A Cesarean Hysterectomy for Invading Placenta
Percreta: Anesthetic Safety Considerations–
A Case Report
Daniel Frasca, CRNA, DNAP
A 41-year-old woman presented to the surgical suite
with an undiagnosed placenta percreta invading the
bladder. The patient lost 16,000 mL of blood before
the hemorrhage was surgically controlled, and a successful cesarean delivery, as well as a total abdominal
hysterectomy, were performed. Ultimately, the patient
was discharged 1 week later with a healthy baby.
Unlike placenta accreta where the placenta strictly
adheres to the musculature of the uterus, placenta
percreta is a rare condition in which the placenta
invades the full thickness of the myometrium and
T
possibly other intra-abdominal organ structures. A
review of the current literature yields recommendations for anesthetic management of this challenging
and potentially life-threatening obstetric scenario.
This case underlines the importance of a well-coordinated multidisciplinary approach to a complex
condition.
Keywords: Anesthesia, cesarean hysterectomies, hemorrhage, pathophysiology, placenta accreta, placenta
percreta.
he fetus derives its nourishment from the
placenta, an intermediary organ that attaches
to the uterine wall. The placenta allows the
uptake of nutrients, the elimination of wastes,
and exchange of gases by way of the mother’s bloodstream. The placenta under normal pregnancy
attaches to the decidualized endometrium, a layer of
stroma formed during pregnancy under the influence of
progesterone.1 The decidualized endometrium stroma
spatiotemporally controls the invasion of extravillous trophoblasts of the placenta such that the trophoblasts adhere
only to the decidualized endometrium and not into the
myometrium.2 This decidual layer allows placental separation from the uterine wall by the shearing action between
the contracting myometrium and the noncontracting
placenta.
At times, however, the placental-uterine relationship develops abnormally, which can contribute to
severe obstetric complications. Research suggests the
pathogenesis of placenta accreta involves a primary deficiency of decidualized endometrium allowing excessive
trophoblastic invasion directly onto or into the myometrium.1,3-6 Placenta accreta adheres to the myometrial
surface.4 When the placenta invades the myometrium,
the term placenta increta is used. Placenta percreta is
the most severe degree of abnormal placental attachment; the extravillous trophoblasts invade beyond the
full thickness of the myometrium and possibly into
other intra-abdominal organ structures, usually the
bladder.3,6-11 Placenta accreta often describes both placenta increta and percreta in the literature.12 To avoid
confusion, this article will use the term abnormal pla-
cental attachment in lieu of the all-purpose name accreta.
Patients presenting with abnormal placental attachment usually have a complicated surgical course and a
high mortality rate.9,13 Anesthetists should be prepared
to manage massive blood loss by using effective teamwork, leadership, and communication strategies. Such
nontechnical skills are paramount to reaching the goal of
a positive outcome for mother and baby.
The author offers a case study of a patient with an
invading placenta percreta who presents with a number
of risk factors associated with this disease. The initial
literature search was performed using these keywords:
anesthesia, cesarean hysterectomies, placenta percreta,
and placenta accreta pathophysiology via Google Scholar.
Additional articles are identified by cross referencing.
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AANA Journal
Case Study
A 41-year-old, 200 pound, gravida 2, para 1 woman at 34
weeks’ gestation presented to the operating room for a
planned repeat cesarean delivery/exploratory laparotomy
and total abdominal hysterectomy. She was diagnosed
with placenta accreta via an ultrasound. The patient appeared alert, oriented, and in no apparent distress. She
denied a pertinent medical history, confirmed nothing
by mouth status, and denied any drug allergies. Previous
surgeries included in vitro fertilization, cesarean delivery,
cervical polyp removal, and extraction of wisdom teeth.
Medications included prenatal vitamins, zolpidem, and
docusate. The preoperative hemoglobin and hematocrit
were 11.5 g/dL and 35.7% respectively with a platelet
count of 221,000/µL. The metabolic panel and coagulation studies results fell within normal parameters.
