Clinical Management Issues

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service and the Intensive Care Unit (ICU) should be alerted.

Anesthesiology management

Historically, general anesthesia, is pre-ferred to reduce the mother’s anxious state, allow the anesthetist to focus on the hem-orrhage and the cardiovascular stability, and avoid the risk for hemodynamic instability due to an urgent shift from locoregional to general anesthesia.

Our protocol, although indicating general anesthesia in emergency regimens, provides the use of epidural anesthesia both during birth and hysterectomy, considering the shift to general anesthesia in case of emergency. In our opinion, epidural analgesia offers sev-eral advantages: y reduced risk of Mendelson syndrome; y better post-surgery pain control; y no risk of awareness; y the fetus is not exposed to the effect of general anesthetics;

y participation of the mother to the birth; y continuous monitoring of the conscious-ness status, which indicates the level of brain perfusion and, thus, of the hemo-dynamic status;

y abolition of the side effects of general anesthetics (e.g., reduction of the uterine tone and platelet functionality).

INTRODUCTION

The incidence of placenta accreta spec-trum (PAS) disorders, characterized by abnormal invasion of trophoblastic tissue through the myometrium and uterine serosa, has been growing considerably [1], thus ex-posing mothers to the risk of massive bleed-ing and death [2].

The most recent guidelines [3] suggest producing in-hospital protocols and estab-lishing a step-by-step plan, from ultrasound-based detection of placenta previa to post-surgery management.

OUR PROTOCOL

The present article is meant to share the internal protocol developed in our center, Villa Sofia-Cervello Hospital, Palermo, Italy, focusing on the anesthesiologic manage-ment (Figure 1).

From the diagnosis to the surgery

An early diagnosis allows to involve a multidisciplinary team, tailor the manage-ment plan, and prepare the elective caesar-ean section and subsequent hysterectomy, also performing ultrasonography, magnetic resonance imaging, and preoperative anes-thetic examination. Finally, the transfusion

Brief Report

Keywords: Placenta accreta; Perioperative care; Epidural Anesthesia; Patient Care Team; HysterectomyCMI 2021; 15(1): 31-34http://dx.doi.org/10.7175/cmi.v15i1.1500

1 Anesthesia and Intensive Care Unit 2, Villa Sofia-Cervello Hospital, Palermo, Italy

2 Gynecology and Obstetric Unit, Villa Sofia-Cervello Hospital, Palermo, Italy. Person in charge for the Perinatal Medicine and Assistance to the Birth Unit at the ARNAS CIVICO of Palermo, Department of Maternal and Nascent Life Health

Francesco Tarantino 1 , Giuseppe Calì 2

Placenta Accreta: Management Protocol and Use

of Epidural Anesthesia

Corresponding authorFrancesco TarantinoAnesthesia and Intensive Care Unit 2,Villa Sofia-Cervello Hospital,Viale Strasburgo, 233,90146 Palermo, Italy.Phone: +393207032427Email: tarantino.f@virgilio.it

Received: 20 April 2021Accepted: 21 April 2021Published: 3 May 2021

32 Clinical Management Issues 2021; 15(1) © 2021 The Authors. Published by SEEd srl. This is an open access article under the CC BY-NC 4.0 license (https://creativecommons.org/licenses/by-nc/4.0)

Placenta Accreta: Management Protocol and Use of Epidural Anesthesia

are cannulated. Then, the antibiotic prophy-laxis and saline are administered. The skin is disinfected, a cutaneous wheal with lidocaine is performed, and the epidural space is iden-tified. The epidural catheter is placed, while monitoring electrocardiogram (ECG), oxygen saturation, and non-invasive blood pressure (NIBP). The aspiration test and dose test are performed with lidocaine. Finally, the patient is moved to the interventional radiology room.

Interventional radiology room

Time 1Colloids are infused and vital parameters

are monitored. Subsequently, ropivacaine and fentanyl are administered. The cannula-tion of the radial artery is performed and a central venous catheter is placed. A wedge is placed under the right buttock of the pa-tient. In the meanwhile, invasive blood pres-sure, oxygen saturation, electrocardiogram,

Interventional radiologists help reducing the vascular inflow to the operating field, thus allowing to use locoregional anesthesia in obstetrics with reduced bleeding, reduced use of blood products in the major obstetric hemorrhage, and better management in the post-surgery pain therapy. Finally, we chose epidural anesthesia over combined com-bined spino-epidural technique because the epidural catheter is placed in the obstetrics operatory room, and 60 minutes (radiologi-cal time) elapse before the skin incision in the interventional radiology room. There-fore, the maximum effect of the spinal an-esthesia would begin to decrease. In our experience, the epidural anesthesia has a reduced hemodynamic effect compared with spino-epidural technique.

