Case study: Cesarean hysterectomy, A multi-purpose, multi-priority, multi-location surgery.   Cesarean hysterectomy as long as placenta accreta Placenta accreta with bladder invasion (MRI scan) Cesarean Hysterectomy Possible adjuncts to care of placenta accreta patient

Case study: Cesarean hysterectomy, A multi-purpose, multi-priority, multi-location surgery.   Cesarean hysterectomy as long as placenta accreta Placenta accreta with bladder invasion (MRI scan) Cesarean Hysterectomy Possible adjuncts to care of placenta accreta patient www.phwiki.com

Case study: Cesarean hysterectomy, A multi-purpose, multi-priority, multi-location surgery.   Cesarean hysterectomy as long as placenta accreta Placenta accreta with bladder invasion (MRI scan) Cesarean Hysterectomy Possible adjuncts to care of placenta accreta patient

Stout, David, Managing Editor has reference to this Academic Journal, PHwiki organized this Journal Case study: Cesarean hysterectomy, A multi-purpose, multi-priority, multi-location surgery. Tom Archer, MD, MBA April 3, 2012 Cesarean hysterectomy as long as placenta accreta Growing problem because of high CS rate. Prior CS creates low anterior uterine scar implantation of next pregnancy in scar low lying, invasive placenta which easily grows across the cervical os Placenta previa + accreta. 1st C-section 2nd pregnancy implants in scar Placenta previa in addition to accreta “Low transverse” incision in uterus above bladder creates scar after first C-section. Scar serves as a low implantation site as long as second pregnancy. Low-lying placenta grows over cervical os, as long as ming placenta previa, in addition to grows deeply into uterine scar, becoming accreta (percreta with bladder invasion shown here). Placenta previa in a patient with a previous C-section should raise suspicion of placenta accreta, which will necessitate Cesarean hysterectomy. Figure 1

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Placenta accreta: Usually occurs in previous CS scar (low in addition to above bladder). Placenta invades deeply within scar (becomes “accreta”) Placenta starts low (growing over cervical os, becoming “previa”) Placenta previa + (multiple) previous CS high likelihood of accreta Commonest organ as long as invasion by the placenta accreta is the bladder Diagnosis by US or MRI. Nursingcrib.com Placenta accreta– abnormally adherent placenta DOES NOT COME OUT AFTER DELIVERY. Patient bleeds because uterus CANNOT CONTRACT WITH PLACENTA INSIDE. Placenta accreta with bladder invasion (MRI scan)

Cesarean Hysterectomy C-section followed by hysterectomy. Most OBs have limited experience with this. Uterus is highly vascular in addition to bleeding is rapid. Extensive planning is extremely important. Possible adjuncts to care of placenta accreta patient Internal iliac balloons to temporarily reduce bleeding. Placed in Interventional radiology. Copyright © 2008 by the American Roentgen Ray Society Tan, C. H. et al. Am. J. Roentgenol. 2007;189:1158-1163 -31-year-old woman with placenta percreta

Possible adjuncts to care of placenta accreta patient Cell saver– OK despite fears of “amniotic fluid embolus”. Use after amniotic fluid is gone. AFE probably not due to AFE. “Anaphylactoid syndrome of pregnancy.” Level 1 or other rapid infusion system Possible adjuncts to care of placenta accreta patient Acute normovolemic hemodilution.

Old “procedure” as long as C-hyst “Night” OB anesthesia team would “place epidural” in addition to “arterial line” so that patient could go to IR at “0530” as long as “0700 OR start”. Day anesthesia team would take patient over from night anesthesia team. Profound disadvantages: fragmentation of care AND absence of full complement of daytime resources. Starting major elective procedure outside of elective OR time BAD IDEA! Any complicated surgery Intersection of: medical, technical, organizational in addition to interpersonal factors. Successful MD or nurse must take all of these aspects into account. Don’t underestimate the problems that can arise with a complicated, multi-site surgery! COMMUNICATE! Cesarean hysterectomy Fraught with dangers (medical, psychological, political). Be aware of this. Don’t fight it. Consult in advance with all parties. Acknowledge points of view, but Remember that ultimate responsibility as long as anesthesia rests with us. Try to say this nicely.