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The obstetrician admitted the patient at 32 weeks’
gestation with oligohydramnios and a tentative diagnosis
of placenta accreta. Ultrasound suggested no other organ
involvement, and there were no signs of hematuria or
lower urinary tract symptoms. Bed rest had been prescribed. At 34.3 weeks’ gestation, the patient experienced
irregular uterine contractions and bright red vaginal
bleeding. The patient, originally scheduled for delivery
the next day, immediately proceeded to surgery.
The anesthesia team consisted of 2 anesthesiologists, 2
nurse anesthetists, and 2 nurse anesthesia students. This
group assigned 1 anesthesiologist to head and organize
the anesthesia care among the anesthesia team. The responsibility of airway management and the maintenance
of anesthesia was given to the primary nurse anesthetist. The student registered nurse anesthetists (SRNAs)
charted and acted as runners for blood products, laboratory tests, and supplies. The other anesthesia staff helped
with administering fluids and blood products, drawing
blood specimens for laboratory evaluation, and acting as
an extra pair of hands.
The primary anesthesiologist and nurse anesthetist
performed a history and physical, verified that informed
consent was obtained, and addressed the patient’s questions and concerns. Four units of packed red blood cells
(PRBCs) were brought into the surgical suite and checked
per hospital protocol, and an order to keep 2 U ahead
was given to the blood bank. The primary nurse anesthetist administered 30 mL of citric acid/sodium citrate
by mouth and 10 mg of metoclopramide intravenously
(IV) to the patient. Cefazolin, 2 g, was administered with
the intravenous fluid. The SRNA, under the guidance of
the primary nurse anesthetist, preoxygenated the patient
by mask for 5 minutes. After the surgical staff prepped
and draped the patient, the anesthesia team performed
a rapid sequence induction with cricoid pressure. The
anesthesiologist administered 40 mg of etomidate and
200 mg of succinylcholine through a 16-gauge peripheral
intravenous line. The SRNA unsuccessfully intubated the
patient with the first laryngoscopy. A second attempt by
the primary nurse anesthetist was successful and atraumatic with a grade 2 view of the vocal cords. The anesthesiologist inserted a 9 French catheter into the subclavian
vein immediately before incision, and a left radial arterial
line was placed simultaneously. Isoflurane and fentanyl
were used for anesthetic maintenance and rocuronium
was used for paralysis throughout the case.
The patient underwent a classical fundal cesarean
delivery and delivered a viable neonate. The surgeon
explored the abdomen noting the placenta extended
through the uterine wall and into the bladder base, and
a diagnosis of placenta percreta was made. The uterus
was closed, at which time intra-abdominal hemorrhage
commenced emanating from the uterus and placental
perforation site. Subsequently, the obstetrical team con-
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sisting of 2 general obstetricians emergently consulted a
gynecologic oncologist who assumed the directing role
of lead surgeon. The surgical team considered the hemorrhage to be life threatening and promptly initiated a
massive blood transfusion.
The patient proceeded to lose approximately 16,000
mL of blood over the next 3 hours. The hemoglobin
dropped to a low of 5.4 g/dL (Table 1) and pH decreased
to 7.21 with a base deficit of 9. The coagulation studies,
which were within normal limits preoperatively, changed
appreciably to a prothrombin time of 20.8 seconds, an
international normalized ratio (INR) of 1.8, a fibrinogen
level of 157 mg/dL, and a D-dimer of 984 ng/mL. In all, 22
U of PRBCs, 12 U of platelets, 8 U of fresh frozen plasma
(FFP), and 12,000 mL of crystalloid were administered
(Table 2). Ten units of cryoprecipitate and 90 µg/kg of
factor VIIa were also given for disseminated intravascular
coagulation (DIC)-like signs and symptoms. The acidosis
was controlled with sodium bicarbonate, and the electrolytes were rebalanced with the administration of potassium and calcium chloride. Throughout surgery, the
anesthesia team maintained the patient’s systolic blood
pressure above 90 mm Hg with intermittent boluses of
phenylephrine as needed. Urine output remained above 3
mL/kg/h with a total urine output of 1,200 mL.
