CMI 2021;15(1)31-34.html

Placenta Accreta: Management Protocol and Use of Epidural Anesthesia

Francesco Tarantino 1 , Giuseppe Calì 2

1 Anesthesia and Intensive Care Unit 2, Villa Sofia-Cervello Hospital, Palermo, Italy

2 Gynecology and Obstetric Unit, Villa Sofia-Cervello Hospital, Palermo, Italy. Person in charge for the Perinatal Medicine and Assistance to the Birth Unit at the ARNAS CIVICO of Palermo, Department of Maternal and Nascent Life Health

Keywords: Placenta accreta; Perioperative care; Epidural Anesthesia; Patient Care Team; Hysterectomy

CMI 2021; 15(1): 31-34

http://dx.doi.org/10.7175/cmi.v15i1.1500

Brief Report

Corresponding author

Francesco Tarantino

Anesthesia and Intensive Care Unit 2,

Villa Sofia-Cervello Hospital,

Viale Strasburgo, 233,

90146 Palermo, Italy.

Phone: +393207032427

Email: tarantino.f@virgilio.it


Received: 20 April 2021

Accepted: 21 April 2021

Published: 3 May 2021

Introduction

The incidence of placenta accreta spectrum (PAS) disorders, characterized by abnormal invasion of trophoblastic tissue through the myometrium and uterine serosa, has been growing considerably [1], thus exposing mothers to the risk of massive bleeding and death [2].

The most recent guidelines [3] suggest producing in-hospital protocols and establishing a step-by-step plan, from ultrasound-based detection of placenta previa to post-surgery management.

Our protocol

The present article is meant to share the internal protocol developed in our center, Villa Sofia-Cervello Hospital, Palermo, Italy, focusing on the anesthesiologic management (Figure 1).

img_04_01.jpg

Figure 1. Summary of the internal protocol for the management of placenta accreta spectrum disorders in the Villa Sofia-Cervello Hospital, Palermo, Italy.

From the diagnosis to the surgery

An early diagnosis allows to involve a multidisciplinary team, tailor the management plan, and prepare the elective caesarean section and subsequent hysterectomy, also performing ultrasonography, magnetic resonance imaging, and preoperative anesthetic examination. Finally, the transfusion service and the Intensive Care Unit (ICU) should be alerted.

Anesthesiology management

Historically, general anesthesia, is preferred to reduce the mother’s anxious state, allow the anesthetist to focus on the hemorrhage and the cardiovascular stability, and avoid the risk for hemodynamic instability due to an urgent shift from locoregional to general anesthesia.

Our protocol, although indicating general anesthesia in emergency regimens, provides the use of epidural anesthesia both during birth and hysterectomy, considering the shift to general anesthesia in case of emergency. In our opinion, epidural analgesia offers several advantages:

  • reduced risk of Mendelson syndrome;
  • better post-surgery pain control;
  • no risk of awareness;
  • the fetus is not exposed to the effect of general anesthetics;
  • participation of the mother to the birth;
  • continuous monitoring of the consciousness status, which indicates the level of brain perfusion and, thus, of the hemodynamic status;
  • abolition of the side effects of general anesthetics (e.g., reduction of the uterine tone and platelet functionality).

Interventional radiologists help reducing the vascular inflow to the operating field, thus allowing to use locoregional anesthesia in obstetrics with reduced bleeding, reduced use of blood products in the major obstetric hemorrhage, and better management in the post-surgery pain therapy. Finally, we chose epidural anesthesia over combined combined spino-epidural technique because the epidural catheter is placed in the obstetrics operatory room, and 60 minutes (radiological time) elapse before the skin incision in the interventional radiology room. Therefore, the maximum effect of the spinal anesthesia would begin to decrease. In our experience, the epidural anesthesia has a reduced hemodynamic effect compared with spino-epidural technique.

Obstetrics operatory room

The patient is prepared in the obstetrics operatory room. Two large peripheral veins are cannulated. Then, the antibiotic prophylaxis and saline are administered. The skin is disinfected, a cutaneous wheal with lidocaine is performed, and the epidural space is identified. The epidural catheter is placed, while monitoring electrocardiogram (ECG), oxygen saturation, and non-invasive blood pressure (NIBP). The aspiration test and dose test are performed with lidocaine. Finally, the patient is moved to the interventional radiology room.

