Placenta percreta, which penetrates the uterus and adheres to the pelvic organs, is one of the most challenging cases for obstetricians and anesthetists, because of its high risk of life-threatening bleeding.1 Unlike placenta accreta or increta, cesarean hysterectomy is likely to be impossible to perform because of severe adherence to a pelvic organ, such as the bladder. That is the reason why it is preferable to perform the hysterectomy a few weeks after cesarean delivery in some cases of placenta percreta.2 One of the concerns associated with this stepwise procedure is postpartum hemorrhage. Although some previous studies have reported a significant role of intraoperative uterine artery embolization (UAE) in the prevention of massive postpartum hemorrhage in cases of cesarean hysterectomy,3,4 there are a few reports of intraoperative UAE in a stepwise procedure for placenta percreta. We present a novel and multidisciplinary plan for the stepwise procedure in a case of placenta percreta that was managed by intraoperative UAE and general anesthesia.
CONSENT FOR PUBLICATION
The Institutional Review Board of the Teikyo University School of Medicine approved this case report and provided written permission for the authors to publish the report. Written consent was obtained from the patient for publication of this case report.
A 37-year-old woman, G3P3, American Society of Anesthesiologists physical status I, weight 63 kg, and height 152 cm, was scheduled for her fourth cesarean delivery at 34 weeks’ gestational age. The placenta percreta was diagnosed by ultrasonography and magnetic resonance imaging (Figure 1) at 28 weeks’ gestational age. In addition, cystoscopy revealed placental invasion of the bladder. These findings led to a multidisciplinary discussion about the perioperative management, and a stepwise approach was implemented, including cesarean delivery without separation of the placenta and intraoperative uterine arterial embolization followed by hysterectomy a few weeks later, to minimize the risk of life-threatening bleeding throughout the perioperative period. Considering the patient’s medical history of panic disorder, a vascular access port was inserted under general anesthesia.
Figure 2 presents the time course of intraoperative multidisciplinary management. At the beginning of the operation, general anesthesia was induced with 250 mg thiopental, 350 μg fentanyl, and 70 mg rocuronium. Sevoflurane was maintained at 3% until the end of the UAE. Systolic blood pressure was maintained greater than 100 mm Hg throughout the operation, as shown in Figure 2.
After intubation, a right jugular central venous line, right radial arterial line, and large-bore peripheral venous lines as well as bilateral femoral arterial sheaths were inserted by an anesthetist and a radiologist. The surface of the uterus was highly vascularized, and the adhesion between the uterus and the bladder was so severe that it was not possible to perform the cesarean hysterectomy. Uterine incision was performed with the goal of avoiding the placenta. After incision of the uterus, the baby was immediately delivered with Apgar scores of 3 and 4, respectively, at 1 and 5 minutes after birth and was intubated by a neonatologist. Any hemorrhage was managed easily and quickly by partial suture, resulting in a relatively small volume of blood loss. At that moment, the uterus apparently remained relaxed and the placenta separated only slightly.
UAE was started just after the hemostasis. During UAE, the uterus was maintained in a relaxed state with sevoflurane. The first angiography revealed highly dispersed neovascularization from both the right and left uterine arteries (Figure 3). An hour later, UAE terminated the arterial blood supply to the bilateral neovascularization, although a number of venous vessels still remained active. Sevoflurane was then replaced with propofol and remifentanil to assess the uterine spontaneous contraction. For approximately half an hour, repeated uterine contractions were observed, but the hemostasis remained. Ultimately, bilateral transversus abdominis plane block and patient-controlled intravenous fentanyl were provided as postoperative analgesia. The duration of anesthesia was 233 minutes, and the duration of the operation was 212 minutes. The total blood loss was 1614 mL, and the amount of transfusion was 3 packs of red blood cells and 3 packs of fresh-frozen plasma. The total infusion volume was 3200 mL (colloid, 2500 mL; crystalloid, 700 mL).
Throughout the postpartum period, vascular invasion was evaluated with ultrasonography twice weekly in the maternal intensive care unit, although no postpartum hemorrhage occurred. The newborn baby was extubated with no acute complications. On the 16th postoperative day, the risk of hemorrhage appeared to be so low that the patient was discharged and the evaluation was continued at the outpatient clinic. After the invading neovessels disappeared, the subsequent hysterectomy was performed and completed uneventfully 25 days later.