The surgeons controlled the hemorrhage via a hysterectomy and a bilateral salpingo-oophorectomy, and the
case proceeded as planned with the addition of a partial
cystectomy performed by the urologist. By the conclusion of the case, the hemoglobin returned to a value of
11.2 g/dL. The coagulation panel also returned to normal
with a prothrombin time of 12.8 seconds, INR of 1.1, and
fibrinogen level of 427 mg/dL. The team transferred the
intubated and sedated patient to the intensive care unit
with stable vital signs. She was extubated the next day
and discharged home 1 week later.
Discussion
The series accreta, increta, and percreta represent abnormalities of placentation, by which placental villi or trophoblasts respectively attach, invade, and even penetrate
the myometrium.8,10,14,15 Placenta percreta invading into
the bladder presents as a very rare obstetrical condition with an incidence of 0.3 to 1 per 10,000 births.13,16
Surgical management is extremely difficult with a maternal mortality rate of 5.6% to 10% secondary to hemorrhage, infection, and damage to adjacent organs.9,16-17
Any abnormal placental attachment is thought to
occur because of an absence or the deficiency of the
Nitabuch’s layer of the decidua. Because of this deficiency, the placenta does not separate cleanly from the
uterus after delivery and maternal hemorrhage ensues.5
Some studies posit that this decrease in decidua occurs
after trauma to the uterus secondary to cesarean deliveries and curettage.9,14,17 Clark et al18 state a uterine scar
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Preoperative
Hemoglobin
PT/INR
Perioperative
Postoperative
11.5 g/dL
5.4 g/dL
11.2 g/dL
WNL
20.8 s/1.8
12.8 s/1.1
Table 1. Hemoglobin and Coagulation Studies
Abbreviations: PT, prothrombin time; INR, international normalized ratio; WNL, within normal limits.
predisposes a patient to the development of abnormal
placental attachment in later pregnancies and Breen et
al8 observe that the absence of decidua is a constant
pathologic feature for both placenta accreta and placenta
previa. Breen et al8 take it a step further and proposes any
event adversely affecting the endometrium could result
in placenta accreta.
The general consensus in the literature suggests the
incidence of abnormal placenta attachment is rising
secondarily to certain risk factors. These risk factors
include increased age of the mother during pregnancy,
multiple pregnancies, previous cesarean deliveries, previous curettages, Asherman syndrome, and the presence
of placenta previa.6,13,19,20 The mother in this particular
case study presented with a number of associated risk
factors including advanced age, a previous pregnancy,
and subsequent cesarean delivery, as well as prior uterine
procedures.
All women presenting with placenta previa combined
with uterine scarring should be evaluated for abnormal
placentation.4,5,10,21 Clark et al18 state there is an 11-fold
increase of placenta previa with women greater than the
age of 40 compared to those under age 20. Clark et al18
note that between 1977 and 1983 of 97,799 delivering
patients at L.A. County Women’s Hospital, placenta
previa was diagnosed in 0.3% (292 patients). The chance
of placenta accreta is 5% in women with concomitant
previa and an unscarred uterus. The incidence jumps to
67% with 4 prior cesarean deliveries and the diagnosis of
placenta previa.18
In 1997, Miller et al14 performed a retrospective
analysis and found the occurrence of placenta accreta
rising from an incidence of 1 per 4,027 in 1985 to approximately 1 per 2,500 deliveries in 1994. Following
this trend, cesarean deliveries also increased from 4.5%
in 1965 to 26.1% in 2002. The cesarean delivery rate in
developed countries now exceeds 30%, and in the United
States the rate of cesarean deliveries has risen by 53%
over the past 10 years.3,4 Wu et al22 found the incidence
of placenta accreta increased concomitantly from 1 per
30,000 in the 1930s to 1960s to 1 per 2,500 in the 1980s.
Wu et al,22 in a retrospective review at the University of
Chicago, found over a 20-year period (1982-2002) an
incidence of accreta at 1 per 533 pregnancies. The Society
for Maternal-Fetal Medicine reports the incidence of placenta accreta has increased from 0.8 per 1,000 deliveries
in the 1980s to 3 per 1,000 deliveries in the last decade
and is rapidly becoming a major cause of obstetric complications worldwide.10 Although there is some disparity
among these numbers between the various researchers,
they all relate the same message: a steep rise in the frequency of abnormal placental placement.
