Berrin Günaydın, MD, PhDGazi University School of Medicine

Department of Anesthesiology, Ankara, Turkey

www.berringunaydin.com

MANAGING A PATIENT WITH ABNORMAL PLACENTATION

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OUTLINE

Definition & Classification of Abnormal Placentation

Epidemiology & Incidence

Management

-Obstetric & Anesthetic

Definition and Classification

Placentation

Normal Abnormal

Adher

ence

of t

he B

LASTOCYST

to th

e de

sidua

lized

ENDOM

ETRIUM

ABNORMAL

adhe

renc

e of

the

place

nta

to M

YOMETRIU

M

1.Placenta Previa

2.Accreta Spectrum

3.Placental Abruption

4.Cesarean scar ectopic pregnancy & cervical pregnancy

ABNORMAL PLACENTATION

Silver & Barbour. Obstet Gynecol Clin N Am 2015

Types of Placenta Previa

-multiparity

-advanced maternal age

-previous cesarean delivery

-other uterine surgery

-previous placenta previa

-smoking

-no identifiable risk factors in 20% of all cases

Conditions Associated with Placenta Previa

Snegovskikh et al. Curr Opin Anesthesiol 2011

SPECTRUM

ACCRETA

INCRETA

PERCRETA

Silver & Barbour. Obstet Gynecol Clin N Am 2015

-1:2500 deliveries

(sole incidence)

-1:2065 (relative risk in the presence of placenta previa)

Epidemiology of Placenta AccretaO

ver

the

past

30

year

s it

incr

ease

d ne

arly

10

fold

Hull & Resnik.Clin Obstet Gynecol 2010

Pathophysiology

Possible mechanisms

1.Abnormal decidualization

Previous cesarean or other surgery scars, pelvic radiation,

placenta previa

2.Pathological over invasiveness of

trophoblast

Over expression of CD44 receptors, changes in growth-angiogenesis-invasion-related factors in trophoblast, alteration in adrenomedullin gene

expression, specific DNA mutations

SEVERE

Maternal & Fetal

Morbidity &

Mortality

Massive hemorrhage &

associated complications

DIC, MOD &/or failure

Clinical implications of abnormal placentation are important because…

WHY?

Abnormal Placentation

Correction & Treatment

Fetal Outcome

• MASSIVE TRANSFUSION• ICU Admission• Interventional Radiologıc Procedures

Fetal morbidity & mortality is related to complications of premature birth

Multidisciplinary

Obstetrician+

Anesthesiologist

Interventional

Radiologist

Gynecologic

Oncologist

Blood Bank

Provider

Specialized

Surgical Team

OBSTETRIC & ANESTHETIC MANAGEMEN

T

Cell S

aver

Mas

sive

Blo

od

Tra

nsfu

sion

Pot

ocol

Internal iliac artery balloon occlusion

Tranexamic A

cid

Preoperative preparation

Uterine Artery Embolization (UAE)

rFVIIa

Anesthesia Choices

Obstetric Management

Elective CS

34 wks

Anticipation of blood loss

Sewing placenta implantation site

Uterine artery or internal iliac

artery ligation

High probability of hysterectomy

Preparation before CS

Autologous

blood transfusion

Uterine artery balloon occlusion

catheterization preoperatively

Obstet Gynecol 2010

Complications

Maternal Hemorrhag

e

Peripartum Hysterecto

my

Goals

Massive Blood

Transfusion

Save uterus

General Management

Prophylactic Internal Iliac Artery Balloon Occlusion

It does reduce pulse pressure

distal to the occlusion site,

thus minimizes blood loss

during hysterectomy

1.To stop hemorrhage for avoiding hysterectomy and saving fertility

2.To decrease obstetric hemorrhage prior to hysterectomy (bleeding vessels are better identified)

Neonatal Outcome after internal iliac artery balloon occlusion for placenta accreta

n=19 parturients with accreta/percreta5-F balloon catheter was inserted in bilateral

common iliac arteries at the department of Interventional Radiology 1 h before CS

Taiwanese J Obstet Gynecol 2011

Apgar 1 min<7 Apgar 5 min<7

Spinal Anesthesia (n=7)0.5% hyperbaric bupivacaine 10-11 mg

1/7 0/7

General Anesthesia (n=12)

