Anesthesia management in patients with abnormally invasive placenta: A single-center experience

Abstract

Aim: Postpartum hemorrhage is a life-threatening obstetric emergent clinical situation accompanied by blood loss of more than 500 ml after vaginal delivery and more than 1000 ml after cesarean section. This situation, frequently encountered in placental adhesion anomalies, is essential in terms of follow-up, treatment, and multidisciplinary management. We aimed to retrospectively evaluate the perioperative anesthesia management, transfusion requirement, and postoperative intensive care unit requirement of patients diagnosed with placental invasion anomaly who had an intraoperative hemorrhage Methods: In our single-center study, a total of 58 female patients diagnosed with of placental invasion anomaly with a cesarean section between 2017-2020 were examined. Patients under 18 years of age and missing data were excluded from the study. Demographic data of patients (age, American Society of Anesthesiologists score (ASA)), diagnosis, duration of operation, perioperative laboratory findings, anesthesia type, perioperative hemodynamics (highest heart rate, lowest mean arterial pressure, shock index), amount of bleeding, blood products, and fluids used, surgical interventions (B-Lynch, Bacri balloon application, uterine artery ligation, hysterectomy), intraoperative vasopressor/inotrope use, ICU stay, laboratory results in the first 24 hours postoperatively, and total hospital stay were recorded. Results: In the preoperative evaluation, 27 (46.5%) patients were diagnosed with placenta accreta, and placenta previa was diagnosed in 19 (32.7%) patients. Perioperatively mean of 3.08 ± 1.7 units of Red blood cell was used. In patients with postoperative intensive care unit hospitalization, the highest intraoperative lactate value was 3.5±1.8 mmol/L, shock index was 1.3±0.3 (0.6-1.8). In patients given intraoperative fibrinogen concentrate, the intraoperative shock index was 1.5±0.2 (0.9-1.8), the amount of intraoperative bleeding was 2575±302.2 ml, and the fibrinogen levels measured in the first 24 hours after surgery were 294.7±79.7 mg/dl. Conclusions: Anesthesia management of patients diagnosed with abnormal placental invasion is important because of significant hemorrhage. Due to unstable hemodynamics, preoperative blood product preparation with a multidisciplinary approach and a postoperative intensive care unit plan should be made for these patients.

Keywords

• Fibrinogen
• intensive care unit
• postpartum hemorrhage
• placental invasion anomaly
• transfusion

Plasental invazyon anomalisi olan hastalarda anestezi yönetimi: Tek merkez deneyimi

Öz

Doğum sonu kanama, vajinal doğum sonrası 500 ml'den fazla, sezaryen sonrası 1000 ml'den fazla kan kaybının eşlik ettiği hayatı tehdit eden acil obstetrik bir klinik durumdur. Plasental adezyon anomalilerinde sıklıkla karşılaşılan bu durum takip, tedavi ve multidisipliner yönetim açısından önemlidir. Plasental invazyon anomalisi tanısı konan ve intraoperatif kanaması olan hastaların perioperatif anestezi yönetimi, transfüzyon gereksinimi ve postoperatif yoğun bakım gereksinimini retrospektif olarak değerlendirmeyi amaçladık. Yöntemler: Tek merkezli çalışmamızda 2017-2020 yılları arasında sezaryen ile plasenta invazyon anomalisi tanısı alan toplam 58 kadın hasta incelendi. 18 yaş altı ve eksik verisi olan hastalar çalışma dışı bırakıldı. Hastaların demografik verileri (yaş, Amerikan Anestezistler Derneği skoru (ASA), tanı, operasyon süresi, perioperatif laboratuvar bulguları, anestezi tipi, perioperatif hemodinami (en yüksek kalp hızı, en düşük ortalama arter basıncı, şok indeksi), kanama miktarı, kan ürünleri ve kullanılan sıvılar, cerrahi girişimler (B-Lynch, Bacri balon uygulaması, uterin arter ligasyonu, histerektomi), intraoperatif vazopressör/inotrop kullanımı, yoğun bakımda kalış, postoperatif ilk 24 saat laboratuvar sonuçları ve hastanede toplam kalış süresi kaydedildi. Bulgular: Ameliyat öncesi değerlendirmede 27 (%46,5) hastaya plasenta akreata, 19 (%32,7) hastaya plasenta previa tanısı konuldu. Perioperatif ortalama 3,08 ± 1,7 ünite eritrosit süspansiyonu kullanıldı. Ameliyat sonrası yoğun bakımda yatan hastalarda en yüksek intraoperatif laktat değeri 3.5±1.8 mmol/L, şok indeksi 1,3±0,3 (0,6-1,8) idi. İntraoperatif fibrinojen konsantresi verilen hastalarda; intraoperatif şok indeksi 1,5±0.2 (0,9-1,8), intraoperatif kanama miktarı 2575±302,2 ml ve ameliyat sonrası ilk 24 saatte ölçülen fibrinojen seviyeleri 294.7±79,7mg/dl bulundu. Sonuç: Anormal plasental invazyon tanısı konulan hastalarda anestezi yönetimi, belirgin kanama nedeniyle önemlidir. Stabil olmayan hemodinami nedeniyle bu hastalarda multidisipliner yaklaşım, preoperatif kan ürünü hazırlığı ve postoperatif yoğun bakım planı yapılmalıdır.