Placenta accreta is defined as an adherent placenta. Its chorionic villi attach partially or completely to the myometrium, where the normal intervening decidua basalis does not exist. There are 3 types of placenta accreta, placenta accreta vera without invasion to the uterine muscle, placenta increta with invasion of the uterine muscle, and placenta percreta, which developed in our patient, with invasion of the uterine serosa or adjacent organs in the pelvic cavity. Its incidence has been widely reported from 1:553 to 1:2500 in total, and the proportion of placenta accreta vera, increta, and percreta to the total abnormal placentation is 78%, 17%, and 5%, respectively.5 One of the most frequent complications of placenta accreta is life-threatening hemorrhage, which is associated with a 7% maternal mortality. A recent retrospective study found an average blood loss of 12,140 ± 8343 mL for placenta percreta.2 This massive bleeding results primarily from placental separation. The generally held opinion is that placenta accreta should be treated by cesarean hysterectomy, with no attempt at removing the placenta6; however, our patient was diagnosed preoperatively with placenta percreta that invaded to the bladder. It is sometimes impossible to perform cesarean hysterectomy in cases of placenta percreta with adhesion to peripheral tissues. Lethal bleeding can occur if cesarean hysterectomy is performed forcibly.
Angstmann et al1 reported that UAE could make it easy to dissect the adhesion of placenta percreta. Sumigama et al2 reported that UAE followed a few weeks later by hysterectomy could minimize perioperative blood loss in the management of placenta previa, increta, or percreta. The possible complications of UAE are uterine necrosis and sepsis, which have been reported in 2 and 7 patients, respectively, of 167 patients who underwent UAE.7 The occurrence of hemorrhage while waiting for second-stage hysterectomy also can be a problem. UAE after cesarean delivery has been advocated because UAE before delivery has the potential to decrease uterine blood flow and jeopardize the fetus. A hybrid suite is an operating room that is provided with equipment for both angiography and surgery. It enables intraoperative UAE immediately after the delivery, which is preferable because postoperative transfer of patients to the radiology department could increase maternal mortality and morbidity.8
With respect to the choice of anesthesia, Lilker et al9 reported that 26% of patients initially were administered general anesthesia, whereas 29% of those with neuraxial anesthesia underwent conversion to general anesthesia. On the other hand, with the expectation of major blood loss, general anesthesia remains reliable, and only with greater experience should this approach be modified. General anesthesia usually is administered after insertion of the vascular access port because the Apgar score decreases with the longer duration of infant exposure to anesthetics. Furthermore, one of the most important aspects of intraoperative anesthesia is to avoid placental separation, which causes a massive bleeding. From this perspective, the anesthetic plan for the ex utero intrapartum treatment procedure, which has been adopted recently to completely relax the uterus and prevent placental separation, is worth considering.
Originally, the ex utero intrapartum treatment procedure was devised to maintain placental blood flow during airway establishment in infants with complicated airways.10 Dahlgren et al11 suggested that deep inhalational anesthetics (1.5–3 minimum alveolar concentration) often are used to relax the uterine muscles and to maintain the uteroplacental circulation. Inhalational anesthetic concentrations of at least 2 minimum alveolar concentration usually are recommended for proper relaxation of the uterine muscles and to prevent early placenta detachment. Indeed, general anesthesia is unlikely to be chosen in cesarean delivery because of the harmful effect on the fetus, but in this case, the preoperative multidisciplinary discussion led to the challenging decision of administering sevoflurane from the beginning of the operation in an attempt to minimize the risk of placental separation.
Maintaining uterine relaxation is also crucial during UAE to obtain appropriate visualization of the arteries. Conversely, in the stepwise treatment, there is the possibility for complications during postpartum period, such as postpartum hemorrhage and infection during the longer hospital stay. These complications sometimes necessitate emergency hysterectomy, leading to increase the rates of maternal mortality and morbidity.12 In particular, in the case of the stepwise treatment, detachment of the retained placenta after cesarean delivery could lead to postpartum hemorrhage. One of the possible causes of detachment of the retained placenta could be postpartum uterine contraction, which is triggered by oxytocin and prostaglandin. Noort et al13 reported that the levels of prostaglandin reached their maximum and started to decrease within 10 minutes after placental separation, which means the strongest uterine contractions should occur during the intraoperative period. Therefore, we considered that evaluating spontaneous uterine contraction may reduce the potential risk of unexpected postpartum hemorrhage and therefore replaced sevoflurane with propofol, which has no effect on uterine contraction.
In conclusion, we successfully managed a critical case of placenta percreta through strategic approaches using intraoperative UAE in a hybrid suite. There are a number of choices in surgical and anesthetic management, and it is essential that the best plan is established preoperatively in each facility through the multidisciplinary discussion to optimize maternal and fetal safety.
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