-IVGA -ketamine+propofol (n=5)-ETGA-Thiopental+sch+sevoflurane (n=7)

4/12

1/53/7

(p=0.393)

0/12

0/50/7

(p=0.879)

Surgical Management of Accreta Spectrum

Criteria for accreta referral

centerMultidiscipilinary

teamICU & facilitiesBlood services

Antepartum management of SUSPECTED accreta

Surgical management of SUSPECTED accreta

Surgical management of previously UNSUSPECTED accreta

Placenta Accreta Spectrum: Accreta, Increta & Percrata. Obstet Gynecol Clin North Am 2015

Preoperative Blood Bank Communication

In case of SUSPECTED placenta accreta, blood bank is called to request blood products & to inform about the possibility of massive transfusion

In routine accreta cases, 4 units of matched RBCs + 4 units of FFP are readily available in the OR beforehand

In emergency cases, when placenta accreta is diagnosed intraoperatively, anesthesiologist calls blood bank for massive transfusion protocol 6 units of O negative RBCs + 4 units of AB FFP

20 min later additional 10 units AB FFP+ 10 units of platelets+ 10 units of

cryoprecipitate (having an option of rFVIIa )

MonitoringAfter massive transfusion, check every hour

PTT

PT*Fibrinogen

levels

Cl

K

Mg

Ca

None of these tests adequately assess platelet function, FXIII, clot stability or fibrinolytic

activity

Iatrogenic;masssive

transfusion of salin

Dilutional or citrate binding

Overload due high K in stored

RBC

Increase in levels of coagulation factors (I, VII, VIII, IX, X & XII)

Reduction in Protein S activity & acquired activated protein C resistance

Physiological Changes in Hemostasis

Procoagulant changes are counterbalanced by activation offibrinolytic system & deactivation of natural antifibrinolytics via decrease in FXI & FXIII

CREATE A HYPERCOAGULABLE STATE

Physiological changes in FXI & FXIII during pregnancy

Lab

ora

tory

in

vest

igat

ion

Relative deficiency of FXI & FXIII cause decreased polymerization of fibrin monomers into fibrin & diminishes the crosslinks of α2-antiplasmin to fibrin (which makes fibrin much less resistant to degradation)

Relatively low levels of FXI & FXIII decrease activation of thrombin activatable fibrinolysis inhibitor resulting in decreased antifibrinolytic potential

Levels of D-dimers & FDP increase with rapid depletion of fibrinogen & FXIII

GOALS CONCERNS

ANESTHESIA TECHNIQUE

GENERALANESTHESIA

REGIONALANESTHESIA

INTRAOPERATIVE RECALL

ASPIRATION

FAILED INTUBATION

DECREASED RISK OF MATERNAL DEATH

Hypotension due to sympathectomy

+

coagulation abnormalities frequently after hemorrhage &

transfusion

Anesthesia Technique

General

Spinal In case of increased risk of massive hemorrhage +vaginal bleeding >1.5 liter (L)+reduction of Hb >4 g/dL +need for acute blood transfusion > 4 unitsgeneral anesthesia is recommendedAvery. Obstet Emergencies. Am J Clin Med 2009

Spinal

Epidural

Neuraxial Anesthesia

or

For PERIPARTUM INTERVENTION it is considered to be a standard practice in many developed countries. Curr Opin Anesth 2011

In patients requiring general anesthesia for emergency deliveries, risk can be reduced by use of regional anesthesia after careful antenatal assessment with no medical contraindication for regional anesthesia. ACOG Anesthesia for emergency deliveries. Number 104. March 1992

Cell saver

Damage Control

Resuscitation

(DCR)

Blood loss

Blood loss management

How much blood is

lost?

Blood loss management• Estimated blood loss for placenta accreta

ranged 2.5-5 liters (average of 3 liters) • Mean transfusion volume was 10 units of

RBCs (3-29units)

• In a recent review of percreta• 40% of the patients received more

than 10 units of RBCs • Half of the cases underwent

emergency postpartum hysterectomy• Coagulopathy & DIC occurred in 25%

of the patients

Clin Obstet Gynecol 2010

Cell saver

in 1970s

Blood loss management

• Use of autologous RBC salvage can decrease transfusion requirements of allogenic blood products

• Concerns about risk of amniotic fluid embolism (AFE) & maternal alloimmunization

