Obstetric anaesthesia08 / 17
Placenta accreta spectrum for caesarean hysterectomy36-year-old woman, 76 kg, para 3 with three previous caesareans, at 34 weeks
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Know this first
- With praevia, accreta risk is 3%, 11%, 40% and over 60% after 0, 1, 2 and 3+ caesareans.
- Average blood loss with accreta is 3–5 L.
- Balloon catheters: efficacy unclear; not recommended by ACOG.
- Cell salvage is advised for planned caesarean hysterectomy.
- Transfusion hyperkalaemia needs fast rates, around 120 mL/min of banked blood.
The patient
36-year-old woman, 76 kg, para 3 with three previous caesareans, at 34 weeks; anterior placenta praevia with suspected percreta into the bladder on MRI.
Mild anaemia, Hb 10.4 g/dL; otherwise well.
Drugs: oral iron.
Planned caesarean hysterectomy in a hybrid theatre with iliac balloon catheters.
Vitals: BP 116/70, HR 84, SpO2 99% on air, RR 16.
The examiner asks
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Consider
What are the key issues?
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- A 36-year-old with praevia and three caesareans, suspected percreta, for planned caesarean hysterectomy. Patient
- At 34 weeks: aspiration risk, swollen airway, caval compression, and a preterm baby.
- Praevia after three caesareans carries an accreta risk of over 60%. Disease
- Average loss is 3–5 L; bladder invasion makes the dissection longer and bloodier. Surgery
Prepare
How do you prepare?
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- Planning meeting: obstetrics, urology, radiology, haematology, neonates, ICU and anaesthesia. Patient
- Consent covers hysterectomy, transfusion and converting to general anaesthesia.
- Blood bank alerted; red cells, plasma, platelets and cryoprecipitate in theatre. Disease
- Cell salvage set up from the start.
- Two large-bore cannulas, an arterial line and a rapid infuser with warming. Patient
- ICU bed booked for afterwards. After surgery
Plan
What is your anaesthetic plan?
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- CSE for the delivery; if bleeding becomes heavy, I convert to general under control. Disease
- Balloons have unclear benefit and ACOG doesn't recommend them; I won't rely on them. Surgery
- Tranexamic acid as bleeding starts; early fibrinogen and balanced products. Disease
- Blood gases every 30 minutes for potassium, ionised calcium, lactate and haemoglobin.
- Warmed fluids and forced-air warming to keep her normothermic.
Crisis
After delivery, as dissection starts, she is in pain and distressed. BP 98/60, HR 120. What do you do?
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- Block failing with heavy bleeding ahead: convert to general now, before she is unstable. (Crisis)
- Surgeon pauses and packs; sodium citrate given, videolaryngoscope and help ready.
- Rapid sequence: ketamine 1 mg/kg to protect her pressure, rocuronium 1.0 mg/kg.
- Her airway may be swollen and bleed easily; size 7.0 tube.
- Low volatile while the uterus is still in; it relaxes uterine muscle.
Crisis
Two hours in, after 12 units, the T waves are peaked; K+ 6.8 mmol/L, ionised calcium 0.78 mmol/L. BP 84/46, HR 130. What do you do?
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- Hyperkalaemia and low ionised calcium from fast transfusion of stored red cells. (Crisis)
- Calcium chloride 500–1000 mg IV over 3 minutes, repeated as needed.
- Insulin 10 units with glucose 50 g IV.
- Correct acidosis with ventilation, and keep her warm.
- Gases every few units; her potassium and calcium change fast.
Fatal mistakes
- Starting with no blood products or cell salvage in theatre.
- Not checking potassium and calcium during massive transfusion.
- Converting to general without airway preparation.
Checked against: Miller 10e · Barash 9e
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