Blood saving possibilities in delivering patients with placenta increta

According to the results of systematic reviews of WHO, maternal mortality associated with massive bleeding almost reached 30% and has no tendency to decrease. Among the causes of massive obstetric hemorrhage, the most challenging ones are uterine hypotension and morbidity adherence placenta. Most severe complication for placentation is placenta increta in the uterine wall. Over the past 50 years, the number of cases with morbidity adherence placenta has increased tenfold. By all indications, this pathology has taken on the character of an epidemic and is one of the main causes for massive blood loss and blood transfusion, as well as peripartum hysterectomy. For surgical hemostasis in this pathology we apply X-ray vascular methods (temporary balloon occlusion of large vessels, vascular embolization), ligation of the iliac, uterine, ovarian arteries, various versions of distal hemostasis, including the use of uterine turnstiles, intrauterine and vaginal cylinders, compression sutures. However, data confirming the advantage of any specified methods are not enough. The risk of massive bleeding is high while using any of these methods. The article analyzes the blood saving methods existing at the present stage and possibility of these methods usage in obstetrics. Besides, we describe efficacy and safety of their use in massive blood loss, including the surgical treatment of morbidity adherence placenta

Выбор анестезиологического пособия при органосохраняющих операциях по поводу врастания плаценты

Abstract Placenta accreta (PAS-disorders) is one of the most serious complications of pregnancy, associated with the risk of massive uterine bleeding, massive hemotransfusion and maternal mortality. Peripartum hysterectomy is a common treatment strategy for patients with placenta accreta. Currently, there is a clear trend of changing surgical tactics in favor of organ-saving operations, but there are no studies devoted to anesthesiological support of such operations.The aim of the study is to substantiate an effective and safe method of anaesthesia in organ-saving operations for placenta accreta spectrum disorders.Materia l and methods The study involved 80 patients with a diagnosis of placenta accreta spectrum disorders, confirmed intraoperatively, who underwent organ-saving operations. The patients were randomized depending on the method of anesthesia into 3 groups: general anesthesia, spinal anesthesia with planned conversion to general after fetal extraction and epidural anesthesia with planned conversion to general also after fetal extraction. The comparison of intraoperative hemodynamics, efficiency of tissue perfusion, efficiency of antinociceptive protection at the stages of surgery was performed. A comparative analysis of the volume of blood loss and blood transfusion, time of patients activation in the postoperative period, severity of pain on the first day after surgery, duration of hospital stay before discharge and comparison of the assessment of the newborn according to Apgar score at first and fifth minute after extraction.Conclusion The study shows that the optimal method of anesthesia in organ-saving operations for placenta accreta spectrum disorders is epidural anesthesia with its planned conversion to general anesthesia with an artificial lung ventilation after fetal extraction. Such an approach to anesthesia allows to maintain stable hemodynamic profile with minimal vasopressor support, sufficient heart performance, providing effective tissue perfusion and a high level of antinociceptive protection at the intraoperative stage and reduce the volume of intraoperative blood loss and hemotransfusion. In the current study there were no differences in neonatal outcomes and duration of hospitalization depending on the method of anesthesia. The advantage of epidural anesthesia with its conversion to general anesthesia was earlier activation after surgery and lower intensity of postoperative pain syndrome.Резюме Врастание плаценты (placenta accreta, PAS-disorders) - одно из наиболее серьезных осложнений беременности, сопряженное с риском массивного маточного кровотечения, массивной гемотрансфузии и материнской смертности. Общепринятой стратегией лечения пациенток с врастанием плаценты является перипартальная гистерэктомия. В настоящее время отмечается отчетливая тенденция изменения хирургической тактики в пользу органосохраняющих операций, но исследований, посвященных анестезиологическому обеспечению таких операций, нет.Цель исследования Обоснование эффективного и безопасного способа анестезиологического пособия при органосохраняющих операциях по поводу врастания плаценты.Материал и методы В исследовании приняли участие 80 пациенток с диагнозом врастания плаценты, который был подтвержден интраоперационно. Всем пациенткам выполнены органосохраняющие операции. В зависимости от способа анестезиологического пособия были сформированы три группы: общей анестезии, субарахноидальной анестезии с плановой конверсией в общую после извлечения плода и эпидуральной анестезии с плановым переходом в общую также после извлечения плода. Выполнено сравнение интраоперационной гемодинамики, показателей эффективности тканевой перфузии, эффективности антиноцицептивной защиты на этапах операции. Проведен сравнительный анализ объемов кровопотери и гемотрансфузии, времени активизации пациенток в послеоперационном периоде, оценки выраженности болевого синдрома в 1-е сутки после операции, длительности пребывания в стационаре до выписки и сравнение оценки новорожденных по шкале Апгар на 1-й и 5-й минутах после извлечения.Зак лючение В исследовании показано, что оптимальным способом анестезиологического пособия при органосохраняющих операциях по поводу врастания плаценты является эпидуральная анестезия с ее плановой конверсией в общую анестезию с искусственной вентиляцией легких после извлечения плода. Подобный подход к анестезии позволяет поддерживать стабильность гемодинамического профиля и минимизировать вазопрессорную поддержку, сохранить достаточную производительность сердца и перфузию тканей. Антиноцицептивный эффект сочетания эпидуральной и общей анестезии был выше как на интраоперационном этапе, так и в послеоперационном периоде. Преимуществом эпидуральной анестезии с ее переходом в общую явилось снижение объемов интраоперационной кровопотери и гемотрансфузии. В проведенном исследовании не выявлено различий в неонатальных исходах и сроках госпитализации в стационаре в зависимости от способа анестезиологического пособия

