Evaluation of
Complications And Anesthesia Practice In Cases
With Cesarean Section For Placenta Previa
......................................................................................................................................................................
Sedat Hakimoglu
(1)
Murat Karcioglu (2)
Kasim Tuzcu (3)
Isil Davarci (4)
Ayse Guler (5)
Atilla Karateke (6)
Ali Sari (7)
Selim Turhanoglu (8)
(1) M.D; Assistant Professor, Department of Anesthesiology
and Reanimation, Mustafa Kemal University Faculty
of Medicine (MKUFM), Hatay, Turkey
(2) M.D; Assistant Professor, Department of Anesthesiology
and Reanimation, MKUFM, Hatay, Turkey
(3) M.D; Assistant Professor, Department of Anesthesiology
and Reanimation, MKUFM, Hatay, Turkey
(4) M.D; Assistant Professor, Department of Anesthesiology
and Reanimation, MKUFM, Hatay, Turkey
(5) M.D; Assistant Professor, Department of Obstetrics
and Gynecology, MKUFM, Hatay, Turkey
(6) M.D; Resident Doctor, Department of Obstetrics
and Gynecology, MKUFM, Hatay, Turkey
(7) M.D; Resident Doctor, Department of Anesthesiology
and Reanimation, MKUFM, Hatay, Turkey
(8) M.D; Professor, Department of Anesthesiology
and Reanimation, MKUFM, Hatay, Turkey
Correspondence:
Sedat Hakimoglu M.D.
Department of Anesthesiology and Reanimation
Mustafa Kemal University Faculty of Medicine,
Antakya, Hatay/Turkey
GSM: +90 505 8610750
Phone: +90 326 2291000
Fax: +90 0 326 24556544
Email: sedathakimoglu@hotmail.com
ABSTRACT
Background: It is reported that preterm
births related to placenta previa increase
perinatal mortality.
Material and Methods: This retrospective
study evaluated operation records for cesarean
sections performed at Mustafa Kemal University
between January 2009 and December 2012 for
which a diagnosis of placenta previa was
made.
Results: We evaluated 67 cases (Table
1). Nineteen cases (28.4%) were urgent and
48 cases (71.6%) were elective. Although
no differences existed according to mean
age of gravida and number of previous cesarean
section operations, significant differences
were found between the urgent and elective
cases with respect to many other characteristics,
including preoperative and postoperative
hemoglobin values, operation periods, number
of cases requiring hysterectomy, hypogastric
artery ligation, number of patients requiring
blood transfusion, and number of patients
requiring postoperative intensive care.
Conclusion: To decrease maternal
and fetal morbidity and mortality, performing
preoperative preparations carefully, choosing
the right anesthesia method, effectively
evaluating blood loss, and optimizing communication
between anesthesiologist, obstetrician,
and blood bank workers are necessary to
manage cesarean section in pregnant women
with placenta previa. Cesarean sections
that are urgent, related to previa, and
in cases where parity is equal to or greater
than 2 can result in the need for hysterectomy.
These conditions increase operation periods,
blood transfusion needs, and risk of admission
to an intensive care unit. Necessary preparations
must be performed preoperatively.
Key words: Cesarean section, placenta
previa, anesthesia
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Placenta previa is defined as
the placenta covering the internal cervical opening
partially or completely; it is the settlement
of placenta within the uterus. When the placenta
covers all of the internal part of the uterus,
it is called total; partial coverage is called
partial placenta previa, and settling closely
is termed marginal placenta previa(1). Bleeding
caused by obstetric procedures in general is one
of the most important causes of maternal mortality
and morbidity (2, 3). Insufficient or untimely
preoperative preparations can lead to more bleeding
and probable and common intravenous coagulation
defections.
Placenta previa is associated with an increase
in preterm birth and perinatal mortality and morbidity
(4). Cases with the anomaly of placental settling
have high rates of coagulation, intensive care
unit admission, and mortality and morbidity. For
these reasons, anesthesiologists and obstetricians
should know how to manage peripartum bleeding
based on the anomaly of placental settlement.
The aim of this study was to retrospectively evaluate
results with the use of anesthesia in placenta
previa during cesarean section.
After obtaining the approval
from the Local Human Ethics Committee, obstetric
and gynecologic operation and anesthesia records
in pregnant women who received a diagnosis of
placenta previa and underwent cesarean section
operation between January 2009-2012 were evaluated
retrospectively. Cases in which bleeding and coagulation
disorders manifested were excluded from the study.
The following information was recorded for every
patient: age; whether an urgent or elective operation
was performed, anesthesia methods (general or
regional), gravida, parity, number of abortions,
previous cesarean section numbers, newborn 1-minute
and 5-minute Apgar scores, duration of operations;
hemoglobin values of preoperative and postoperative
and hysterectomy, hypogastric artery ligation,
history of bladder repairing, and number of existing
to postoperative intensive care and blood transfusion
needs were recorded.