Interventional radiology room

Time 1

Colloids are infused and vital parameters are monitored. Subsequently, ropivacaine and fentanyl are administered. The cannulation of the radial artery is performed and a central venous catheter is placed. A wedge is placed under the right buttock of the patient. In the meanwhile, invasive blood pressure, oxygen saturation, electrocardiogram, and body temperature are monitored, and a pre-surgery arterial blood gas analysis is performed. When the anesthetic plan reaches T4-T5 dermatomal level and Hollmen scale is 3, the urinary catheterization is performed and the radiological-vascular time starts with the placement of endovascular catheters in the hypogastric arteries.

Time 2

The caesarean section is performed, with the patient awake, painless, and participating to the birth. Subsequently, uterotonic agents are administered to trigger the uterus contraction, facilitate the possible placental stage, and further reduce blood loss.

Time 3

If placenta is not delivered, the morbid placenta adhesion is confirmed. Therefore, the obstetric team performs hysterectomy. In this phase, a mild sedation may be administered with i.v. benzodiazepine (midazolam) and, in the absence of apparent hemorrhage signs, after some minutes propofol in bolus may be slowly administered, so that the patient may breathe spontaneously, with Ventimask®. Subsequently, a continuous infusion of propofol may be administered. The sedation reduces tractions and adherences discomfort, strengthens the status of controlled hypotension, further reducing intraoperative bleeding, and facilitates shift to general anesthesia, if necessary.

Time 4

In the last time of the procedure, a proper evaluation and, eventually, management of the possible hemorrhage are performed, in accordance with the current guidelines of the Italian Ministry of Health [4]. Finally, the possible referral to ICU is considered. Otherwise, after suturing the abdominal belt, the sedation is suspended, with awakening of the patient in a very short time.

Post-surgery monitoring

After surgery, patients remain under observation in the Recovery Room in the Obstetrics and Gynecology Unit. After 4 hours, if the vital parameters are within normal range, Aldrete score is 9-10, and numerical rating scale—NRS is 2, the patient is moved to the ward, where the blood and continuous pressure monitoring continue.

Post-surgery pain control

The protocol provides the 24/48-hour epidural pain management by the pump for Programmed Intermittent Epidural Boluses—PIEB, through which ropivacaine and acetaminophen are administered. Epidural catheter is removed at the third day, 12 hours after the last low-molecular-weight heparin administration and upon assessment of possible alteration in the coagulation status.

Conclusions

The efficiency of this protocol made us become a reference center for the management of placenta accreta beyond the borders of our region. We treated more than 20 patients and we obtained positive results in terms of bleeding, packed red blood cells used, postoperative sequelae, and ICU admissions. No patients died.

A few procedures were carried out in emergency regimen and in these cases general anesthesia was used: they required the greatest amount of blood products, as also confirmed by the literature [5]. In our experience, both in case of elective and emergency surgeries, fibrinogen administration considerably reduced the need for packed red blood cells. Among those treated in elective regimen, blood loss never exceeded 1800 mL.

Funding

Publishing support, journal styling services, and open access publication of this article were funded by CSL Behring, Italy. The sponsor had no role in the collection, analysis, and interpretation of data, in the writing of the report, and in the decision to submit the article for publication.

Conflicts of Interests

Dr. Tarantino reports non-financial support from CSL the conduct of the study; personal fees from Boehringer, outside the submitted work. Dr. Calì reports non-financial support from CSL Behring, during the conduct of the study.

ORCiD

Francesco Tarantino: https://orcid.org/0000-0002-9819-5410

References

1. Morlando M, Sarno L, Napolitano R, et al. Placenta accreta: incidence and risk factors in an area with a particularly high rate of cesarean section. Acta Obstet Gynecol Scand 2013; 92: 457-60; https://doi.org/10.1111/aogs.12080

2. O’Brien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative strategies. Am J Obstet Gynecol 1996; 175: 1632-8; https://doi.org/10.1016/s0002-9378(96)70117-5

3. Society of Gynecologic Oncology, American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine, Cahill AG, et al. Placenta Accreta Spectrum. Am J Obstet Gynecol 2018; 219: B2-B16; https://doi.org/10.1016/j.ajog.2018.09.042

4. Ministero della Salute. Parto, Linea guida nazionale per la prevenzione e il trattamento dell’emorragia post partum. Available at http://www.salute.gov.it/portale/news/p3_2_1_1_1.jsp?lingua=italiano&menu=notizie&p=dalministero&id=2740 (last accessed April, 2021).

5. Allen L, Jauniaux E, Hobson S, et al. FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management. Int J Gynaecol Obstet 2018; 140: 281-90; https://doi.org/10.1002/ijgo.12409

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