Anahtar Kelimeler

• fibrinojen
• yoğun bakım ünitesi
• doğum sonu kanama
• plasental invazyon anomalisi
• transfüzyon

References

1. 1. Jauniaux E, Collins SL, Jurkovic D, Burton GJ. Accreta placentation: a systematic review of prenatal ultrasound imaging and grading of villous invasiveness. Am J Obstet Gynecol. 2016;215:712-21.
2. 2. Flood KM, Said S, Geary M, Robson M, Fitzpatrick C, Malone FD. Changing trends in peripartum hysterectomy over the last 4 decades. Am J Obstet Gynecol. 2009;200:632.e1-6.
3. 3. Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017;130:e168-e186.
4. 4. Sheldon WR, Blum J, Vogel JP, Souza JP, Gülmezoglu AM, Winikoff B; WHO Multicountry Survey on Maternal and Newborn Health Research Network. Postpartum hemorrhage management, risks, and maternal outcomes: findings from the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG. 2014;121:5-13.
5. 5. Reale SC, Easter SR, Xu X, Bateman BT, Farber MK. Trends in Postpartum Hemorrhage in the United States From 2010 to 2014. Anesth Analg. 2020;130:e119-e122.
6. 6. Lockwood CJ, Krikun G, Schatz F. The decidua regulates hemostasis in the human endometrium. Semin Reprod Endocrinol. 1999;17:45-51.
7. 7. Rady MY, Nightingale P, Little RA, Edwards JD. Shock index: a re-evaluation in acute circulatory failure. Resuscitation. 1992;23:227-34.
8. 8. Nathan HL, El Ayadi A, Hezelgrave NL, Seed P, Butrick E, Miller S, Briley A, Bewley S, Shennan AH. Shock index: an effective predictor of outcome in postparhemorrhagehage? BJOG. 2015;122:268-75.

9. 9. Szecsi PB, Jørgensen M, Klajnbard A, Andersen MR, Colov NP, Stender S. Haemostatic reference intervals in pregnancy. Thromb Haemost. 2010;103:718-27.
10. 10. Ahmed S, Harrity C, Johnson S, Varadkar S, McMorrow S, Fanning R, et al. The efficacy of fibrinogen concentrate compared with cryoprecipitate in major obstetric haemorrhage--an observational study. Transfus Med. 2012;22:344-9.
11. 11. Wikkelsø AJ, Edwards HM, Afshari A, Stensballe J, Langhoff-Roos J, Albrechtsen C, et al. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial. Br J Anaesth. 2015;114:623–33.
12. 12. Hawkins R, Evans M, Hammond S, Hartopp R, Evans E. Placenta accreta spectrum disorders - Peri-operative management: The role of the anaesthetist. Best Pract Res Clin Obstet Gynaecol. 2021;72:38-51.
13. 13. Park H, Cho H. Management of massive hemorrhage in pregnant women with placenta previa. Anesth Pain Med 2020;15:409-16.
14. 14. Binici O, Büyükfırat E. Anesthesia for Cesarean Section in Parturients with Abnormal Placentation: A Retrospective Study. Cureus. 2019;11:e5033.
15. 15. Seyhan T, Sungur M, Demircan F, Kalelioglu İ, İyibozkurt A, Şentürk M. Perioperative Anaesthetic Approach For Placenta Accreta Cases (A Retrospectıve Analysis). Anestezi Dergisi 2012;20:223-32.
16. 16. Kalelioğlu İ, Esmer AÇ, Has R, Çalı H, Seyhan TÖ, Sungur MO, et al. Management of placenta invasion anomaly and ce- sarean hysterectomy: eight-year experience of a tertiary center. J Turk Soc Obstet Gynecol 2013;10:143-50.
17. 17. Okada A, Okada Y, Inoue M, Narumiya H, Nakamoto O. Lactate and fibrinogen as good predictors of massive transfusion in postpartum hemorrhage. Acute Med Surg. 2019;7:e453.
18. 18. Sahin A, Ozkan S, Treatment of Obstetric Hemorrhage with Fibrinogen Concentrate. Med Sci Monit. 2019;5:1814-21.
19. 19. Butwick A, Lyell D, Goodnough L. How do I manage severe postpartum hemorrhage? Transfusion. 2020;60:897-907.
20. 20. Karacaer F, Biricik E, Ilgınel M, Tunay D, Sucu M, Ünlügenç H. Retrospective Analysis of Eighty-Nine Caesarean Section Cases with Abnormal Placental Invasion. Turk J Anaesthesiol Reanim. 2019;47:112-9.
21. 21. Mount T, MacLennan K. Obstetric hemorrhage. Anaesth Intensive Care. 2016;17:379-83.