Comparison of general and epidural anesthesia in elective cesarean section for placenta previa totalis: maternal hemodynamics, blood loss and neonatal outcome

doi:10.1016/S0959-289X(02)00183-8

International Journal of Obstetric Anesthesia

Volume 12, Issue 1, January 2003, Pages 12-16

https://doi.org/10.1016/S0959-289X(02)00183-8 Get rights and content

Abstract

There are few consistent guidelines in choosing anesthesia for cesarean section for a parturient with placenta previa. This prospective randomized trial was organized to compare the maternal hemodynamics, blood loss and neonatal outcome of general versus epidural anesthesia for cesarean section with the diagnosis of grade 4 placenta previa. After giving informed consent, 12 patients received general anesthesia and 13 received epidural. Intraoperative blood pressures demonstrated a more stable course in the epidural group than in the general group. Blood loss did not differ significantly between the groups (1622±775 mL vs. 1418±996 mL). General anesthesia resulted in lower immediate postoperative hematocrit level (28.1±3.5% vs. 32.5±5.0%, P<0.05). The patients in the general group received a significantly larger transfusion than the epidural group (1.08±1.6 vs. 0.38±0.9 units, P<0.05). The Apgar scores at 1 and 5 min were similar in the two groups (8 [4–9] vs. 8 [7–9] and 10 [6–10] vs. 9 [9–10], respectively). We concluded that epidural anesthesia is superior to general anesthesia in elective cesarean section for grade 4 placenta previa with regard to maternal hemodynamics and blood loss. There was no difference in neonatal outcome.

Introduction

Placenta previa complicates 4.8 per 1000 deliveries and is fatal in 0.03%.¹ It is one of the major causes of massive obstetric hemorrhage and maternal and fetal morbidity or mortality. Anesthesia for cesarean section for placenta previa remains controversial. Some believe that spinal or epidural anesthesia may be used if the patient requests it and if no evidence of hypovolemia is present, while others believe that general anesthesia is still preferable because of the possible increased blood loss in these patients.² Some anesthesiologists assert that regional anesthesia can be used for cesarean section even for placenta previa totalis in an elective situation when the patient is not bleeding.³ In our hospital, general endotracheal anesthesia has been preferred for placenta previa but there is some evidence that suggests these views may be changing.[4], [5], [6] In a retrospective study of maternal and perinatal morbidity resulting from 147 cases of placenta previa, regional anesthesia was used in 25% of cases with no maternal morbidity attributed to the anesthetic techniques used.⁷ Little is known, however, about the effect of anesthetic technique on the surgical course and outcome of patients particularly with grade 4 placenta previa (placenta covering the cervical os completely).

This prospective randomized trial compared the effects of general and epidural anesthesia on Apgar scores, maternal intraoperative hemodynamics, blood loss and postoperative course in patients undergoing elective cesarean section for grade 4 placenta previa.

Section snippets

Method

The study was approved by the Institutional Review Board and informed consent was obtained from all patients. The period covered by the study was 1 November 2000 to 31 June 2001. Twenty-five women with grade 4 placenta previa without bleeding scheduled for elective cesarean section were included. Demographic data and ultrasound findings were recorded by reviewing the patients’ charts (Table 1).

Cesarean section was performed under general anesthesia (n=12) or epidural anesthesia (n=13). All

Results

There were 5510 deliveries during the study period. Twenty-five consecutive patients with grade 4 placenta previa who underwent elective cesarean section were identified, giving an overall incidence of 0.45%. The general and epidural groups were similar in age, weight, height, gestational age, gravidity, number of previous cesarean sections, and findings of ultrasound scans at 34 weeks’ gestation (Table 1). None of the 13 patients who received epidural anesthesia required intraoperative

Discussion

The use of ultrasound permits the diagnosis of placenta previa to be established. Effective tocolysis and safe transfusion have given obstetricians more freedom to delay delivery safely.⁸ Despite these advances, it is clear that placenta previa still poses a grave danger. In particular, the risks of massive hemorrhage, placenta accreta and gravid hysterectomy are great. With the paucity of published evidence available on which to base any objective recommendation, our hospital has had no firm

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Emergency postpartum hysterectomy in women with placenta previa and prior cesarean section
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The anaesthetic management of caesarean section for placenta previa: a questionnaire survey
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International Journal of Obstetric Anesthesia
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Reg. Anesth.
(1996)

There are more references available in the full text version of this article.

