Elective LSCS for Placenta Previa with Suspected Placenta Accreta - Complete Anaesthetic Management

I. PREOPERATIVE PREPARATION

A. Multidisciplinary Team Assembly

• Maternal-fetal medicine (MFM) specialist
• Experienced obstetric anaesthesiologist
• Senior obstetrician/gynaecological oncologist (skilled in hysterectomy)
• Interventional radiologist (if balloon occlusion planned)
• Neonatology team
• Haematology / blood bank
• ICU team on standby
• Delivery at a Level III or IV maternal care facility is mandatory

B. Clinical Assessment

• Thorough history: prior scar types (classical vs. lower segment), bleeding episodes, haematological status, comorbidities
• Review antenatal imaging: ultrasound (sensitivity ~80-90% for PAS) - features include loss of hypoechoic boundary between placenta and bladder, intraplacental sonolucent lacunar spaces, turbulent colour Doppler flow at placenta-uterus interface
• MRI if diagnosis uncertain or to define extent (especially bladder/bowel involvement with percreta)
• Gestational age: typically 34-36 weeks is targeted for elective delivery to preempt labour and emergency haemorrhage

C. Haematological Optimisation

• Baseline: FBC, blood group + cross-match, coagulation screen (PT, aPTT, fibrinogen), LFTs, RFTs, serum ferritin
• Treat iron-deficiency anaemia preoperatively (IV iron if time permits; target Hb >10 g/dL)
• Autologous blood donation generally not recommended in obstetrics due to anaemia risk
• Cross-match minimum 6 units packed red blood cells (PRBCs); fresh frozen plasma (FFP), cryoprecipitate, and platelets should be available
• Notify blood bank: activate massive haemorrhage protocol (MHP) pathway

D. Intravenous Access

• Two large-bore peripheral IV cannulae (14G or 16G) as minimum
• Central venous access (internal jugular or subclavian) for CVP monitoring and rapid infusion
• Arterial line (radial) for beat-to-beat BP monitoring and frequent ABG/haematocrit sampling

E. Interventional Radiology Options

• Bilateral internal iliac / uterine artery balloon catheters can be placed preoperatively under fluoroscopy - inflated during surgical dissection to reduce blood loss. However, evidence remains controversial; benefit is unclear and embolic complications have been reported (Miller's Anesthesia, 10e)
• Uterine artery embolisation - more useful postoperatively if conservative management is planned
• Decision to place balloons should be individualised and facility-dependent

F. Consent and Counselling

• Inform patient of high likelihood of caesarean hysterectomy if accreta confirmed
• Risk of massive haemorrhage, transfusion, bladder/ureter injury (especially percreta)
• ICU admission postoperatively
• Potential loss of fertility
• Risk to fetus (prematurity if delivery at 34-36 weeks)

G. Fasting and Pharmacological Premedication

• Nil by mouth: 6 hours solids, 2 hours clear fluids (elective)
• Antacid prophylaxis: ranitidine 150 mg orally the night before and morning of surgery + sodium citrate 30 mL orally immediately preoperatively
• Metoclopramide 10 mg IV (prokinetic, reduces aspiration risk)
• Dexamethasone 12 mg IM 48 and 24 hours prior if delivering at 34-36 weeks (fetal lung maturity)
• Urinary catheter placement + ureteric stent consideration if percreta suspected (facilitates urological injury identification)

II. ANAESTHETIC PLAN

A. Choice of Anaesthesia

Option 1: Regional Anaesthesia (Preferred for uncomplicated cases)

• Avoids airway risks of general anaesthesia in the pregnant patient (difficult airway, aspiration)
• Patient remains awake for initial delivery of baby (maternal-neonatal bonding)
• Epidural component provides: (a) extension of block for prolonged surgery (hysterectomy may take 2-4 hours), (b) postoperative analgesia, (c) supplementation if block wears thin
• If haemorrhage worsens intraoperatively, can convert to GA

• Intrathecal: hyperbaric bupivacaine 0.5% - 10-12.5 mg + fentanyl 15-25 mcg + morphine 100-200 mcg
• Epidural: loading with 0.5% bupivacaine via epidural catheter as needed for prolonged surgery
• Position: left lateral tilt throughout (after spinal placed in sitting/lateral position)

Option 2: General Anaesthesia

• Active massive haemorrhage / haemodynamic instability
• Coagulopathy (precluding neuraxial technique)
• Patient refusal of regional
• Failed regional block
• Anticipated prolonged complex surgery from the outset (e.g., confirmed percreta with bladder involvement)
• Rapid sequence induction required

• Preoxygenate 3-5 minutes (100% O2)
• RSI: Propofol 2 mg/kg OR thiopentone 4-6 mg/kg IV + Succinylcholine 1.5 mg/kg IV (or rocuronium 1.2 mg/kg if sugammadex available) with cricoid pressure
• Intubation with video laryngoscopy (difficult airway anticipated in obstetrics - short neck, prominent breasts, oedema)
• Maintenance: isoflurane/sevoflurane in O2/N2O or TIVA (propofol infusion) - avoid high volatile agent concentrations which cause uterine relaxation
• Avoid awareness: BIS monitoring recommended
• Analgesics: IV fentanyl, morphine (after cord clamping to avoid neonatal depression)

Hybrid Approach (Increasingly used)

• Start with CSE for delivery of baby under regional anaesthesia
• Convert to GA when hysterectomy commences (if regional proving inadequate, or patient request)