Miller et al14 place the risk of placenta accreta at 10%
in the presence of placenta previa. Clark et al18 find the
risk of having placenta accreta rises from 24% with patients having 1 cesarean delivery to 67% in patients who
have 3 or more prior cesarean deliveries when placenta
previa was present. Miller et al14 state in their report 89%
of patients found with placenta accreta also had coexisting placenta previa. Seventy-three percent of patients
with placenta accreta have a history of greater than 1
cesarean delivery. Researchers also often associate placenta accreta with placenta previa and multiple cesarean
deliveries in women who have a history of dilation and
curettage.3,4,14 Conversely, Kamani et al15 believe that at
least part of the increase in incidence of abnormal placental attachment is probably a reflection of better reporting.
Breen et al8 report a survey of data beginning in 1891 to
1972 showing the incidence of placenta accreta, increta,
and percreta anywhere from 0 per 70,000 deliveries to
1 per 540 deliveries. Breen’s own institution reports 1
placenta accreta per 2,700 deliveries. This study includes
40 patients diagnosed with placenta accreta, increta, and
percreta. The average age of the patient was 29.5 years
and 30% of the diagnosed patients had previous cesarean
deliveries.
Early signs and symptoms of placenta percreta are
nonspecific and may not be found until a sentinel event
such as antepartum hemorrhage or spontaneous uterine
rupture takes place.13,23 Taefi et al24 present a case in
which a 39-year-old patient with 6 prior cesarean deliveries and a history of dilation and curettage developed
gross hematuria with eventual hemorrhage. They found
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AANA Journal
PRBCs
22 U
Platelets
12 pack
FFP
8U
Cryoprecipitate
10 U
Coagulation factor VIIa
90 µg/kg
Crystalloid
12,000 mL
Blood loss
16,000 mL
Table 2. Fluids and Blood Products
Abbreviations: PRBCs, packed red blood cells; FFP, fresh frozen
plasma.
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a placenta percreta invading into the bladder only after
an exploratory laparotomy was performed. Definitive diagnosis of placenta accreta, increta, and percreta cannot
be made until after delivery and a tentative diagnosis
of accreta is usually not made until the third trimester;
however, clinicians are able to identify patients at risk
early in the pregnancy.8,15 Patients who fall into an
at-risk category such as a history of multiple parity, multiple cesarean deliveries, prior curettage, advanced age,
and a diagnosis of placenta previa require more aggressive surveillance.14,17 Clark et al18 find an increased association of accreta with a history of low transverse uterine
incision and placenta previa. Placenta accretas are often
found in the anterior region of the uterus in close association with previous cesarean incisions.11 Regardless of
the risk factors, women with suspected placenta accreta
should be scheduled for an elective cesarean delivery in
an institution with an up-to-date surgical facility and an
experienced multidisciplinary care team.10,25
Mothers presenting with placenta accreta, as well
as their fetuses, have a complicated surgical course
and a high mortality rate.9,13 One reason for this high
morbidity and death rate is that definitive diagnosis of
placenta accreta is difficult to elicit before surgery and
many times recognized only after hemorrhage or uterine
rupture.16,23,26 The importance of early diagnosis cannot
be overemphasized. The single greatest factor affecting
outcome is early recognition.15 Doppler flow studies,
magnetic resonance imaging, as well as vaginal and abdominal ultrasound examinations, should be initiated
early for patients who have a high suspicion of abnormal
placentation secondary to a significant obstetric history.