• Theoretically, washing process and leukocyte-reducing filter should eliminate the risk of AFE

• Contamination of maternal circulatory system with amniotic fluid during CS with or without cell saver is similar

• However, caution for risk of severe hypotension if cell salvage is used for CS

Anesthesiology 2000, J Crit Care 2001

Damage Control

resuscitation in 2005

Blood loss management

• Decreased use of crystalloids & colloids • Matching of RBC transfusion in a 1:1:1 ratio

with FFP and platelets• With an increase in FFP:RBC ratio from 1:8 to

1:1.4, mortality dropped from 65% to 19%

J Trauma 2007 & 2008

Strategies for massively bleeding parturients

EARLY administration of criyoprecipitate & tranexamic acid are currently considered

for bleeding obstetric patients

Curr Opin Anesthesiol 2011 J Anesth 2007

Optimize FFP to RBC ratioAccording to DCR mixture of 1 U RBC+1 U FFP + 1 U platelet has a hematocrit of 29%, platelet of 85 000/mm3 & coagulation factor activity of 62%

Use of cryoprecipitate & antifibrinolytic agents-Fibrinogen 2-3 g/L recommended for adequate hemostasis-FXIII level should be kept >50-60%-30 mL/kg of FFP or 3 mL/kg of criyoprecipitate is required to increase fibrinogen level by 1 g/L

Consider FVII rFVIIa of 81.5-92 μg/kg reduced hemorrhage in 76-85% of patients without thromboembolic events(hypothermia, acidosis or low fibrinogen may cause failure to respond to rFVIIa)

Minimize use of crystalloids & colloids to avoid dilutional coagulopathy

BJOG 2014

Therapies for prevention & treatment

Fitzpatrcik et al. BJOG 2014

Matsuoka et al. Anesthetic management of patients with placenta previa accreta  for CS: a 7-year single-center experience. Masui 2015

Weiniger et al. Outcomes of prospectively-collected consecutive cases of antenatal-suspected placenta accreta. IJOA 2013

Placenta Accreta

Lilker et al. Anesthetic considerations for placenta accreta. IJOA 2011

n=56892 deliveries including n=23 placenta accreta underwent UAE under epidural &/or general anesthesia

Bayram, Ilgıt, Altan Gunaydin et al. Evaluation UAE on size and

symptomatology of Leiomyoma under PCA with meperidine

Placenta Increta(Sultan et al. CSA for cesarean hsyterectomy and massive hemorrhage

in a parturient with placenta increta. Can J Anesth 2012)A multiparous parturient with complete

placenta previa scheduled for CS under CSE anesthesia

However, continuous spinal anesthesia (CSA) was employed because of the inadvertent dural puncture occurred during epidural insertion

After delivery, surgical team confirmed placenta previa with increta followed by hysterectomy with adherent placenta in situ

Because of the extensive bleeding, 3.8 L RL + 1.5 L hespan + 16 units of RBC & FFP + 4 units apheresis platelets + 1 unit cryoprecipitate were given and CSA was converted to general anesthesia

Case 1. Placenta Previa

ES 34 yr old medical doctor36 weeks gestation84 kg, 161 cm Repeat CSPelvic USG & MRI revealed placenta previa totalis (+)Potantial placenta accreta??increta??percreta??

Gunaydin et al. The Management of Neuraxial Anesthesia of Emergent CS for Placenta Previa. TurkJ Anesthesiol Reanim 2015

on the 276 weeks gestation

Total placenta previa was diagnosed by USG. Lacunar structure was

observed close to previous uterine incsision (arrow).

Placenta

Bladder

Abnormal hypervascularization was observed by color doppler (arrow).

PlacentaBladder

Maternal History

2006 Missed abortion (8 weeks)

2007 CS was performed due to fetal distress CS at the 383weeks,

3150 g newborn was born2009

Biochemical pregnancy 2012

CS was performed due to oligohydramniosis, 2650 g newborn was born 2014

MTHFR mutation (heterozygot), Clexan 0.4 IU

Laboratory

O Rh (+)Hb: 12.3 g/dL (Htc 36.3%)HBsAg (-), AntiHBs(+), AntiHCV (-)Rubella & Toxo IgG (-)HbA1C :5.150 g of glucose tolerans test at 1 hour 139 mg/dLTFT (T3, T4 & TSH) within normal limits

