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CLINICAL COMMUNICATIONS
Year : 2021  |  Volume : 65  |  Issue : 2  |  Page : 153-156  

Placenta accreta spectrum anaesthetic management with neuraxial technique can be facilitated by multidisciplinary groups


1 Placenta Accreta Spectrum Clinic; Department of Anesthesiology, Fundación Valle del Lili, Cali, Colombia
2 Placenta Accreta Spectrum Clinic, Fundación Valle del Lili, Cali, Colombia

Date of Submission06-Oct-2020
Date of Decision23-Oct-2020
Date of Acceptance14-Jan-2021
Date of Web Publication10-Feb-2021

Correspondence Address:
Albaro Jose Nieto-Calvache
Fundación Valle Del Lili, Cali, Carrera 98# 18-49 Cali 760032
Colombia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_1216_20

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Background: The concern about massive haemorrhage associated with placenta accreta spectrum (PAS) prompts the routine use of general anaesthesia (GA) at many centres. We aimed to describe the effects of establishing a fixed multidisciplinary team (PAS team) on anaesthetic practices and clinical results. Methods: In this before-and-after study, we included patients with prenatal PAS suspicion treated between December 2011 and December 2019. We evaluated the anaesthetic techniques used before (Group 1) and after (Group 2) a PAS team was established. Results: Eighty-one patients were included. Neuraxial anaesthesia (NA) was used in 23.3% of group 1 patients and 76.4% of group 2 patients. Likewise, the frequency of conversion to GA after initial management with NA decreased from 14.3% in group 1 to 7.7% in group 2. Conclusions: The establishment of a PAS team is related to increased use of NA during the management of PAS patients.

Keywords: Anaesthesia obstetrical, interdisciplinary communication, placenta accreta spectrum


How to cite this article:
Lopez-Erazo LJ, Sánchez B, Blanco LF, Nieto-Calvache AJ. Placenta accreta spectrum anaesthetic management with neuraxial technique can be facilitated by multidisciplinary groups. Indian J Anaesth 2021;65:153-6

How to cite this URL:
Lopez-Erazo LJ, Sánchez B, Blanco LF, Nieto-Calvache AJ. Placenta accreta spectrum anaesthetic management with neuraxial technique can be facilitated by multidisciplinary groups. Indian J Anaesth [serial online] 2021 [cited 2021 Jun 14];65:153-6. Available from: https://www.ijaweb.org/text.asp?2021/65/2/153/309091




   Introduction Top


Placenta accreta spectrum (PAS) is one of the main causes of massive obstetric haemorrhage. Although neuraxial anaesthesia (NA) has advantages over other surgical techniques among pregnant woman in terms of the risk of maternal pulmonary aspiration and neonatal results,[1] general anaesthesia (GA) is routinely used as the standard anaesthetic method in some centres for PAS patients.[2],[3] This is especially true in developing countries where the availability of PAS fixed multidisciplinary teams (PAS team) are often lacking.[4]

The organisation of available human, and technological resources, as well as the level of experience provided by PAS teams, has been shown to affect clinical outcomes.[5] The current study aimed to determine the impact of establishing a PAS team for the protocolised management of women with PAS on the anaesthetic practices of an obstetric referral centre.


   Methods Top


This retrospective study has the approval of the IRB/EC institutional biomedical research ethics committee (in March 2020 under the protocol number 929) and was conducted between December 2011 and December 2019. We included patients with prenatal PAS suspicion (ultrasound or magnetic resonance imaging) who underwent a caesarean section at Fundación Valle de Lili, Cali, Colombia. Patients without prenatal PAS suspicion (incidental finding during surgery) were excluded. The included population was divided into those treated by the on-call specialists on the day of surgery (Group 1: from December 2011 to April 2016) and those treated by the PAS team (Group 2: from May 2016 to December 2019).

The surgical protocols used at our institution before and after April 2016 have been described previously[6] and can be consulted in the addendum [Supplementary Material 1].



In both groups, the anaesthetic technique was selected at the discretion of the treating anaesthesiologist. However, since April 2016 formal communication (before, during and after surgery) was established between anaesthesiologists and surgeons to promote the use of NA [Supplementary Material 2].