Events were classified according to whether an
operation was urgent (Group U) or elective (Group
E), and also according to whether the woman was
going to have 2 or more (parity > 2;
Group P > 2) or less than 2 (parity<2;
Group P<2) parity numbers. Events in group
U and group E were compared with respect to preoperative
and postoperative hemoglobin values, operation
periods, number of intraoperative complications
(hysterectomy, hypogastric artery ligation, bladder
reparation) numbers; number of patients taken
to postoperative intensive care; and number of
patients receiving intraoperative blood transfusions.
Some parameters were compared for Group P >
2 and Group P<2. Statistical analysis was performed
with the SPSS (SPSS for Windows, release 13.0)
statistical package and data are presented as
means and standard deviations. Comparison of intraoperative
and postoperative complications between groups
was made with Chi-square and Fisher's Exact tests;
data obtained from measurement was evaluated by
Mann-Whitney U tests. Results were evaluated with
a reliability interval of 95%, and the significance
level is P<0.05.
A total of 67 cases were examined.
Average age of subjects at the time of the cesarean
sections was 31 (5).
The operations lasted for between 45 minutes and
180 minutes; average period was 89.6 (40.2) minutes.
General anesthesia was used in 60 (89.6%) of cases;
in the other 7 cases (10.4%) regional anesthesia
was used. Prior cesarean sections ranged from
0-3 and the average was 1.3 (0.8) (Table 1).
Table 1: The demographic data of the patients
with anesthetic and operative management
Fifty-eight (86.6%) of the sixty seven cases involved
in the study were in women who had at least one
previous cesarean section. With respect to hysterectomy,
none of the 9 women with no cesarean section had
undergone the procedure; 2 (6.9%) of patients
with one cesarean underwent hysterectomy; and
4 patients (66.7% of the total) with 3 cesarean
sections in their medical history had undergone
hysterectomy. When the cases are classified as
Group U and Group E, 19 (28.4%) of procedures
were urgent, and 48 (71.6%) were elective. No
difference existed between these two groups according
to age, gravida, and number of previous cesarean
sections. Preoperative (10.2 [1.2] and 11.0 [1.1];
P=0.33) and postoperative (9.3 [0.9] and 9.9 [1];
P=0.027) hemoglobin values, duration of operations
(107.5 [39.4] and 82.5 [38.7]; P=0.015); number
of hysterectomies (8 [42.1%] and 8 [16.7%]; P=0.028)
were found to be significantly different between
those undergoing elective or urgent surgery. Some
other points of comparison between group U and
group E, respectively, for which very significant
differences were found include hypogastric artery
ligation (14 [73.7%] and 16 [33.3%]; P<0.01);
number of patients requiring blood product transfusion
(15 [78.9%] and 16 [33.3%]; P<0.01); and number
of patients exiting to the intensive care unit
(5 [26.3%] and 2 [4.2%]; P<0.01) (Table 2)
(Graph 2).
Table 2: Comparison of groups for according
to operations. Group U; Urgent, Group E; Elective.
*p<0.05,**p<0.01
Figure 1: The percentage of blood transfusion
according to the state for operations *P?0.01,
Group U; Urgent, Group E; Elective
Figure 2: The percentage of hysterectomy with
the number of previous cesarean
The cases were grouped according to the number
of parity, if parity number was 2 (GroupP >
2) case numbers were (43.3%) 29, and if parity
number was <2 (GroupP<2), that was (56.7%)
38. No differences existed between groups according
to age, preoperative and postoperative hemoglobin
values, or number of bladder repairs. For the
patients who were exited to postoperative intensive
care (7 [18.4%] and 0 [0%]; P= 0.015), significantly
different operation periods were found (107.3
[41.4%] and 66.4 [23.8%]; P<0.01) incidence
of hypogastric artery ligation (23 [60.5%] and
7 [24.1%]; P<0.013] incidence of hysterectomy
(14 [36.8%] and 2 [6.9%]; P<0.013) and number
of patients needing blood product transfusions
(25 [65.8%] and 6 [20.7%]; P<0.01) were also
significantly different (Table 3).
Table 3: Comparison of groups according to
the number of parity .Group P > 2; Parity
> 2, Group P<2; Parity <2. *p<0.05,**p<0.01
A diagnosis of abnormal placentation
can cause life-threatening consequences and affects
obstetric surgery and anesthesia methods (5).
In cesarean operations with placenta previa, complications
can include more bleeding, disseminated intravascular
coagulation, sepsis, reoperation, hysterectomy,
bladder and ureter injuries depending on the placental
settlement place. Furthermore, placenta previa
cases have high rates of admission to intensive
care(6). This complication can affect surgical
procedures as well, including the time it takes
to perform surgery and intraoperative liquid management
(blood transfusion is also common). Insufficient
preparation can cause an increase in perioperative
mortality and morbidity risk.