Although definitive diagnosis is not confirmed until after
surgery, these diagnostic tools yield encouraging results
and allow time for effective medical management and
the coordination of a well-organized surgical team. This
allows for a delivery in an elective setting.3,4,10,13,16,17,27
Teamwork is essential to the effective management of
an obstetric emergency. A multidisciplinary effort consisting of an experienced surgical and anesthesia team,
neonatal care team, blood bank, and laboratory personnel, as well as intensive care unit staff, is vital for optimal
management of the patient and fetus.4,10,13,16,28 A gynecological oncologist, interventional radiologist, and urologist may need to be readily available.3,4,9 A surgical plan
and prior communication of this plan between the teams
are paramount. A disorganized, leaderless extended care
team creates confusion, miscommunication, and misinterpretation of pertinent facts, which may lead to an increase in morbidity and mortality. The anesthetist’s role
is to maintain the patient’s vital functions, replace blood
volume, and if applicable, assume the responsibility as
the team leader and coordinator of duties. The surgeon
and anesthetist must communicate regularly throughout
the case. The obstetrician has the best sight of the field
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and should continually relay to the anesthesia team the
best estimate of blood loss. The anesthetist has the most
knowledge and understanding of the patient’s hemodynamic status and may need to ask the surgeon for a surgical break with tamponade to catch up with blood loss.28
Placenta accreta is responsible for up to 50% of cesarean hysterectomies, most of which are unplanned,
and is now the most common cause for cesarean hysterectomy in developed countries. Excessive blood loss
is a major concern of cesarean hysterectomies, and the
extent of blood loss is almost always underestimated in
these obstetric patients.5,28 Blood products should always
be available, and communication with the blood bank
should be initiated early lest the elective case change to
an urgent case.
Retrospectively, in the case presented above, the order
for 4 U of blood and keeping 2 U ahead was too conservative. Fortunately, the blood bank was able to keep
up with the demand. Hunter and Kleiman13 routinely
set up 10 units of PRBCs, 4 units of FFP, and a 10-pack
of platelets in suspected cases. Hull and Resnik4 believe
all obstetric units should have an obstetric hemorrhage
protocol. All patients are cross matched for 10 units of
PRBCs, 4 units of FFP, and a 10 pack of platelets. Because
of an increased chance of bleeding after 36 weeks, patients should be scheduled for delivery around 34 to 35
weeks’ gestation. But even with early diagnosis, blood
loss remains high.29 Plauché et al,30 after analyzing 108
cases of cesarean hysterectomies, found blood transfusions were needed in 66.6% of emergency cesarean hysterectomies versus only 11.8% in elective cases. Weiniger
et al26 in a prospective and observational study strongly
suggested anesthetists be ready for massive blood loss
with all suspected placenta accretas. Hudon et al31 in
1998 found the average blood loss for abnormal placental
attachment at 3,000 to 5,000 mL. Gallos et al28 state 90%
of patients with placenta percreta lose greater than 3,000
mL of blood, and O’Brien et al17 found the median blood
transfusion for placenta percreta to be 7 units of PRBCs.
Angstmann et al32 reported in some cesarean hysterectomies a 10 L or more blood loss. Recent studies of massive
blood transfusion from battlefield trauma support a 1:1
ratio in the transfusion of PRBCs and FFP/platelets to
reduce mortality.4,10,33 This recommendation suggests
that when an anesthetist is confronted with a patient presenting with abnormal placentation, a more aggressive
use of FFP and platelets may improve outcome compared
to standard replacement protocols.
Techniques to decrease blood loss and control bleeding vary, but all serve to help restore hemodynamic
stability. These techniques include manual compression
or cross clamping the aorta, oxytocics administration,
utilizing cell saver, hemodilution, bilateral iliac artery
occlusion/embolization, and factor VIIa administration
to name a few.6,9,13,15,28,29,34 Cell saver is controversial in
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obstetric patients though recent data attest to its safety.6
Gallos et al28 states cell saver is quick, inexpensive, and
no cross matching is necessary. However, the major
drawback is the potential introduction of fetal hemoglobin into the mother’s blood stream.