Cited by (73)

Neuraxial anesthesia and postoperative opioid administration for cesarean delivery in patients with placenta accreta spectrum disorder: a retrospective cohort study
2022, International Journal of Obstetric Anesthesia
Citation Excerpt :
The reported incidence of placenta accreta spectrum (PAS) disorder has almost doubled in recent years, from 0.02%-0.04% in 1982, to 0.19% in 2002, and to 0.37% in 2016.1 There is no consensus on the optimal anesthetic management of patients with suspected PAS.1–7 Anesthesia techniques vary based on hospital practices, anesthesiologist and patient preference, and anticipated surgical complexity.4
There is no consensus on optimal anesthetic and analgesic management of patients presenting for cesarean delivery with suspected placenta accreta spectrum disorder. Neuraxial anesthesia is preferred for uncomplicated procedures, but general anesthesia may be indicated for those at risk of hemorrhage and hysterectomy. We compared the effect of anesthesia techniques on postoperative maternal opioid administration and neonatal respiratory distress.
A single-center retrospective study from 2016 to 2019 using electronic records to identify singleton pregnancies with a high index of suspicion of placenta accreta spectrum disorder. Patients were categorized by the anesthetic technique they received: general, neuraxial, or neuraxial with conversion to general anesthesia following delivery. Postoperative maternal opioid administration (oral morphine in mg equivalents) and risk of neonatal respiratory distress were compared using linear mixed models.
Thirty-nine records were analyzed. Mean-adjusted oral morphine mg equivalents were 192 for patients receiving general anesthesia vs. 90 for neuraxial anesthesia only (P=0.009) and 104 for neuraxial with conversion to general anesthesia (P=0.052). Neonates delivered under general anesthesia had a 3.5 times relative risk (95% CI 1.3 to 9.8, P=0.017) of respiratory distress compared with those exposed to neuraxial anesthesia alone.
Patients receiving general anesthesia alone were administered more opioids than those undergoing neuraxial anesthesia or neuraxial with conversion to general anesthesia. This finding was maintained when accounting for whether or not the patient underwent hysterectomy. Deciding on anesthetic management requires consideration of patient comorbidities, severity of placenta accreta spectrum pathology, and surgical requirements.
Guideline No. 402: Diagnosis and Management of Placenta Previa
2020, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
If the placenta is transected during delivery, immediate cord clamping is needed to avoid exsanguination of the baby. Regional anaesthesia is preferred as first line, with general anaesthesia being reserved for usual obstetric indications.59,64–65 If cesarean delivery is planned, timing should be based primarily on the location of the placenta.
To summarize the current evidence and to make recommendations for diagnosis and classification of placenta previa and for managing the care of women with this diagnosis.
To manage in hospital or as an outpatient and to perform a cesarean delivery preterm or at term or to allow a trial of labour when a diagnosis of placenta previa or a low-lying placenta is suspected or confirmed.
Prolonged hospitalization, preterm birth, rate of cesarean delivery, maternal morbidity and mortality, and postnatal morbidity and mortality.
Family physicians, obstetricians, midwives, and other maternal care providers.
Pregnant women with placenta previa or low-lying placenta.
Medline, PubMed, Embase, and the Cochrane Library were searched from inception to October 2018. Medical Subject Heading (MeSH) terms and key words related to pregnancy, placenta previa, low-lying placenta, antepartum hemorrhage, short cervical length, preterm labour, and cesarean. This document represents an abstraction of the evidence rather than a methodological review.
This guideline has been reviewed by the Maternal–Fetal Medicine and Diagnostic Imaging committees of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and approved by the SOGC Board of Directors.
Women with placenta previa or low-lying placenta are at increased risk of maternal, fetal and postnatal adverse outcomes that include a potentially incorrect diagnosis and possibly unnecessary hospitalization, restriction of activities, early delivery, or cesarean delivery. Optimization of diagnosis and management protocols has potential to improve maternal, fetal and postnatal outcomes.
