Cesarean section for morbidly adherent placenta can be successfully managed with neuraxial anesthesia, although with a modest conversion rate to general anesthesia.pearl
- John C Markley, Michaela K Farber, Nicola C Perlman, and Daniela A Carusi.
- From the Department of Anesthesia and Perioperative Care, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, California.
- Anesth. Analg. 2018 Oct 1; 127 (4): 930-938.
BackgroundGeneral anesthesia (GA) is often selected for cesarean deliveries (CD) with placenta previa and suspected morbidly adherent placenta (MAP) due to increased risk of hemorrhage and hysterectomy. We reviewed maternal outcomes and risk factors for conversion to GA in a cohort of patients undergoing CD and hysterectomy under neuraxial anesthesia (NA).MethodsWe performed a single-center, retrospective cohort study of parturients undergoing nonemergent CD for placenta previa with suspected MAP from 1997 to 2015. Patients were classified according to whether they received GA, NA, or intraoperative conversion from NA to GA. The primary outcome measure was postoperative acuity, defined as the need for intensive care unit admission, arterial embolization, reoperation, or ongoing transfusion with ≥3 units packed red blood cells. We additionally identified variables positively associated with intraoperative conversion from NA to GA during hysterectomy. Confounding was controlled with logistic regression models.ResultsOf 129 patients undergoing nonemergent CD for placenta previa with suspected MAP, 122 (95%) received NA as the primary anesthetic. NA was selected in the majority of patients with a body mass index ≥40 kg/m (9 of 10, 90%), a history of ≥3 prior CDs (18 of 20, 90%), suspected placenta increta or percreta (29 of 35, 83%), and Mallampati classification ≥3 (19 of 21, 90%). Of 72 patients with NA at the time of delivery who required hysterectomy, 15 (21%) required conversion to GA intraoperatively. Converted patients had a higher rate of major packed red blood cell transfusion (60% vs 25%; P = .01), with similar rates of massive transfusion (9% vs 7%; P = 1.0). Converted patients also had a higher incidence of postoperative acuity (47% vs 4%; P < .0001), including 5 intensive care unit admissions for airway management after large-volume resuscitation. After adjusting for multiple confounders, the only independent predictors of conversion among hysterectomy patients were longer surgical duration (adjusted odds ratio 1.54, 95% CI, 1.01-2.42) and a history of ≥3 prior CDs (adjusted odds ratio, 6.45; 95% CI, 1.12-45.03).ConclusionsNA was applied to and successfully used in the majority of patients with suspected MAP. Our findings support selective conversion to GA during hysterectomy in these patients, focusing on those with the highest levels of surgical complexity.
What did they do?
Markley et al. conducted a single-center retrospective cohort study of 23 years of data from a tertiary North American academic hospital. The investigators identified 129 patients meeting criteria, requiring elective Cesarean delivery (CD/CS) for suspected morbidly adherent placenta (MAP): placenta accreta, increta or percreta.
Why the fuss?
Historically there has been concern that neuraxial anaesthesia may add additional complexity when managing a major haemorrhage associated with MAP CS, by:
- Complicating large volume resuscitation in an awake patient.
- Accentuating hypotension due to sympathectic block.
- Having an unsecured airway in the event of intraoperative crisis.
- Creating neuraxial uncertainty when coagulopathy occurs.
And they found...
The majority of patients with morbidly adherent placentas can be safely managed with neuraxial anesthesia alone. GA conversion was also safe for those requiring it.
Of the 129 patients, 5% were electively given a GA. Of the 122 (95%) who received neuraxial anesthesia (NA), only 15 (12%) were converted to GA after delivery.1 There were three difficult intubations (AFOI, VL and bougie each) among the 22 GAs. NA was predominately combined-spinal epidural or epidural.
Of the 72 patients requiring hysterectomy, 21% (15) needed NA-GA conversion.
The only independent predictors for GA conversion were history of ≥3 previous CS and long surgical duration.
The big question
Although retrospective, this data again reassures that neuraxial anesthesia can be a safe and appropriate choice for cesarean delivery with placenta accreta, increta or percreta. The big question will be whether you are happy managing an emergent NA-GA conversion and intubation in the 1-in-8 requiring it (or 1-in-5 with hysterectomy) or plan for an elective GA pre-surgery.
Notably, a further 5 (4%) required GA conversion before delivery due to inadequate block. ↩
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