Anaesthesia considerations for placenta percreta posted for obstetric hysterectomy

1. Preoperative planning

• Multidisciplinary meeting and explicit surgical plan
  • Maternal-fetal medicine/experienced obstetric surgeon
  • Obstetric anaesthesia consultant
  • Gynaecologic oncologist or pelvic surgeon where appropriate
  • Urologist, particularly if bladder/ureteric invasion is suspected
  • Interventional radiology only if locally experienced
  • Haematology, blood bank/transfusion service, ICU, neonatology, theatre nursing.
• Review imaging to determine:
  • Location of placenta and safest uterine incision
  • Extent of parametrial, bladder, or ureteric involvement
  • Likely duration and degree of blood loss.
• Counsel the patient and family about:
  • Planned cesarean hysterectomy and permanent loss of fertility
  • Massive transfusion, cell salvage, possible ICU ventilation and admission
  • Possible bladder resection, ureteric stenting/reimplantation, vascular injury, re-operation, and maternal mortality.
• Optimise maternal condition:
  • Correct iron-deficiency anaemia before surgery where time permits.
  • Check full blood count, blood group and antibody screen, PT/INR, aPTT, fibrinogen, renal function, electrolytes, and baseline coagulation.
  • Evaluate airway, obesity, cardiac disease, hypertensive disorders, and aspiration risk.
  • Give aspiration prophylaxis and antibiotic prophylaxis.
  • Mechanical thromboprophylaxis before induction, unless contraindicated.

2. Blood and haemorrhage preparation

• Activate or pre-alert the massive transfusion protocol (MTP).
• Ensure immediate availability of:
  • Cross-matched red cells
  • Fresh frozen plasma
  • Platelets
  • Cryoprecipitate or fibrinogen concentrate, according to local protocol.
• Use a blood-loss plan with frequent communication between the anaesthetist, surgeons, and blood bank.
• Arrange:
  • Rapid infuser/pressure bags
  • Fluid and forced-air warming
  • Blood warmer
  • Point-of-care blood gas analyser
  • Ionised calcium monitoring and replacement
  • Viscoelastic coagulation testing, such as TEG/ROTEM, if available.
• Cell salvage should be prepared and used where available and accepted by the patient.
• Avoid indiscriminate crystalloid loading. Use warmed blood products and goal-directed replacement to avoid dilutional coagulopathy and pulmonary oedema.
• Anticipate hypothermia, acidosis, hypocalcaemia, hyperkalaemia, and DIC during major haemorrhage.

3. Monitoring and vascular access

• Two large-bore peripheral IV cannulae, preferably 14-16G.
• Invasive arterial pressure monitoring, ideally inserted before induction or before major bleeding is expected.
• Standard ASA monitoring plus continuous temperature monitoring.
• Central venous access if peripheral access is poor, vasoactive infusion access is required, or massive transfusion is anticipated. It should not delay surgery in a bleeding patient.
• Consider point-of-care cardiac ultrasound for uncertain volume status or haemodynamic instability.
• Urinary catheter with hourly urine output. Coordinate with urology if cystoscopy, ureteric stents, bladder opening, or resection is planned.

4. Choice of anaesthesia

• A combined spinal-epidural or epidural technique can allow the mother to be awake for delivery.
• It may be suitable in a stable, planned case, with immediate readiness for conversion to GA.
• The epidural can provide postoperative analgesia if coagulation remains normal.
• Risks include hypotension after sympathectomy, inadequate duration for prolonged surgery, and difficult emergency conversion to GA after major blood loss.

• Is appropriate as the primary technique if there is:
  • Major anticipated haemorrhage or haemodynamic instability
  • Extensive percreta with bladder/parametrial invasion
  • Need for prolonged radical pelvic surgery
  • Inability to tolerate lying flat
  • Coagulopathy or contraindication to neuraxial block
  • Urgent/emergency delivery.
• A common planned approach is neuraxial anaesthesia for delivery followed by a controlled conversion to GA before hysterectomy and high-risk pelvic dissection.
• If GA is used, prepare for a difficult airway and aspiration. Use rapid-sequence induction, left uterine displacement until delivery, and ensure a second experienced anaesthetist is present.

5. Intraoperative surgical-anaesthetic coordination

• Confirm the plan before incision: uterine incision site, anticipated timing of delivery, hysterectomy sequence, and triggers for MTP.
• Deliver the fetus through an incision well away from the placenta.
• Do not attempt manual placental separation. Clamp and divide the cord, leave placenta in situ, close the hysterotomy, then proceed to hysterectomy.
• Avoid repeated uterotonic escalation solely to separate an invasive placenta. Oxytocin may be used after delivery as per the surgical plan, but the definitive treatment is hysterectomy with placenta undisturbed.
• Give tranexamic acid promptly if significant haemorrhage develops, consistent with the institutional obstetric haemorrhage protocol.
• Be ready for sudden blood loss during:
  • Bladder dissection
  • Parametrial dissection
  • Uterine vessel ligation
  • Unexpected placental disruption or vascular injury.
• Maintain normothermia, adequate oxygen delivery, ionised calcium, and coagulation factors.
• Communicate blood loss and haemodynamic trends continuously, not only at fixed intervals.

6. Postoperative care

• Plan postoperative ICU/HDU admission rather than routine recovery discharge.
• Continue close surveillance for:
  • Ongoing intra-abdominal or pelvic bleeding
  • Coagulopathy
  • Hypothermia, acidosis, electrolyte disturbance
  • Fluid overload, pulmonary oedema, TRALI/TACO
  • Acute kidney injury
  • Bladder/ureteric injury, urinary leak, fistula
  • Sepsis and venous thromboembolism.
• Repeat Hb, platelets, coagulation profile, fibrinogen, blood gas, lactate, electrolytes, and ionised calcium.
• Extubate only when haemostasis, temperature, gas exchange, and haemodynamic state are satisfactory.
• Provide multimodal analgesia. Epidural analgesia is useful only if there is no ongoing bleeding or coagulopathy.
• Restart pharmacologic thromboprophylaxis after satisfactory surgical haemostasis and after neuraxial safety requirements are met.
• Provide compassionate psychological support, bereavement support if needed, and counselling regarding unexpected hysterectomy and critical-care experience.

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