The most important treatment for minimizing blood
loss is a hysterectomy with the implanted placenta left in
place. Cesarean delivery with a total abdominal hysterectomy is the preferred approach.8,9,11,14 Nevertheless, this
management is associated with significant risk of lethal
hemorrhage.34 Another option to minimizing blood loss
favors the more conservative approach of leaving the
placenta and uterus in situ, closing the abdomen, and
letting the placenta reabsorb over a period of weeks.11
Clinicians reserve this option for patients who want to
preserve fertility, present as Jehovah’s Witnesses, or have
no active bleeding. Although decreased bleeding is a
benefit of this treatment, placental reabsorption carries
an increased risk of sepsis and hemorrhage postoperatively necessitating a total abdominal hysterectomy in an
emergency setting and thereby increasing the risk of
serious complications.34 Some researchers feel the use
of methotrexate and iliac artery embolization and/or
balloon occlusion facilitate a positive outcome with the
conservative approach of placental reabsorption, though
the literature varies with results.21,35 After the delivery,
clinicians should follow the patient’s beta human chorionic gonadotropin until normalized to monitor placental
reabsorption progress. Patients who decide on the conservative approach may need to be watched closely for
bleeding and infection for up to 5 months.19
Most anesthesia providers choose general anesthesia
as the anesthetic of choice for patients undergoing cesarean hysterectomies.15,36 In this case study, the anesthesia
team and the obstetric team deliberated the best strategy
for the anesthetic course and planned for a general anesthetic. Regional anesthesia was not considered in the
best interest of this particular patient for 2 main reasons;
the airway would not be secure allowing for a strong
possibility of rescuing the airway during a demanding
anesthetic course and because hemorrhage was a significant concern.
Regional anesthesia for patients presenting with abnormal placentation is controversial. Hunter and Kleiman13
demonstrated no excessive bleeding with regional anesthesia when compared with general anesthesia in this
population. If regional anesthesia is chosen, an epidural
catheter is the preferred technique. Oyelese and Smulian9
and Gallos et al28 found regional anesthesia safe for patients who have abnormal placentation with the caveat
that general anesthesia should be initiated at the first
signs of significant blood loss.
Regardless of the anesthetic technique, adequate intravenous access and invasive monitoring are crucial to
a successful outcome. At a minimum, 2 large bore IVs
are needed for fluid resuscitation, however, a central line
with catheter access is preferred. An arterial line is useful
for continuous blood pressure measurements and access
to serial blood sampling for blood gasses and laboratory analysis. A rapid infusion device and/or pressure
bags should be readily available in the suite. Vasoactive
medications, blood products, and fluid warmers must
be available and set up ahead of time. Body warming
devices should be placed on the patient before incision.15
Expect complications such as DIC, surgical injury, invasive tissue to the ureter and bladder, adult respiratory distress syndrome, infection, and multisystem organ
failure.5,9,10,28
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Conclusion
Patients presenting with abnormal placentation have a
complicated surgical course and a high mortality rate.
The general consensus in the literature suggests the
incidence of abnormal placental attachment is rising secondarily to the increasing incidence of risk factors. These
include increased maternal age, multiple pregnancies,
previous cesarean deliveries, previous curettages, and the
presence of placenta previa. The incidence of abnormal
placentation is rare but rising and is responsible for up
to 50% of cesarean hysterectomies, the majority of which
are unplanned. The single greatest factor affecting a
positive patient outcome is early recognition. This allows
time for the organization of teamwork, leadership, and
communication between services, which is paramount to
reaching the goal of an optimal outcome for both mother
and baby. In conclusion, anesthetists must have plenty
of assistance and be prepared for massive blood loss in
all cases of abnormal placentation. Adequate amounts
of blood products should be set up before surgery with
an order to keep ahead for at least 4 U PRBCs. At a
minimum, 2 large bore IV catheters (16 gauge or larger)
should be in place for the procedure. General anesthesia
is the anesthetic of choice for patients undergoing cesarean hysterectomies for placenta accreta. The author
offers a case study of a patient with an invading placenta
percreta who presented with a number of risk factors associated with this disease as an example of a successful
way to manage this complex population.
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AUTHOR
Daniel Frasca, CRNA, DNAP, is a staff CRNA and student coordinator
at St. Mary’s Hospital, Bons Secours, West End Anesthesia Group, Richmond, Virginia. Email: dpfrasca1960@comcast.net.
www.aana.com/aanajournalonline