Obstetrics operatory room

The patient is prepared in the obstetrics operatory room. Two large peripheral veins

Figure 1. Summary of the internal protocol for the management of placenta accreta spectrum disorders in the Villa Sofia-Cervello Hospital, Palermo, Italy.

33© 2021 The Authors. Published by SEEd srl. This is an open access article under the CC BY-NC 4.0 license (https://creativecommons.org/licenses/by-nc/4.0)

Clinical Management Issues 2021; 15(1)

F. Tarantino, G. Calì

Post-surgery monitoring

After surgery, patients remain under ob-servation in the Recovery Room in the Ob-stetrics and Gynecology Unit. After 4 hours, if the vital parameters are within normal range, Aldrete score is 9-10, and numerical rating scale—NRS is 2, the patient is moved to the ward, where the blood and continuous pressure monitoring continue.

Post-surgery pain control

The protocol provides the 24/48-hour epidural pain management by the pump for Programmed Intermittent Epidural Bolus-es—PIEB, through which ropivacaine and acetaminophen are administered. Epidural catheter is removed at the third day, 12 hours after the last low-molecular-weight heparin administration and upon assess-ment of possible alteration in the coagula-tion status.

CONCLUSIONS

The efficiency of this protocol made us be-come a reference center for the management of placenta accreta beyond the borders of our region. We treated more than 20 patients and we obtained positive results in terms of bleeding, packed red blood cells used, post-operative sequelae, and ICU admissions. No patients died.

A few procedures were carried out in emergency regimen and in these cases gen-eral anesthesia was used: they required the greatest amount of blood products, as also confirmed by the literature [5]. In our ex-perience, both in case of elective and emer-gency surgeries, fibrinogen administration considerably reduced the need for packed red blood cells. Among those treated in elective regimen, blood loss never exceeded 1800 mL.

and body temperature are monitored, and a pre-surgery arterial blood gas analysis is per-formed. When the anesthetic plan reaches T4-T5 dermatomal level and Hollmen scale is 3, the urinary catheterization is performed and the radiological-vascular time starts with the placement of endovascular cath-eters in the hypogastric arteries.

Time 2The caesarean section is performed, with

the patient awake, painless, and participat-ing to the birth. Subsequently, uterotonic agents are administered to trigger the uterus contraction, facilitate the possible placental stage, and further reduce blood loss.

Time 3If placenta is not delivered, the morbid

placenta adhesion is confirmed. Therefore, the obstetric team performs hysterectomy. In this phase, a mild sedation may be adminis-tered with i.v. benzodiazepine (midazolam) and, in the absence of apparent hemorrhage signs, after some minutes propofol in bo-lus may be slowly administered, so that the patient may breathe spontaneously, with Ventimask®. Subsequently, a continuous infusion of propofol may be administered. The sedation reduces tractions and adher-ences discomfort, strengthens the status of controlled hypotension, further reducing intraoperative bleeding, and facilitates shift to general anesthesia, if necessary.

Time 4In the last time of the procedure, a proper

evaluation and, eventually, management of the possible hemorrhage are performed, in accordance with the current guidelines of the Italian Ministry of Health [4]. Finally, the possible referral to ICU is considered. Oth-erwise, after suturing the abdominal belt, the sedation is suspended, with awakening of the patient in a very short time.

FundingPublishing support, journal styling services, and open access publication of this article were funded by CSL Behring, Italy. The sponsor had no role in the collection, analysis, and interpretation of data, in the writing of the report, and in the decision to submit the article for publication.Conflicts of InterestsDr. Tarantino reports non-financial support from CSL the conduct of the study; personal fees from Boehringer, outside the submitted work. Dr. Calì reports non-financial support from CSL Behring, during the conduct of the study.ORCiDFrancesco Tarantino: https://orcid.org/0000-0002-9819-5410

34 Clinical Management Issues 2021; 15(1) © 2021 The Authors. Published by SEEd srl. This is an open access article under the CC BY-NC 4.0 license (https://creativecommons.org/licenses/by-nc/4.0)

Placenta Accreta: Management Protocol and Use of Epidural Anesthesia

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