The Choice of Anesthesia During Organ-Saving Operations Concerning Patients With Placenta Accreta Spectrum Disorders

Abstract Placenta accreta (PAS-disorders) is one of the most serious complications of pregnancy, associated with the risk of massive uterine bleeding, massive hemotransfusion and maternal mortality. Peripartum hysterectomy is a common treatment strategy for patients with placenta accreta. Currently, there is a clear trend of changing surgical tactics in favor of organ-saving operations, but there are no studies devoted to anesthesiological support of such operations.The aim of the study is to substantiate an effective and safe method of anaesthesia in organ-saving operations for placenta accreta spectrum disorders.Materia l and methods The study involved 80 patients with a diagnosis of placenta accreta spectrum disorders, confirmed intraoperatively, who underwent organ-saving operations. The patients were randomized depending on the method of anesthesia into 3 groups: general anesthesia, spinal anesthesia with planned conversion to general after fetal extraction and epidural anesthesia with planned conversion to general also after fetal extraction. The comparison of intraoperative hemodynamics, efficiency of tissue perfusion, efficiency of antinociceptive protection at the stages of surgery was performed. A comparative analysis of the volume of blood loss and blood transfusion, time of patients activation in the postoperative period, severity of pain on the first day after surgery, duration of hospital stay before discharge and comparison of the assessment of the newborn according to Apgar score at first and fifth minute after extraction.Conclusion The study shows that the optimal method of anesthesia in organ-saving operations for placenta accreta spectrum disorders is epidural anesthesia with its planned conversion to general anesthesia with an artificial lung ventilation after fetal extraction. Such an approach to anesthesia allows to maintain stable hemodynamic profile with minimal vasopressor support, sufficient heart performance, providing effective tissue perfusion and a high level of antinociceptive protection at the intraoperative stage and reduce the volume of intraoperative blood loss and hemotransfusion. In the current study there were no differences in neonatal outcomes and duration of hospitalization depending on the method of anesthesia. The advantage of epidural anesthesia with its conversion to general anesthesia was earlier activation after surgery and lower intensity of postoperative pain syndrome