What is the recommended anesthetic management for patients with placenta percreta?

Anesthetic Management for Placenta Percreta

The optimal anesthetic management for placenta percreta requires a multidisciplinary approach with early planning, neuraxial anesthesia as the initial technique, preparation for massive hemorrhage, and readiness to convert to general anesthesia if needed. 1, 2

Preoperative Considerations

• Preoperative consultation with anesthesiology should be arranged as part of the multidisciplinary planning team, which includes maternal-fetal medicine, gynecologic oncology, interventional radiology, and neonatology 1, 3
• Thorough evaluation of airway, hemoglobin levels, and coagulation status should be performed, with optimization of hemoglobin values through iron supplementation when indicated 1
• Delivery timing should be planned for 34 0/7-35 6/7 weeks of gestation in stable patients to balance maternal hemorrhage risk with neonatal outcomes 1
• Notification and collaboration with the blood bank is essential given the frequent need for large-volume transfusion 1
• Consider placement of arterial line and central venous access preoperatively for hemodynamic monitoring and administration of blood products 4, 2

Anesthetic Technique

• Neuraxial anesthesia (combined spinal-epidural) is recommended as the initial approach for cesarean delivery in hemodynamically stable patients 4, 2
• Benefits of neuraxial anesthesia include:
  • Maternal awareness during delivery
  • Reduced blood loss compared to general anesthesia
  • Avoidance of airway manipulation in potentially difficult scenarios 4
• Be prepared to convert to general anesthesia if massive hemorrhage occurs or extensive surgery is required 4, 2
• Ensure adequate large-bore intravenous access (at least two 16-gauge or larger IVs) 2

Intraoperative Management

• Invasive hemodynamic monitoring with arterial line is strongly recommended for all cases 4, 2
• Central venous catheter placement should be considered for administration of vasopressors and monitoring of volume status 4
• Prepare for massive transfusion protocol with a 1:1:1 to 1:2:4 ratio strategy of packed red blood cells:fresh frozen plasma:platelets 1
• Cell salvage technology should be available when possible 1
• Consider use of tranexamic acid to reduce blood loss 1
• Maintain close communication with surgical team regarding blood loss estimation and hemodynamic status 2

Management of Massive Hemorrhage

• Activate massive transfusion protocol early rather than late 1
• Consider conversion to general anesthesia if massive hemorrhage occurs 4
• Maintain normothermia to prevent coagulopathy 2
• Monitor and correct coagulopathy with appropriate blood products and point-of-care testing if available 2
• Be prepared for vasopressor support as needed 1

Postoperative Care

• Patients with placenta percreta are at high risk for ongoing abdominopelvic bleeding and other complications 1
• Consider postoperative intensive care unit admission for patients with significant blood loss or hemodynamic instability 4
• Monitor for complications including renal failure, liver failure, infection, unrecognized injuries, pulmonary edema, and disseminated intravascular coagulation 1
• Be vigilant for Sheehan syndrome (postpartum pituitary necrosis) in cases with significant hypoperfusion 1
• Provide appropriate postoperative pain management, which may be complex after cesarean hysterectomy 2

Special Considerations for Low-Resource Settings

• Even with limited resources, good outcomes are possible with proper planning 4
• Focus on early recognition of placenta percreta, blood product availability, and surgical expertise 4
• If interventional radiology is not available, other techniques such as aortic compression or uterine compression sutures may be considered 5

Pitfalls and Caveats

• Underestimation of blood loss is common in placenta percreta cases 2
• Complications associated with invasive monitoring can occur and should be anticipated 4
• Delayed recognition of placenta percreta intraoperatively can lead to catastrophic hemorrhage; if suspected, the case should be temporarily paused until optimal surgical and anesthetic expertise arrives 1
• Transfer to a higher level of care facility should be considered if the diagnosis is made at a center without appropriate resources, assuming maternal and fetal stability 1