78th Annual PostGraduate Assembly in Anesthesiology (PGA78) 2024

Intraoperative Management of Complete Placenta Previa with Placenta Accreta

Complicated by Suspected Amniotic Fluid Embolism

Genevieve Monanian, MD, Bahaa Daoud, MD, Tiffany Angelo, DO, Morgane Factor, MD

Department of Anesthesiology, Stony Brook University Hospital

Background:

Placenta previa is a complete or partial covering of the cervical os by placenta

This condition is associated with placenta accretaspectrum, where there is abnormal placentation with varying degrees of invasion through the uterine wall
Both conditions increase risk of postpartum hemorrhage and disseminated intravascular coagulation

Incidence:

Placenta previa - 0.3% to 2% of pregnancies in the third trimester
Placenta accreta - 0.04% of deliveries

Risk Factors for Placenta Accreta:

Prior cesarean section/multiparity
Prior placenta previa/presence of placenta previa
Advanced maternal age

Amniotic Fluid Embolism (AFE):

Involves release of amniotic fluid into maternal circulation with subsequent hemodynamic instability and maternal coagulopathy
Studies suggest disorders of abnormal placentation increase risk for AFE

Case Presentation:

31-year-old G4P1021 with complete placenta previa and focal placenta accreta who presented for scheduled repeat cesarean section at 34 weeks and 3 days gestation in the main operating room following a multidisciplinary meeting and consultations with maternal fetal medicine, obstetric anesthesiology, gynecology oncology, urology and neonatology

Intravenous Access and Invasive Monitoring:

Large bore intravenous access with 18 gaugeangiocath, 16-gauge angiocath, 20-gauge left brachial arterial line

Blood Product Availability and Delivery:

6 units of Packed red blood cells, 6 units of Fresh frozen plasma, 2 units of Platelets, 1 unit of Cryoprecipitate
Belmont rapid infuser assembled and in OR

Anesthetic Plan:

Combined spinal and epidural, intrathecal medications of 1.6cc of hyperbaric bupivacaine with 10mcg of fentanyl, 0.15 mg of morphine, and 0.1 mg of epinephrine

Postpartum Hemorrhage:

Transfusion of 2 units of packed red blood cells and 2 units of fresh frozen plasma utilizing Belmont rapid infuser
Uterotonics
Oxytocin intravenous

infusion

Methergine intramuscular

injection

Antifibrinolytic
Tranexamic acid

intravenous infusion

Intraoperative events:

Rapid Hemodynamic Instability:

Hypotension, tachycardia, diffuse urticarial rash, and transient episode of hypoxia concerning for continued hemorrhage vs urticarial transfusion reaction vs transient amniotic fluid embolism
>500cc gush of blood passed via vagina following abdominal closure by obstetric surgical team

Immediate Interventions:

100% FiO2 from anesthesia machine via face mask with appropriate response
Massive transfusion protocol activated and executed via Belmont
Bakri balloon placed and subsequently ejected due to continued pressure from bleeding
100 mcg of epinephrine, 50 mg of diphenhydramine, 10 mg of dexamethasone, and 25 mg of famotidine administered for possible urticarial transfusion reaction
1mg of atropine, 8 mg of ondansetron and 50 mg of ketorolac administered for suspected transient amniotic fluid embolism (A-OK protocol)

Decision for Emergent Hysterectomy:

Conversion to general endotracheal anesthesia for airway protection in setting of high transfusion requirements, suspected transfusion reaction and concern for transient AFE
Hemodynamic stability achieved following hysterectomy
Estimated blood loss of 4L
Total transfusion requirements: 9 units of packed red blood cells, 9 units of fresh frozen plasma, 2 units of platelets, and 2 units of cryoprecipitate

Postoperative Course:

Continued monitoring in the post-anesthesia care unit
Postoperative mechanical ventilation and extubation
Allergy and immunology consultation

Anesthetic planning:

Pre-Operative:

Multidisciplinary discussion and consultations
Discussion about morbidity and mortality
Discussion about future fertility
Date of surgery (DOS) and location
Maximizing hemoglobin

Intra-Operative:

Discussion DOS about morbidity and mortality as well as fertility
Confirm availability of back up consultants
Confirm availability of blood products and point of care testing
Anesthetic management – Combined spinal-epidural, large bore IV access, arterial line placement, possible conversion to general endotracheal anesthesia
Resuscitation
Management of complications

Post-Operative:

Continued monitoring
Possible intubation and mechanical

ventilation

Intensive care consultation

Conclusion:

Placenta previa and placenta accreta spectrum are disorders of pregnancy with increased maternal/fetal morbidity and mortality. Rates of disorders of abnormal placentation have risen in parallel with rates of cesarean delivery. Studies have suggested these disorders to be associated with risk of amniotic fluid embolism. These disorders are associated with risk of hemorrhage, coagulopathy, and hemodynamic instability. Multidisciplinary care and proper planning is paramount to managing patient expectations and potential complications that may arise.

78th Annual PostGraduate Assembly in Anesthesiology (PGA78) 2024

Intraoperative Management of Complete Placenta Previa with Placenta Accreta complicated by Suspected Amniotic Fluid Embolism

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