title: Continuous spinal anesthesia for Cesarean hysterectomy and massive hemorrhage in a parturient with placenta increta.
abstract: OBJECTIVE
  We present anesthetic management using a continuous spinal anesthesia (CSA) technique in a patient with placenta increta who underwent elective Cesarean hysterectomy with massive postpartum hemorrhage.
  
  
  METHODS
  A 34-yr-old parturient (G3P2) was scheduled for Cesarean delivery and possible hysterectomy at 35(+3) weeks due to suspected placenta accreta. Her body mass index was 21 kg·m(-2) and she had a reassuring airway. Inadvertent dural puncture occurred during combined spinal-epidural (CSE) placement, and a decision was made to thread the epidural catheter and utilize a CSA technique. Following delivery of a healthy infant, morbid adherence of the placenta to the myometrium was confirmed, and a supracervical hysterectomy was performed. Eight litres of blood loss occurred postpartum requiring resuscitation with crystalloid 3,800 mL, colloid 1,500 mL, red blood cells 16 units, fresh frozen plasma 16 units, platelets 4 units, and cryoprecipitate 1 unit. The patient developed pulmonary edema requiring conversion to general anesthesia. The patient's cardiovascular status was stable throughout surgery, and her lungs were mechanically ventilated for 18 hr postoperatively in the intensive care unit. The intrathecal catheter was removed 24 hr after placement. She developed no adverse neurological sequelae and reported no postdural puncture headache. The pathology report confirmed placenta increta.
  
  
  CONCLUSIONS
  A CSA technique may be a viable option in the event of inadvertent dural puncture during planned CSE or epidural placement in patients with a reassuring airway undergoing Cesarean delivery. Although a catheter-based neuraxial technique is appropriate for Cesarean hysterectomy for abnormal placentation, conversion to general anesthesia may be required in the event of massive perioperative hemorrhage and fluid resuscitation.
authors.affiliation: Department of Anaesthesia, University College London Hospital, 235 Euston Road, London, UK. p.sultan@doctors.org.uk
authors.forename: Pervez
authors.initials: P
authors.lastname: Sultan
authors.forename: Gill
authors.initials: G
authors.lastname: Hilton
authors.forename: Alexander
authors.initials: A
authors.lastname: Butwick
authors.forename: Brendan
authors.initials: B
authors.lastname: Carvalho
mesh_terms: D000328:Adult; D000768:Anesthesia, General / Q000379:methods; D000775:Anesthesia, Spinal / Q000379:methods*; D002585:Cesarean Section / Q000379:methods*; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D010921:Placenta Accreta / Q000601:surgery*; D006473:Postpartum Hemorrhage / Q000209:etiology / Q000601:surgery; D011247:Pregnancy; D011256:Pregnancy Outcome; D012121:Respiration, Artificial