Case study: Cesarean hysterectomy,
A multi-purpose, multi-priority,
multi-location surgery.
Tom Archer, MD, MBA
April 3, 2012
Cesarean hysterectomy for
placenta accreta
• Growing problem because of high CS rate.
• Prior CS creates low anterior uterine scar
implantation of next pregnancy in scar low
lying, invasive placenta which easily grows
across the cervical os Placenta previa +
accreta.
Figure 1
Placenta previa in a
patient with a previous
C-section should raise
suspicion of placenta
accreta, which will
necessitate Cesarean
hysterectomy.
1st C-section
2nd pregnancy
implants in scar
Placenta previa
and accreta
“Low transverse”
incision in uterus
above bladder
creates scar after first
C-section.
Scar serves as a low
implantation site for
second pregnancy.
Low-lying placenta
grows over cervical os,
forming placenta
previa, and grows
deeply into uterine scar,
becoming accreta
(percreta with bladder
invasion shown here).
Placenta accreta:
1) Usually occurs in previous CS scar (low
and above bladder).
2) Placenta invades deeply within scar
(becomes “accreta”)
3) Placenta starts low (growing over
cervical os, becoming “previa”)
4) Placenta previa + (multiple) previous
CS high likelihood of accreta
5) Commonest organ for invasion by the
placenta accreta is the bladder
6) Diagnosis by US or MRI.
Placenta accreta– abnormally adherent placenta DOES NOT COME OUT AFTER DELIVERY.
Patient bleeds because uterus CANNOT CONTRACT WITH PLACENTA INSIDE.
Nursingcrib.com
Placenta accreta with
bladder invasion (MRI scan)
Cesarean Hysterectomy
• C-section followed by hysterectomy.
• Most OBs have limited experience with this.
• Uterus is highly vascular and bleeding is rapid.
• Extensive planning is extremely important.
Possible adjuncts to care of
placenta accreta patient
• Internal iliac balloons to temporarily reduce
bleeding. Placed in Interventional radiology.
--31-year-old woman with placenta percreta
Tan, C. H. et al. Am. J. Roentgenol. 2007;189:1158-1163
Copyright © 2008 by the American Roentgen Ray Society
Possible adjuncts to care of
placenta accreta patient
• Cell saver– OK despite fears of “amniotic fluid
embolus”. Use after amniotic fluid is gone. AFE
probably not due to AFE. “Anaphylactoid
syndrome of pregnancy.”
• Level 1 or other rapid infusion system
Possible adjuncts to care of
placenta accreta patient
• Acute normovolemic hemodilution.
Cardiac output
10
Figure 2
0
Systemic vascular resistance
2000
0
Blood pressure
150
0
Heart rate and stroke volume
Heart rate
100
0
0
15
Start ANH
30 min
60
End ANH
Ind/Inc
Del
Old “procedure” for C-hyst
• “Night” OB anesthesia team would “place
epidural” and ? “arterial line” so that patient could
go to IR at “0530” for “0700 OR start”. Day
anesthesia team would take patient over from
night anesthesia team.
• Profound disadvantages: fragmentation of care
AND absence of full complement of daytime
resources. Starting major elective procedure
outside of elective OR time  BAD IDEA!
Any complicated surgery
• Intersection of: medical, technical,
organizational and interpersonal factors.
• Successful MD or nurse must take all of these
aspects into account.
• Don’t underestimate the problems that can
arise with a complicated, multi-site surgery!
• COMMUNICATE!
Cesarean hysterectomy
• Fraught with dangers (medical, psychological,
political).
• Be aware of this. Don’t fight it. Consult in
advance with all parties. Acknowledge points
of view, but…
• Remember that ultimate responsibility for
anesthesia rests with us. Try to say this nicely.
Multiple voices will be heard
• Patient preference (GA or epidural)
• Surgeon preference (GA or epidural)
• “Baby-friendly” advocates may promote
maternal bonding with infant.
• Listen carefully to all opinions, but ultimate
decision is yours. You are responsible for
anesthesia
Cesarean hysterectomy
• In your discussions, acknowledge points of
view, but PRIORITIZE:
• “Yes, it would be great if you could be awake
for the birth, but Dr. X thinks that in your case
the bleeding may be more than usual and for
this reason we want to do the general
anesthetic because…..”
Multiple voices will be heard
• My advice: consult early, abundantly and
respectfully.
• Explain your decision to all concerned.
Assume that there will be poor
communications, rumors, misinformation.
• Straight GA is sometimes the best answer in
an accreta with extensive invasion.
Current approach
• If you do epidural, must be before balloon
placement in IR (patient hip flexion impossible
after balloon placement).
• If you do epidural and dose it for balloon
placement, you must go to IR with patient.
• At least two “large bore” IVs.
• Arterial line (awake)
• Possible Cordis sheath (awake)
Current approach
• Emotional support for Mom– extensive,
frightening and painful preparation before
what should be a happy event.
• Judicious use of fentanyl, midazolam for line
placement.
• Once patient is asleep there is no time for
Cordis placement before baby is delivered and
hemorrhage occurs.
Factors favoring epidural:
Analgesia for balloon placement in interventional
radiology suite (but local is easy too)
Surgical anesthesia (hopefully it works well
enough).
Patient awake for birth
Post-op pain control (epidural morphine)
Factors opposing epidural:
Need to monitor patient and fetus in multiple locations
(Epidural placed in L&D, then IR, then OR).
Sympathectomy is dangerous in setting of heavy blood
loss.
May not be adequate anesthesia for hysterectomy.
Psychological factors (long surgery, awake patient with
heavy bleeding, transfusion, hypotension-- caregiver
and patient stress).
Unprotected airway during big/long surgery.
Straight GA
Pro: simple, straightforward, one anesthetic,
avoids sympathectomy and psychological
issues.
Con: Patient asleep for birth, pushback from
“patient advocates”. Inferior pain control postop compared to epidural. Baby may be born
“depressed” (by GA).
If you use GA
• Make sure everyone understands that baby
“depressed” by GA is NOT SICK or HYPOXIC.
• As much as we may understand this, nonanesthesia people will associate “depressed”
baby with hypoxia and damage and will worry
a great deal about this.
Cesarean hysterectomy
Current Policy
• One anesthesia team will do all physical
preparation of the patient, starting at the
designated start time. No “line placement” by
the “night team”.
• Purely informational consults are performed
as early as possible and someone from the OB
anesthesia team should do this when possible.
Cesarean hysterectomy
Current Policy
• There is no “standard” anesthetic.
• The choice of anesthesia is up to the attending
anesthesiologist for the case, after
consultation with patient and surgeons.
The (current) “solution” came from
several interdisciplinary conferences.
• OR management (MDs and nursing) made
“0730 start” available to OBs, even though OR
may not be physically used until 0900-1000,
due to patient preparation in IR. Agreement to
let room sit unused.
• One anesthesia team starts at 0700 with ALL
of the physical preparation of the patient:
epidural (if used), go to IR (if used), arterial
line and IV access (Cordis sheath vs. mult PIV)
Advantages of
The (current) “solution”
• Only one anesthesia team provides continuity
of care and responsibility re:
– Epidural (does it really work?),
What happened in IR,
Patient emotional state,
Presence of father of baby in OR,
Communication with OB team
OBs have guaranteed OR once patient is done in IR
Summary
• C-hyst: increasing CS rate is creating the
iatrogenic problem of placenta previa and
accreta in subsequent pregnancies.
• Placenta accreta: potentially fatal due to
torrential hemorrhage.
• Extensive multidisciplinary planning and
discussion is required to do these cases well.