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• W2894762724 abstract "In 2010, the Joint Commission issued an alert that maternal mortality in the United States had nearly doubled from a rate of 7 per 100,000 deliveries to 13.3 per 100,000 deliveries in only 10 years.1 One of the contributors to this increase in mortality is maternal hemorrhage, and one of the leading causes of maternal hemorrhage is a morbidly adherent placenta (MAP) that in the years 1982–2002 occurred in approximately 1/500 deliveries.2 This represents a 5-fold increase from just 10 years before when the incidence was closer to 1/2500 deliveries.3 Risk factors for a MAP include advanced maternal age, placenta previa, and repeat cesarean delivery.4 Therefore, it is not surprising that the incidence of MAP is increasing as the cesarean delivery rate in the United States increases, peaking at 32.9% in 2009—though it has decreased since then to 31.9% in 2016.5 The risk of mortality from MAP is not insignificant and may be as high as 1%.6,7 The etiologies of mortality include massive hemorrhage, disseminated intravascular coagulation, electrolyte disturbances, pulmonary edema and adult respiratory distress syndrome, sepsis, and venous thromboembolism. Solheim et al8 created a model to predict future mortality from MAP based on the current and projected cesarean delivery rate. They found that the mortality rate is likely to increase further even if the cesarean delivery rate remained the same because increases in mortality will lag the increase in the cesarean delivery rate by approximately 6 years. One of the controversies surrounding the anesthetic care of the parturient with a MAP is whether to proceed under neuraxial anesthesia (NA) or general anesthesia (GA). In this issue of Anesthesia & Analgesia, Markley et al9 conclude that in most cases, NA is a safe alternative to GA. Their retrospective study is the largest to date that addresses this important question, and the authors should be commended for their study. But what is the controversy? In the otherwise healthy parturient, NA has many advantages and is generally considered to be safer than GA. NA allows the mother to be awake, experience the delivery of her baby, and avoid intubation of her trachea. Tracheal intubation of the parturient has been shown to be 8–10 times more difficult than of the nonpregnant woman.10 Furthermore, the mother is at risk for pulmonary aspiration, which is essentially eliminated if the delivery proceeds under NA. The neonate also has better outcomes when the mother receives NA rather than GA as evidenced by higher Apgar scores, higher neurologic and adaptive capacity scores, and shorter time to breast feeding.11 Why would not all of these advantages of NA apply when anesthetizing the parturient with MAP? There may be another potential benefit to performing a procedure that involves increased risk for massive hemorrhage under NA in terms of hemodynamic stability and transfusion therapy. In a canine model of experimental hemorrhage, dogs that had a thoracic level of epidural anesthesia and GA had a significantly greater likelihood of survival than dogs that received only GA.12 In one of the few randomized studies comparing NA to GA in parturients with placenta previa, there was better hemodynamic stability and fewer units of blood transfused in the NA group. However, this study involved only 25 parturients, and the results need to be confirmed in a larger number of patients.13 The concern with NA in the parturient who has a MAP is that hemorrhage can be rapid and massive and can result in hypotension that may be difficult to manage in the face of a sympathectomy, even if the technique is converted to GA. If the mother bleeds and requires an extensive procedure or the procedure is prolonged and the decision is made not to convert to GA, then sedating the mother places her at increased risk for pulmonary aspiration. Furthermore, inducing GA in the hypovolemic parturient and intubating her trachea, especially after she may have received large-volume fluid resuscitation, can be life threatening. Indeed, at my institution, a parturient who was undergoing a cesarean delivery under NA suffered a pulseless electrical activity cardiac arrest during induction of GA with ketamine in the face of massive hemorrhage. Prior studies have been divided on the topic, with some suggesting NA as the preferred technique14 and others that GA is the preferred technique.15 These studies have been retrospective and, by and large, all patients, whether they received GA or NA, ultimately did well, although many (20%–40%) who started with NA required conversion to GA. It is important to note that in these studies, conversion to GA generally occurred when the patient was bleeding or required more extensive surgery. In this issue of Anesthesia & Analgesia, Markley et al9 report a single-center retrospective cohort study of parturients with placenta previa and suspected MAP undergoing elective cesarean delivery. There were 129 patients who met inclusion criteria of whom 122 (95%) received NA and 7 (5%) GA. Of those who received NA, 5 (4%) required conversion to GA before delivery of the baby due to inadequate surgical anesthesia and 15 (12%) required conversion to GA after delivery of the baby. Seventy-two women required a hysterectomy, and it was among these cases that the 15 women required GA primarily due to resuscitation (n = 7), intraoperative pain (n = 6), enhanced surgical exposure (n = 1), and unknown etiology (n = 1). Thus, if a woman required a hysterectomy, the incidence of conversion to GA was 15/72 (21%). As compared to the NA group, the need to convert to GA was significantly associated with requiring >4 units of packed red blood cells (60% vs 25%), a history of ≥3 prior cesarean deliveries (38% vs 23%), and longer surgical duration (4 vs 2.56 hours). Also, those who required conversion to GA had a greater incidence of postoperative acuity (47% vs 4%), defined as the need for intensive care unit admission in ≤24 hours of the procedure, reoperation or uterine arterial embolization, and ≥3 units of transfused packed red blood cells after the procedure. The etiology for all 5 of the patients admitted to the intensive care unit among those who required conversion to GA was concern for airway swelling after large-volume fluid resuscitation. The strength of the