- 1
  All women with placenta previa or low-lying placenta have an increased risk of a morbidly adherent placenta, particularly those who have had a prior cesarean delivery (strong/moderate).
- 2
  In women with placenta previa or a low-lying placenta, presence of a marginal/velamentous cord insertion close to the cervical os or a succenturiate placental lobe increases the risk of vasa previa (strong/moderate).
- 3
  History of antepartum hemorrhage (first episode <29 weeks or recurrent episodes [≥3]), a thick placental edge covering (or close to) the cervical os, short cervical length (<3 cm with placenta previa, <2 cm with low-lying placenta), and a previous cesarean delivery are risk factors with an associated increased risk of urgent/preterm cesarean delivery (strong/moderate).
- 4
  In the absence of risk factors, outpatient management of women with placenta previa is safe (strong/moderate).
- 5
  Bed rest or reduced activity is not beneficial in women with placenta previa and can be potentially harmful. However, sexual intercourse/insertion of foreign bodies in vagina or rectum should be avoided (conditional [weak]/low).
- 6
  Preoperative bedside ultrasound assessment of placental location can be useful for planning of surgical technique and may reduce risk of intraoperative transection of placenta (conditional [weak]/low).
- 7
  Regional anaesthesia is safe and adequate as a first-line anaesthetic approach for the peripartum management of patients with placenta previa or low-lying placenta (conditional [weak]/low).
- 8
  When deciding the location of delivery, consider ultrasound assessment of placental location, any risk factors, the patient's history, and logistical factors, including available resources at the delivery unit (conditional [weak]/low).
- 1
  Classify placental location as placenta previa (placenta covering the cervical os), low-lying placenta (edge located ≤20 mm from cervical os), or normally located placenta (edge located >20 mm from cervical os) (strong/moderate).
- 2
  Diagnosis of placenta previa or low-lying placenta should not be made <18 to 20 weeks gestation, and the provisional diagnosis must be confirmed after >32 weeks gestation, or earlier if the clinical situation warrants. In women with a low-lying placenta, a recent ultrasound (within 7 to 14 days) should be used to confirm placental location prior to a cesarean delivery (strong/moderate).
- 3
  Assessment by transvaginal ultrasound is recommended in all cases where placenta previa or a low-lying placenta is present or suspected by transabdominal sonography, with attempt to clearly define placental location (including laterality), characteristics of placental edge (including thickness, presence of a marginal sinus), and associated findings (succenturiate lobe, cord insertion close to the cervix) (strong/moderate).
- 4
  In women with placenta previa or low-lying placenta and in the presence of risk factors or limited access to urgent obstetrical care, consider in-hospital management (strong/moderate).
- 5
  A cervical cerclage can be considered in women with a short cervical length, particularly in association with antepartum hemorrhage, but not as a prophylactic measure for all women with placenta previa (conditional [weak]/low).
- 6
  Administer antenatal corticosteroids for potential preterm delivery only if the risk of delivery within 7 days is very high and not solely because admission to the hospital is deemed necessary (strong/moderate).
- 7
  Tocolysis can be considered in women with antepartum hemorrhage associated with uterine contractions in order to allow administration of corticosteroids or transfer of care, but not for prolongation of pregnancy (conditional [weak]/low).
- 8
  Cesarean delivery is recommended in women with placenta previa at 36⁰ to 36⁶ weeks gestation in the presence of risk factors and at 37⁰ to 37⁶ weeks gestation in the absence of risk factors (strong/moderate).
- 9
  Cesarean delivery is recommended in women with a low-lying placenta with the placental edge ≤10 mm from the cervical os at 37⁰ to 37⁶ weeks gestation in the presence of risk factors and at 38⁰ to 38⁶ weeks gestation in the absence of risk factors (strong/moderate).
- 10