III. INTRAOPERATIVE MONITORING

IV. ANTICIPATED PERIOPERATIVE COMPLICATIONS AND MANAGEMENT

1. MASSIVE HAEMORRHAGE (Most Critical)

• Activate Massive Haemorrhage Protocol (MHP) early - do not wait for haemodynamic compromise
• Transfuse in 1:1:1 ratio - PRBCs : FFP : platelets (damage control resuscitation)
• Target: Hb >7-8 g/dL, fibrinogen >2 g/L, platelets >75 × 10⁹/L, INR <1.5
• Tranexamic acid 1 g IV (repeat at 30 min if ongoing bleeding) - antifibrinolytic
• Cell salvage (intraoperative autologous transfusion) - acceptable in obstetrics with leucocyte depletion filter
• Oxytocin 5 IU slow IV after cord clamping (avoid bolus - causes hypotension)
• Ergometrine, carboprost (PGF2α), misoprostol for uterotonic effect if needed
• Recombinant Factor VIIa if refractory coagulopathy with uncontrollable haemorrhage

2. DIFFICULT/FAILED AIRWAY (if GA)

• Pregnancy changes (Mallampati worsening, mucosal oedema, weight gain) significantly increase difficult intubation risk
• Video laryngoscope (McGrath, C-MAC) as first-line device
• Difficult airway trolley immediately accessible
• Senior anaesthesiologist and failed intubation drill rehearsed
• In "can't intubate, can't oxygenate" - front-of-neck access (cricothyrotomy)

3. HYPOTENSION (regional anaesthesia)

• Spinal anaesthesia causes sympathetic block → vasodilation → hypotension (occurs in ~80% of obstetric spinals if not prevented)
• Prevention: Left lateral uterine displacement, IV crystalloid/colloid co-loading, prophylactic phenylephrine infusion (first-line vasopressor in obstetrics - maintains uteroplacental blood flow better than ephedrine)
• Treatment: Phenylephrine 50-100 mcg IV boluses or infusion; ephedrine 5-10 mg IV if bradycardia present

4. COAGULOPATHY / DIC

• Massive transfusion, amniotic fluid embolism, placental abruption, prolonged shock all precipitate DIC
• Monitor: fibrinogen, PT, aPTT, platelets, D-dimer; use TEG/ROTEM where available
• Replace: FFP (1 unit per 4-6 units PRBCs), cryoprecipitate (target fibrinogen >2 g/L), platelets (>75 × 10⁹/L)
• Avoid dilutional coagulopathy: use blood products rather than excessive crystalloid

5. UROLOGICAL INJURY (Bladder/Ureter)

• Placenta percreta can invade the bladder in up to 20% of cases
• Prevention: Preoperative ureteric stent insertion aids identification; careful surgical dissection
• Management: Intraoperative urology consultation, cystotomy repair, ureteroneocystostomy or stenting if ureteric injury

6. HYPOTHERMIA

• Prolonged surgery + massive transfusion cause hypothermia → worsens coagulopathy
• Prevention: Forced-air warming blankets, warm IV fluids, warming mattress, increase OR temperature
• Target core temperature >36°C

7. AMNIOTIC FLUID EMBOLISM (AFE)

• Rare but catastrophic (mortality 20-60%)
• Presents as sudden cardiovascular collapse, hypoxia, DIC
• Management: Supportive - CPR, vasopressors, ECMO in extreme cases, treat DIC aggressively

8. ASPIRATION

• Highest risk at induction of GA in parturient (full stomach, raised intraabdominal pressure)
• Prevention: RSI with cricoid pressure, antacid prophylaxis
• Management if occurs: Immediate suction, bronchoscopy, supportive ventilation, antibiotics if secondary infection

9. VENOUS THROMBOEMBOLISM (VTE)

• Post-LSCS + prolonged surgery = high VTE risk
• TED stockings + pneumatic compression devices intraoperatively
• LMWH (enoxaparin) 12-24 hours postoperatively (once bleeding controlled) per local protocol

10. NEONATAL COMPROMISE

• Prematurity (34-36 weeks) → risk of RDS, hypoglycaemia, hypothermia
• Anaesthetic drugs may cause neonatal depression if GA used
• Neonatal team must be present at delivery
• Minimise time from uterine incision to delivery of baby

V. POSTOPERATIVE CARE

• ICU/HDU admission postoperatively in all suspected/confirmed accreta cases
• Continue invasive monitoring (arterial line, CVP)
• Serial Hb, coagulation studies, urine output monitoring
• Continue uterotonic infusion (oxytocin 20-40 IU in 500 mL saline over 4-8 hours)
• Pain management: epidural infusion (if catheter in situ), IV morphine PCA, paracetamol, NSAIDs (after 24 hours)
• Watch for delayed haemorrhage, vault haematoma, infection, ileus
• VTE prophylaxis as above
• Uterine artery embolisation may be performed in IR suite post-delivery if conservative uterine management was chosen
• Psychological support and debriefing for patient (loss of uterus, intensive care admission)

Summary: Key Points

Textbook sources: Miller's Anesthesia 10e; Morgan & Mikhail's Clinical Anesthesiology 7e; Creasy & Resnik's Maternal-Fetal Medicine, 7e

Recent evidence note: A 2024 systematic review (PMID 39277964, Hung et al., Eur J Obstet Gynecol Reprod Biol) reviewed evidence-based surgical approaches for cesarean hysterectomy in PAS - confirming multidisciplinary care at experienced centres optimises outcomes.