Multiple voices will be heard Patient preference (GA or epidural) Surgeon preference (GA or epidural) “Baby-friendly” advocates may promote maternal bonding with infant. Listen carefully to all opinions, but ultimate decision is yours. You are responsible as long as anesthesia Cesarean hysterectomy In your discussions, acknowledge points of view, but PRIORITIZE: “Yes, it would be great if you could be awake as long as the birth, but Dr. X thinks that in your case the bleeding may be more than usual in addition to as long as this reason we want to do the general anesthetic because ” Multiple voices will be heard My advice: consult early, abundantly in addition to respectfully. Explain your decision to all concerned. Assume that there will be poor communications, rumors, misin as long as mation. Straight GA is sometimes the best answer in an accreta with extensive invasion. Primary goal is maternal survival.

Current approach If you do epidural, must be be as long as e balloon placement in IR (patient hip flexion impossible after balloon placement). If you do epidural in addition to dose it as long as balloon placement, you must go to IR with patient. At least two “large bore” IVs. Arterial line (awake) Possible Cordis sheath (awake) Current approach Emotional support as long as Mom– extensive, frightening in addition to painful preparation be as long as e what should be a happy event. Judicious use of fentanyl, midazolam as long as line placement. Once patient is asleep there is no time as long as Cordis placement be as long as e baby is delivered in addition to hemorrhage occurs. Factors favoring epidural: Analgesia as long as balloon placement in interventional radiology suite (but local is easy too) Surgical anesthesia (hopefully it works well enough). Patient awake as long as birth Post-op pain control (epidural morphine)

Factors opposing epidural: Need to monitor patient in addition to fetus in multiple locations (Epidural placed in L&D, then IR, then OR). Sympathectomy is dangerous in setting of heavy blood loss. May not be adequate anesthesia as long as hysterectomy. Psychological factors (long surgery, awake patient with heavy bleeding, transfusion, hypotension- caregiver in addition to patient stress). Unprotected airway during big/long surgery. Straight GA Pro: simple, straight as long as ward, one anesthetic, avoids sympathectomy in addition to psychological issues. Con: Patient asleep as long as birth, pushback from “patient advocates”. Inferior pain control post-op compared to epidural. Baby may be born “depressed” (by GA). If you use GA Make sure everyone underst in addition to s that baby “depressed” by GA is NOT SICK or HYPOXIC. As much as we may underst in addition to this, non-anesthesia people will associate “depressed” baby with hypoxia in addition to damage in addition to will worry a great deal about this.

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Cesarean hysterectomy Current Policy One anesthesia team will do all physical preparation of the patient, starting at the designated start time. No “line placement” by the “night team”. Purely in as long as mational consults are per as long as med as early as possible in addition to someone from the OB anesthesia team should do this when possible. Cesarean hysterectomy Current Policy There is no “st in addition to ard” anesthetic. The choice of anesthesia is up to the attending anesthesiologist as long as the case, after consultation with patient in addition to surgeons. The (current) “solution” came from several interdisciplinary conferences. OR management (MDs in addition to nursing) made “0730 start” available to OBs, even though OR may not be physically used until 0900-1000, due to patient preparation in IR. Agreement to let room sit unused. One anesthesia team starts at 0700 with ALL of the physical preparation of the patient: epidural (if used), go to IR (if used), arterial line in addition to IV access (Cordis sheath vs. mult PIV)

Advantages of The (current) “solution” Only one anesthesia team provides continuity of care in addition to responsibility re: Epidural (does it really work), What happened in IR, Patient emotional state, Presence of father of baby in OR, Communication with OB team OBs have guaranteed OR once patient is done in IR Summary C-hyst: increasing CS rate is creating the iatrogenic problem of placenta previa in addition to accreta in subsequent pregnancies. Placenta accreta: potentially fatal due to torrential hemorrhage. Extensive multidisciplinary planning in addition to discussion is required to do these cases well.

Stout, David Managing Editor

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