similar in the two groups (8 [4-9] vs. 8 [7-9] and 10 [6-10] vs. 9 [9-10], respectively). We concluded that epidural anesthesia is superior to general anesthesia in elective cesarean section for grade 4 placenta previa with regard to maternal hemodynamics and blood loss. There was no difference in neonatal outcome.

Anaesthesia for caesarean section complicated by placenta praevia

Placenta praevia is present when the placenta implants below the presenting part of the fetus. It is classified into grades I—IV depending on the relationship between the placenta and the cervical os. Placenta praevia complicates 1 in 200 deliveries and is associated with considerable maternal and fetal morbidity and mortality (Iyasu et al, 1993; Department of Health, 2001). Increased bleeding is seen from the placental bed, which is abnormally implanted into the less contractile, lower segment of the uterus. A morbidly adherent placenta (accreta) further increases these risks.

Spinal anaesthesia for caesarean section: current clinical practice

Spinal anaesthesia has evolved as the preferred anaesthetic technique for most cases of caesarean section. Having been extensively studied and refined over the years, there are few situations where a spinal is absolutely contraindicated. While general anaesthesia will always have a place in obstetrics, in experienced hands a spinal offers safety, efficacy and an improvement in maternal morbidity.

Interventions for suspected placenta praevia

BACKGROUND

Because placenta praevia is implanted unusually low in the uterus, it may cause major, and/or repeated, antepartum haemorrhage. The traditional policy of care of women with symptomatic placenta praevia includes prolonged stay in hospital and delivery by caesarean section.

OBJECTIVES

To assess the impact of any clinical intervention applied specifically because of a perceived likelihood that a pregnant woman might have placenta praevia.

SEARCH STRATEGY

A comprehensive electronic search was performed to identify relevant literature. Searched databases included the Trials Register maintained by the Cochrane Pregnancy and Childbirth Group, and the Cochrane Controlled Clinical Trials Register.

SELECTION CRITERIA

Any controlled clinical trial that has assessed the impact of an intervention in women diagnosed as having, or being likely to have, placenta praevia.

DATA COLLECTION AND ANALYSIS

Data were extracted from the three identified trial reports, unblinded, by the author without consideration of results.

MAIN RESULTS

Two comparisons could be made - home versus hospitalisation and cervical cerclage versus no cerclage. Both were associated with reduced lengths of stay in hospital antenatally. Otherwise, there was little evidence of any clear advantage or disadvantage to a policy of home versus hospital care. Cervical cerclage may reduce the risk of delivery before 34 weeks, or the birth of a baby weighing less than 2 kg or having a low 5 minute Apgar score. In general, these possible benefits were more evident in the trial of lesser methodological quality.

REVIEWER'S CONCLUSIONS

There are insufficient data from trials to recommend any change in clinical practice. Available data should, however, should encourage further work to address the safety of more conservative policies of hospitalisation for women with suspected placenta praevia, and the possible value of insertion of a cervical suture.

Placenta previa: a 22-year analysis

OBJECTIVE

Our purpose was to identify what anesthetic method is safer for women with a placenta previa.

STUDY DESIGN

We retrospectively reviewed all women with placenta previa who underwent cesarean delivery during the period January 1, 1976-December 31, 1997 at Northwestern Memorial Hospital.

RESULTS

Of 93,384 deliveries, placenta previa was found in 514 women. Identifiable trends with time included an increasing incidence of placenta previa (r = 0.54, P <.01); cesarean hysterectomy (r = 0.54, P <.01); placenta accreta (r = 0.45, P <.03); and regional anesthesia (r = 0.84, P <.0001). The mean gestational age at delivery was 35.3 +/- 3.4 weeks and did not change with time. General anesthesia was used for delivery in 380 women and regional anesthesia was used for 134 women. Prior cesarean delivery and general anesthesia were independent predictors of the need for blood transfusion, but only prior cesarean delivery was a predictor of the need for hysterectomy. General anesthesia increased the estimated blood loss, was associated with a lower postoperative hemoglobin concentration, and increased the need for blood transfusion. Elective and emergent deliveries did not differ in estimated blood loss, in postoperative hemoglobin concentrations, or in the incidence of intraoperative and anesthesia complications. Regional and general anesthesia did not differ in the incidence of intraoperative and anesthesia complications.

CONCLUSIONS

In women with placenta previa, general anesthesia increased intraoperative blood loss and the need for blood transfusion. Regional anesthesia appears to be a safe alternative.