The evaluation of patients before the operation
in terms of clinical and laboratory data has great
importance for planning anesthesia methods. Urgency
of surgery and patient preference guide choice
of anesthesia method(7).
Placenta previa is seen in approximately 0.5%
of the general population; its incidence is higher
in women who have undergone multiple cesarean
sections, who smoke, or who have a uterine scar.
Other factors include high maternal age, multiparity,
previous abortions, drug utilization, pathologic
presentation, uterine anomalies, and preterm activities
(8, 9). A study by Milosevic et al reported frequently
the recurrent cesarean numbers that caused risk
factors for placenta previa. In our study, while
there was no cesarean history in 13.4% of cases,
cesareans were done in 86.6% at least (10). In
the study by Zaki and colleagues in 23,070 births,
it was shown that pregnant women with placenta
previa have a higher risk rate for postpartum
bleeding and intraoperative blood product use
(11). Placental settlement anomalies can be seen
with bladder invasion and so cause for a radical
operation for the patient. So the operation period
can prolong and increase the need for blood products
during surgery (12, 13). Although intravenous
oxytocin is administered after birth to women
with placenta previa, placenta implantation place
cannot be contracted adequately and so there is
a direct correlation between placenta previa and
blood transfusion as a result (14).
In cesarean section operations in patients diagnosed
by placenta settlement anomaly, it is important
to have an adequate blood supply and cardiovascular
support protocols in place, as placenta previa
is an important reason for obstetric bleeding
(1,6,15). Gaundan A et al have reported that in
13.71% of urgent cesarean sections and 5.06% of
elective cases that is included (15). In our study,
46.3% of all study cases needed blood tranfusion,
and the difference was significantly different
between urgent or elective cesarean section cases
with placenta previa taken to the operating room.
While blood products were needed in 78.9% urgent
caesarean section cases, they were given in 33.3%
of cases with elective caesarean section operations.
The placental settlement anomaly is one of the
most common causes for peripartum hysterectomy
(16). Complication rates are higher in urgent
cesarean sections than in instances where it is
an elective surgery (17). In our study, patients
undergoing elective cesarean received from previa
according to the emergency cesarean hysterectomy,
hypogastric artery ligation, bladder repairing,
and removal rates of postoperative intensive care
unit was different. Having recurring cesarean
section operations also contributed to complications
because it made placenta previa more likely and
also caused uterine scars (18). Patients with
complete placenta previa or placenta accreta who
have cesarean section operations in their history
have a high risk of postpartum bleeding, transfusion,
obstetric hysterectomy, and perinatal morbidity
(19). In cesarean sections executed because of
placenta previa, the risk of hysterectomy is approximately
4 times higher. In one study, it was asserted
that for one cesarean section the risk was 0.65%,
ascending to 1.5% with 2 cesarean sections, 2.2%
with 3, and more than 10% with 4 cesarean sections
(20). In this study, while one of the women with
placenta previa and no cesarean history had to
undergo hysterectomy, 6.9% of cases of placenta
previa that had one caesarean section underwent
hysterectomy; this percentage increased greatly
to 43.5% with two cesarean sections and 66.7%
with 3 cesarean sections. Overall, hysterectomy
was performed in 27.6% of women who had cesarean
section before. On the other hand, hysterectomy
was performed in none of the women who had not
undergone caesarean section before. Although the
difference was insignificant, it is thought to
be due to the limited number of our study cases.
Furthermore, high parity and existing placenta
previa also combine to increase the risk of hysterectomy
(21-23).
Of our 67 cases of placenta previa in this study,
38 (56.7%) had parity of 2 or more. A significant
difference existed with parity < 2 versus
>2 in terms of the incidence of hysterectomy,
hypogastric artery ligation, operation period,
blood product transfusion, and rate of existing
postoperative intensive care.
General and regional anesthesia had no difference
in intraoperative effects for these patients (6).
We also found no difference between general and
regional anesthesia in caesarean sections. Type
of anesthesia also had no significant impact in
many of the other parameters studies (hysterectomy,
blood product transfusion, hypogastric artery
ligation, and bladder reparation).
As a conclusion, decreasing maternal and fetal
mortality and morbidity with cesarean sections
performed due to placenta previa requires careful
preoperative preparations, the right anesthesia
method, effective evaluation of blood loss, and
strong communication between the anesthesiologist,
obstetrician, and blood bank workers. Cesarean
sections that are related to previa urgent in
cases where parity is equal to or greater than
two can result in hysterectomy. These conditions
increase operation periods, blood transfusion
needs, and risk of intensive care admission; necessary
preparation should therefore be performed preoperatively.
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