  A trial of labour is recommended in women with a low-lying placenta where the placental edge is 11 to 20 mm from the cervical os and can be considered in carefully selected women where the placental edge is ≤10 mm from the cervical os (strong/moderate).
Directive clinique n<sup>o</sup> 402: Placenta prævia: Diagnostic et prise en charge
2020, Journal of Obstetrics and Gynaecology Canada
Résumer les données probantes actuelles et formuler des recommandations pour le diagnostic et la classification du placenta prævia et pour la prise en charge des femmes ayant reçu ce diagnostic.
En cas de diagnostic soupçonné ou confirmé de placenta prævia ou de placenta bas inséré, prendre en charge la patiente en milieu hospitalier ou en consultation externe puis pratiquer une césarienne avant ou à terme ou effectuer une épreuve d'accouchement.
Hospitalisation prolongée, accouchement prématuré, taux de césariennes, morbidité et mortalité maternelles, et morbidité et mortalité postnatales.
Médecins de famille, obstétriciens, sages-femmes, et autres fournisseurs de soins de maternité.
Femmes enceintes présentant un placenta prævia ou un placenta bas inséré.
Une recherche a été effectuée dans les bases de données Medline, PubMed et Embase ainsi que dans Cochrane Library, de leur création jusqu’à octobre 2018, au moyen de termes MeSH (Medical Subject Heading) et de mots-clés liés aux termes suivants : grossesse, placenta prævia, placenta bas inséré, hémorragie ante partum, col court, travail avant terme et césarienne. Le présent document est un résumé des données probantes et non pas une revue méthodologique.
La présente directive clinique a été revue par le comité de médecine fœto-maternelle et le comité d'imagerie diagnostique de la Société des obstétriciens et gynécologues du Canada (SOGC) puis approuvée par le conseil d'administration de la SOGC.
Les femmes ayant un placenta prævia ou un placenta bas inséré présentent un risque accru d'issues maternelles, fœtales et postnatales défavorables, ce qui comprend un diagnostic potentiellement erroné et une hospitalisation possiblement injustifiée, une restriction des activités, un accouchement précoce ou une césarienne. L'optimisation des protocoles de diagnostic et de prise en charge peut améliorer les issues maternelles, fœtales et postnatales.
- 1
  Toutes les femmes ayant un placenta prævia ou un placenta bas inséré présentent un risque accru d'adhérence morbide du placenta, en particulier celles qui ont déjà subi une césarienne (forte, moyenne).
- 2
  Chez les femmes ayant un placenta prævia ou un placenta bas inséré, la présence d'une insertion marginale ou vélamenteuse du cordon ombilical près de l'orifice interne du col ou d'un lobe placentaire accessoire augmente le risque de vasa prævia (forte, moyenne).
- 3
  Les facteurs associés à une augmentation du risque de césarienne d'urgence ou avant terme sont les antécédents d'hémorragie ante partum (premier épisode < 29 semaines d'aménorrhée ou épisodes répétés [≥ 3]), le bord placentaire épais recouvrant (ou près de) l'orifice interne du col, le col court (< 3 cm pour le placenta prævia, < 2 cm pour le placenta bas inséré) et la présence d'une cicatrice césarienne (forte, moyenne).
- 4
  En l'absence de facteur de risque, la prise en charge en consultation externe des femmes ayant un placenta prævia est sécuritaire (forte, moyenne).
- 5
  L'alitement et la réduction des activités ne sont pas bénéfiques pour les femmes ayant un placenta prævia et sont potentiellement nuisibles. Toutefois, il y a lieu de déconseiller les rapports sexuels et l'insertion de tout corps étranger dans le vagin ou le rectum (conditionnelle [faible], basse).
- 6
  L’évaluation échographique préopératoire faite au lit de la patiente pour déterminer la localisation placentaire peut s'avérer utile pour planifier la technique chirurgicale et réduire le risque de section transversale peropératoire du placenta (conditionnelle [faible], basse).
- 7
  L'anesthésie régionale est sécuritaire et constitue un mode d'anesthésie de première ligne adéquat pour la prise en charge périnatale des patientes ayant un placenta prævia ou un placenta bas inséré (conditionnelle [faible], basse).
- 8
  Pour déterminer le lieu de l'accouchement, il y a lieu de prendre en compte l’évaluation échographique de la localisation placentaire, la présence de facteurs de risque, les antécédents de la patiente et les facteurs logistiques, y compris les ressources disponibles à l'unité des naissances (conditionnelle [faible], basse).