Markley et al9 study clearly lies in its size. The authors present data on 129 patients, which makes this the largest such study to date. All 129 patients, whether they received only NA or required conversion to GA, ultimately had good outcomes, demonstrating that NA is a viable approach to the parturient with MAP. The Markley et al9 retrospective study has several limitations, many of which the authors acknowledge. Seven patients received GA as their primary anesthetic. Because of the retrospective nature of the study, it is unclear why GA was chosen for these patients, and selection bias is a possibility. It should be noted that all 7 (ie, 100%) of these patients required a hysterectomy, compared to 62% in the balance of the patients, suggesting that they were a higher risk group. Due to the retrospective nature of the study, the authors could not report on hemodynamic instability after conversion to GA—another major concern of starting with NA. The hospital in which the procedures took place is a major academic center with resources not available at many other centers. Such resources include interventional radiology (IR), residents and fellows, and multiple obstetric providers, including specialized surgeons and a postanesthesia care unit located on the obstetric floor capable of invasive monitoring. These additional resources may limit the applicability of the results to other centers. The anesthesiologists at the hospital have a bias toward providing NA for these procedures and therefore are better prepared to manage the complex nature of these cases in a parturient who is awake.16 Paradoxically, some may use the Markley et al9 data to strengthen their argument that GA is the preferred technique. In their study, there were 3 cases of difficult tracheal intubation out of only 20 cases. This is one of the reasons/concerns expressed by those who start with GA because they would prefer to secure the airway before the patient becomes unstable and more edematous from transfusions. Further, 86% of those patients who were converted from NA to GA for resuscitation required a pressor agent immediately after induction of GA, compared to 46% of those converted to GA because of pain, demonstrating hemodynamic instability in the face of bleeding. Also, 21% of the patients who remained under NA for the entire case required significant sedation, which may have placed them at increased risk for pulmonary aspiration, although this did not occur in any studied patient. The authors concluded, “…restricting primary GA to those patients with the highest surgical complexity, and waiting until neonatal delivery and confirmation of MAP, may allow successful NA for most women.” The problem is identifying women who are at greatest risk for intraoperative issues, especially massive hemorrhage. Wright et al17 tried to identify preoperative risk factors that would predict which women with placenta accreta would require massive blood transfusion. Risk factors assessed included age, gravidity, number of prior cesarean deliveries, and degree of placental invasion; none was found to be of predictive value. I would agree with Markley et al9 that the choice of anesthetic technique should be individualized and GA should be used when massive hemorrhage is likely; otherwise we will be subjecting many patients to GA who never bleed or bleed minimally. Further, the anesthesiologist must be cognizant of her/his own resources and those of the institution. As the authors themselves state, “these findings from our tertiary care facility with 24-hour access to multiple obstetric anesthesia providers may not extrapolate to centers with more limited resources.” The literature is now replete with studies demonstrating safety of NA, and it is becoming clear that in the appropriate circumstances, the type of anesthetic is but 1 consideration. Adequate intravenous access, massive transfusion protocols, availability of resuscitation drugs, and equipment and ancillary services (eg, IR) are probably more critical than the choice of anesthetic technique. At my own institution, as we perform more such cases under NA, what we find invaluable is a preoperative interdisciplinary meeting with obstetricians, gynecological oncologists, IR, general surgery, urology, blood bank, and nursing, as needed. At the meeting, the anesthesiologist focuses on trying to predict who will bleed massively, which helps guide our anesthetic plan. We discuss the extent of the placental abnormality, whether the obstetricians will attempt uterine preservation and utilize IR, which are usually associated with a greater degree of blood loss, or whether the surgeons will immediately perform a hysterectomy in the case of a placenta accreta or increta, which is generally associated with less blood loss. Alternatively, in the face of a placenta percreta, the obstetricians may choose to leave the placenta in situ, which is also generally associated with less blood loss, although there have been reports of delayed hemorrhage even up to 49 days later.18 Finally, we carefully assess the parturient’s airway because if a difficult airway is predicted, it will be safer to intubate the trachea and control the airway before starting the surgery. Also, it is important to always have a plan B, and if the decision was to start with NA but massive hemorrhage ensues, we convert to GA at the start of the bleed before the patient is hypovolemic and the airway more edematous from transfusions. As the cesarean delivery rate increases, it is inevitable that more women with MAP will require our care. The Markley et al9 study adds considerably to the literature and combined with the other studies to date should persuade those who always used GA to at least consider NA in select cases.14 More studies, preferably prospective and randomized studies that better identify which parturient is at risk for massive hemorrhage and demonstrate the safety of NA, are encouraged. DISCLOSURES Name: Yaakov Beilin, MD. Contribution: This author wrote the article. This manuscript was handled by: Jill M. Mhyre, MD." @default.
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• W2894762724 date "2018-10-01" @default.
• W2894762724 modified "2023-10-14" @default.
• W2894762724 title "Maternal Hemorrhage—Regional Versus General Anesthesia: Does It Really Matter?" @default.
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