Placenta Accreta Spectrum Disorders: Knowledge Gaps in Anesthesia Care

Abstract

Placenta accreta spectrum (PAS) disorder is a potentially life-threatening condition that can occur during pregnancy. PAS puts pregnant individuals at a very high risk of major blood loss, hysterectomy, and intensive care unit admission. These patients should receive care in a center with multidisciplinary experience and expertise in managing PAS disorder. Obstetric anesthesiologists play vital roles in the peripartum care of pregnant patients with suspected PAS. As well as providing high-quality anesthesia care, obstetric anesthesiologists coordinate peridelivery care, drive transfusion-related decision making, and oversee postpartum analgesia. However, there are a number of key knowledge gaps related to the anesthesia care of these patients. For example, limited data are available describing optimal anesthesia staffing models for scheduled and unscheduled delivery. Evidence and consensus are lacking on the ideal surgical location for delivery; primary mode of anesthesia for cesarean delivery; preoperative blood ordering; use of pharmacological adjuncts for hemorrhage management, such as tranexamic acid and fibrinogen concentrate; neuraxial blocks and abdominal wall blocks for postoperative analgesia; and the preferred location for postpartum care. It is also unclear how anesthesia-related decision making and interventions impact physical and mental health outcomes. High-quality international multicenter studies are needed to fill these knowledge gaps and advance the anesthesia care of patients with PAS.

Anesthesia Considerations for Placenta Accreta Spectrum

“…In a survey of obstetric anesthesia experts based at multiple academic centers, 100% of respondents reported that PAS surgeries were staffed by an attending obstetric anesthesiologist. 5 In the event of an emergency cesarean hysterectomy, the assigned anesthesiologist may benefit from the use of a standardized cesarean hysterectomy anesthetic protocol or checklist (►Table 1). The use of a protocol or checklist may standardize care, particularly when delivery is necessary outside of normal working hours with providers who are not part of the primary care team.…”

“…The use of a protocol or checklist may standardize care, particularly when delivery is necessary outside of normal working hours with providers who are not part of the primary care team. 1,5 We also recommend a preoperative briefing between all PAS team members to confirm the perioperative plan and contingency plans in the event of major bleeding, surgical injury, or major hemodynamic compromise. Preoperative briefings can improve patient safety, operating room efficiency, and team communication.…”

“…In a recent survey of obstetric anesthesia experts across multiple academic centers, 90% respondents place an arterial line for cases of suspected PAS. 5 The rate of central venous catheter placement for suspected PAS cases varies from 2.5 to 15%. 15 (J. Markley, personal communication).…”

“…Abbreviations: GA, general anesthesia; ICU, intensive care unit; PAS, placenta accreta spectrum. Note: Table reproduced with permission from Warrick et al5 It includes information presented in Warrick et al1 and Markley et al9 …”

Emergencies in obstetric anaesthesia: a narrative review

“…There is no consensus on the optimal anaesthetic technique and multiple clinical and institutional factors may influence these choices [67]. The key to successful management is anticipating the need for rapid and massive transfusion.…”