All statistical analyses were conducted using the STATA® statistical software package. The quantitative variables were presented as median and interquartile ranges or means and standard deviations (according to the distribution of the values), and the qualitative variables were presented as frequencies and proportions.

Between-group comparisons of the qualitative variables were conducted using a Chi-square or Fisher's exact test. For the quantitative variables, the Mann–Whitney U test was used.


   Results Top


A total of 81 patients with prenatal suspicion of PAS were included in the analysis. The median interquartile range (IQR) age was 33 (28–34) years, with a median (IQR) gestational age of 35 weeks (34–36).

NA was used in 23.3% of the patients in group 1 patients and 76.4% of the patients in group 2 [Table 1]. One patient in group 1 (14.3%) and three in group 2 (7.7%) required the conversion to GA after initial management with NA due to insufficient pain control during surgery.
Table 1: Clinical characteristics of patients with prenatal PAS suspicion according to the surgical protocol applied

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Prenatal PAS suspicion was confirmed with intraoperative or histological findings in 80% of the group 1 of patients and 68.6% of the group 2 patients, and placenta percreta was detected in 16.7% and 15.7% of the patients in groups 1 and 2, respectively. The lower uterine segment, cervix o parametrium involvement (S2 involvement) was detected in 43.3% and 45.1% of the patients in group 1 and group 2, respectively.

The median (IQR) for intraoperative bleeding was 2000 mL (1500–2500) in group 1 and 1480 (800-1975) mL in group 2. The median (IQR) volume of packed red blood cells was 0.5 (0-3) and 0 (IQR 0-2) units in groups 1 and 2, respectively.

The operative time (anaesthesia plus surgical time) was shorter in group 2 than in group 1 (190 minutes vs. 275 minutes in group 1). Additionally, the hysterectomy rate was lower in group 2 (49% vs. 76.7% in group 1), and these patients had a shorter length of hospital stay (2 days vs. 4 days in group 1). Scheduled surgeries (c-sections) were performed in 66.7% and 76.7% of the patients in groups 1 and 2, respectively. Although these results are related to the characteristics of PAS involvement, they are important to analyse the frequency of NA use in each group.

Group 2 had a lower need for pelvic tamponade (9.8% vs. 33.3% in group 1), lower incidence of infectious complications (7.8% vs. 20% in group 1) and rate of complications related to surgery (17.6% vs. 36.7% in group 1). The frequency of bladder injury (16.6% in group 2 vs. 17.6% in group 1) was similar between the groups.

One complication related to anaesthesia was documented in group 1 (bronchoaspiration during orotracheal intubation in a scheduled surgery), and no such complications were documented in group 2.


   Discussion Top


In this before-and-after study, we found a higher frequency of use of NA as the initial strategy for PAS patients after the introduction of a PAS team (76.4% in Group 2 vs. 23.3% in Group 1).

The frequency of use of NA in Group 1 was much lower than that reported in industrialised countries, where up to 95% of patients were managed with NA,[7] but higher than that reported in other developing countries, where up to 96.4% of cases were handled with GA.[8]

It seems that the implementation of a PAS team facilitates the use of NA. This can be explained because multidisciplinary work dynamics facilitated the development of trust among the group of surgeons and anaesthesiologists, allowing them to understand the local capacities for the prevention and immediate control of bleeding. Additionally, the PAS team acquired more experience as they treated more cases, simplifying the procedure and shortening the surgical time.[5]

Although centres that have all the desired human and technological resources available are more common in developed countries, it is possible to organise these technological resources and interdisciplinary groups in some specialised centres in developing countries.[6]

The conversion rate to GA in patients initially managed with NA has been reported to be as high as 44% in some case series.[4] Although it is difficult to rule out factors associated with the operator when talking about NA failure, our study sought to evaluate the impact of forming a fixed interdisciplinary group (with all the variables like teamwork and greater expertise acquired) in the anaesthetic technique used. We observed a lower conversion rate to GA in patients managed by the PAS team (7.7% in group 2 vs. 14.3% in group 1), without associated complications as bronchoaspiration, and always motivated by insufficient control of operative pain.