Anesthesia

16&18 G 2 IV accesses for RL & %6 HES infusion Monitorization

ECG, SpO2,HR, Non-invasive BP, urinary catheter Peoperative Aspiration & Antibiotic Prophylaxis

Metoclopramid 10 mg + Ranitidin 50 mg+1 g sefazolin IV Spinal block

Midline approach in the sitting position between L3-4 with a 25 G Pencan spinal needle using 12 mg hiperbaric bupivacaine+10 µg fentanyl+ 150 µg morphine

Operation table tilted to left 15

After delivery

2520 gram, 49 cm newborn 1 & 5 minute Apgar scores were 9 & 10, respectivelyAfter clamping of the umbilical cord 20 IU oksitosin IV infusion within 1000 mL RL (Synpitan forte 5 IU/mL ampul, Deva) 0.2 mg (1 ampul) metilergonovin maleat IM (Metiler 0.2 mg/mL ampul, Adeka) 250 mg (1 ampul) tranexamic acid (TXA) IV (Transamin %10, 250 mg, 2.5 mL ampul, Actavis)

Surgery

Hysterotomyfor delivery

Hysterectomy

(TAH+BSO)

Lower midline incision

After hysteretomy placenta was left in situ, anterior wall of the uterus was seen. Arrow shows the previous uterine incision and the PLACENTA INCRETA (myometrial invasion)

Systematic Review Cochrane Database 2015

12 RCTs involving 2678 participants with blood loss during & after CS

1 g TXA (9 RCTs) and 10 mg/kg TXA prior to skin incision (3 RCTS)

Significantly reduced blood loss & transfusion need

Postoperative high Hb levels + no serious side effects & complications

TXA (in addition to uterotonics) decreases postpartum blood loss & prevents PPH and blood transfusions after vaginal birth & CS. Effects of TXA on thromboembolic events & mortality as well as its use in high-risk women should be investigated further

Tranexamic Acid (TXA)

SUSPECTED Placenta Previa - Increta

We performed an elective cesarean delivery under spinal anesthesia at 36 weeks’ gestation and hysterectomy for our patient

According to a retrospective study, it is considered to be a traditional approach for the management of placenta accreta with a hysterectomy rate of 98%

(Obstet Gynecol 2009)We prepared 4 units of matched RBC+ 4 unıts of FFP2 large bore IV cannula were inserted CV and/or arterial lines were consideredRapid infusor devices and warmers were kept ready

Case 2. SUSPECTED Placenta Previa

GG 33 yr old, secretary, at 38 weeks gestation59 kg, 156 cm, Repeat CS with placenta previaUneventful CS under spinal anesthesiaShe was readmitted to the OR because of bleeding (Hb 4

g/dL), hypotension (60/30 mmHg) at postpartum 3 hoursGeneral anesthesia using ketamine (0.5 mg/kg) +propofol

(1 mg/kg) with rocuronium (0.6 mg/kg) 4 units of matched RBC+ FFP & 2.5 L IV ınfusionIn addition to 2 large bore IV cannula, CV and arterial

lines were placedRapid infusor devices and warmers were used

A case with placenta percrata underwent emergency CS under general anesthesia due to vaginal bleeding

Total abdominal hysterectomy + partial cystectomy were performed because of the persistent massive hemorrhage

Bleeding could be controlled after bilateral internal iliac artery embolization using a cell salvage device for stabilization of hemodynamics

Patient was discharged on the 32nd postoperative day without any major complications

Kume et al. A case of placenta percreta with massive hemorrhage during CS..J Med Invest 2014;61: 208-212

Placenta Percreta

Although national guidelines advise preoperative placement of internal iliac artery occlusion balloon catheters to reduce haemorrhage, to avoid caesarean hysterectomy and to preserve fertility, it may cause puncture-site complications, arterial thrombosis and/or ischaemic nerve injury.

Teare et al. Sciatic nerve ischaemia after iliac artery occlusion balloon catheter placement for placenta percreta. IJOA 2014;23(2):178-81

Placenta Percreta

Antenatal diagnosis

Prophylactic methods to reduce blood loss (balloon occlusion)

Take home messages

Preoperative preparation

Close team work to reduce maternal mortality & morbidity

Aggressive intervention for massive blood loss (ligation & volume replacement)

19th European Veteran Athletics Championship (EVACS) 2014

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