- 1
  La localisation placentaire doit être classée comme un placenta prævia (placenta recouvrant l'orifice interne du col), un placenta bas inséré (bord à ≤ 20 mm de l'orifice interne du col) ou un placenta normalement localisé (bord à > 20 mm de l'orifice interne du col) (forte, moyenne).
- 2
  Le diagnostic du placenta prævia ou de placenta bas inséré ne doit pas être fait avant 18 à 20 semaines d'aménorrhée; ce diagnostic provisoire nécessite une confirmation, laquelle peut être obtenue à compter de 32 semaines d'aménorrhée ou plus tôt si la situation clinique le justifie. Chez les femmes ayant un placenta bas inséré, il y a lieu d'utiliser une évaluation échographique récente (dans les 7 à 14 jours) pour confirmer la localisation placentaire avant la césarienne (forte, moyenne).
- 3
  L’évaluation par échographie endovaginale est recommandée pour tous les cas soupçonnés ou confirmés de placenta prævia ou de placenta bas inséré d'après l’échographie obstétricale afin de tenter de déterminer clairement la localisation placentaire (y compris la latéralisation), les caractéristiques du bord placentaire (y compris l’épaisseur, la présence d'un sinus marginal) et les observations associées (lobe placentaire accessoire, insertion du cordon près du col) (forte, moyenne).
- 4
  Chez les femmes ayant un placenta prævia ou un placenta bas inséré, il y a lieu d'envisager la prise en charge en milieu hospitalier en présence de facteurs de risque ou en cas d'accès limité à des soins obstétricaux d'urgence (forte, moyenne).
- 5
  Il est possible d'envisager le cerclage du col chez les femmes présentant un col court, en particulier en association avec une hémorragie ante partum, mais il ne s'agit pas d'une mesure préventive pour toutes les femmes ayant un placenta prævia (conditionnelle [faible], basse).
- 6
  Il convient d'administrer une corticothérapie prénatale pour l'accouchement prématuré potentiel uniquement si le risque d'accouchement dans les 7 jours est très élevé et non pas seulement parce que l'hospitalisation est jugée nécessaire (forte, moyenne).
- 7
  La tocolyse peut être envisagée chez les femmes qui présentent une hémorragie ante partum associée à des contractions utérines pour gagner du temps afin d'administrer une corticothérapie ou d'effectuer un transfert de soin et non pas pour prolonger la grossesse (conditionnelle [faible], basse).
- 8
  En cas de césarienne indiquée pour un placenta prævia, il est recommandé de la pratiquer entre 36 SA + 0 j et 36 SA + 6 j en présence de facteurs de risque et entre 37 SA + 0 j et 37 SA + 6 j en l'absence de facteur de risque (forte, moyenne).
- 9
  En cas de césarienne indiquée pour un placenta bas inséré avec un bord placentaire à ≤ 10 mm de l'orifice interne du col, il est recommandé de la pratiquer entre 37 SA + 0 j et 37 SA + 6 j en présence de facteurs de risque et entre 38 SA + 0 j et 38 SA + 6 j en l'absence de facteur de risque (forte, moyenne).
- 10
  L’épreuve de travail est recommandée chez les femmes ayant un placenta bas inséré dont le bord se situe de 11 à 20 mm de l'orifice interne du col; l’épreuve peut aussi être envisagée dans les cas soigneusement sélectionnés de bord placentaire à ≤ 10 mm de l'orifice interne du col (forte, moyenne).
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Comparison of general and epidural anesthesia in elective cesarean section for placenta previa totalis: maternal hemodynamics, blood loss and neonatal outcome

Abstract

Introduction

Section snippets

Method

Results

Discussion

Am. J. Obstet. Gynecol.

Int. J. Gynecol. Obstet.

The epidemiology of placenta previa in the United States, 1979 through 1987

Am. J. Obstet. Gynecol.

Shnider and Levinson’s Antepartum and postpartum hemorrhage

Anesthesia for Obstetrics

The anaesthetic management of caesarean section for placenta previa: a questionnaire survey

Anaesthesia

A survey of the anaesthetic management of patients presenting for caesarean section with ‘high risk’ obstetric conditions

International Journal of Obstetric Anesthesia

How anesthesiologists practice obstetric anesthesia. Responses of practicing obstetric anesthesiologists at the 1993 meeting of the Society for Obstetric Anesthesia and Perinatalogy

Reg. Anesth.