The absence of NA-associated complications and its utility even in severe cases, with prolonged surgical times, make us agree with other authors that considering NA as the first option in the management of patients with PAS is a safe strategy,[9],[10] even in developing countries, as long as the procedure is carried out by experienced groups in centres with the necessary resources. However, it should not be ignored that each centre must consider the specific condition of each patient when selecting the type of anaesthesia.[11],[12]

Limitations of our study include its design; we performed a retrospective before and after study, which makes our results at high risk of selection and information biases. Second, the small sample size imposes limitations on subgroup analyses and limits the external validity of our results. However, PAS is a rare condition with multiple management options, and it is difficult to include larger populations in studies.


   Conclusion Top


The participation of PAS team improves the frequency of use of NA. NA is safe to use during the surgical treatment of PAS, even in severe cases, when it is used in reference centres.

Acknowledgements

The authors extend special appreciation to the Clinical Research Center team of Fundación Valle del Lili (FVL), Cali, Colombia, for support during the development of the article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Beilin Y. Maternal hemorrhage-regional versus general anesthesia: Does it really matter? Anesth Analg 2018;127:805-7.  Back to cited text no. 1
    
2.
Stubbs MK, Wellbeloved MA, Vally JC. The management of patients with placenta percreta: A case series comparing the use of resuscitative endovascular balloon occlusion of the aorta with aortic cross clamp. Indian J Anaesth 2020;64:520-3.  Back to cited text no. 2
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3.
Dhenuka T, Kapadia D, Bhorkar N, Shaikh T. Anaesthesiologist's role in the multidisciplinary approach to placenta percreta. Indian J Anaesth 2015;59:513-5.  Back to cited text no. 3
    
4.
Muñoz LA, Mendoza GJ, Gomez M, Reyes LE, Arevalo JJ. Anesthetic management of placenta accreta in a low-resource setting: A case series. Int J Obstet Anesth 2015;24:329-34.  Back to cited text no. 4
    
5.
Shamshirsaz AA, Fox KA, Erfani H, Clark SL, Salmanian B, Baker BW, et al. Multidisciplinary team learning in the management of the morbidly adherent placenta: Outcome improvements over time. Am J Obstet Gynecol 2017;216:612.e1-5.  Back to cited text no. 5
    
6.
Nieto AJ, Echavarría MP, Carvajal JA, Messa A, Burgos JM, Ordoñez C, et al. Placenta accreta: Importance of a multidisciplinary approach in the Colombian hospital setting. J Matern Fetal Neonatal Med 2020;33:1321-9.  Back to cited text no. 6
    
7.
Markley JC, Farber MK, Perlman NC, Carusi DA. Neuraxial anesthesia during cesarean delivery for placenta previa with suspected morbidly adherent placenta: A retrospective analysis. Anesth Analg 2018;127:930-8.  Back to cited text no. 7
    
8.
Urfalıoglu A, Öksüz G, Bilal B, Teksen S, Calışır F, Boran ÖF, et al. Retrospective evaluation of anesthetic management in cesarean sections of pregnant women with placental anomaly. Anesthesiol Res Pract; 2020;2020:1358258. doi: 10.1155/2020/1358258.  Back to cited text no. 8
    
9.
Cal M, Ayres-de-Campos D, Jauniaux E. International survey of practices used in the diagnosis and management of placenta accreta spectrum disorders. Int J Gynaecol Obstet 2018;140:307-11.  Back to cited text no. 9
    
10.
Chen X, Shan R, Song Q, Wei X, Liu W, Wang G. Placenta percreta evaluated by MRI: Correlation with maternal morbidity. Arch Gynecol Obstet 2020;301:851-7.  Back to cited text no. 10
    
11.
Tawfik MM, Tolba MA, Moawad SS, Ismail KS, Taman ME. Is neuraxial anesthesia appropriate for cesarean delivery in all cases of morbidly adherent placenta? Anesth Analg 2018;127:e80-1.  Back to cited text no. 11
    
12.
Ranasinghe JS, Birnbach D. Current status of obstetric anaesthesia: Improving satisfaction and safety. Indian J Anaesth 2009;53:608-17.  Back to cited text no. 12
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