title: Mode of anesthesia and clinical outcomes of patients undergoing Cesarean delivery for invasive placentation: a retrospective cohort study of 50 consecutive cases.
abstract: OBJECTIVE
  Invasive placentation is one of the most important causes of postpartum hemorrhage and Cesarean hysterectomies (CHyst). The optimal mode of anesthesia in the management of these patients remains uncertain. The purpose of this study was to review the impact of mode of anesthesia on maternal and neonatal outcomes in women with invasive placentation undergoing Cesarean delivery (CD).
  
  
  METHODS
  A retrospective cohort study was conducted in women with invasive placentation who delivered at our hospital during 2000-2012. Patients' charts and electronic health records were searched for relevant data, including obstetric and anesthetic procedures, blood loss, use of resuscitation fluids, and neonatal and maternal complications. Based on the initial planned mode of anesthesia (i.e., general or regional) for CD, comparisons were made between groups for maternal blood loss and transfusion, respiratory complications, and neonatal Apgar scores.
  
  
  RESULTS
  Of the 50 women with confirmed invasive placentation, 25 (50%) underwent elective CD, while the remaining 25 (50%) had unplanned CD; 36 (72%) required CHyst. Surgery for 34 (68%) patients commenced under regional anesthesia (RA), and surgery for 16 (32%) patients commenced under general anesthesia (GA). In women who received GA vs RA, there was no difference in mean (SD) blood loss [3,206 (3,777) mL vs 1,906 (1096) mL, respectively; mean difference, 1,300 mL; 95% confidence interval (CI), -739 to 3,339 mL; P = 0.20] or median [IQR] blood transfusion (4 [0-6] units vs 2 [0-4] units, respectively; median difference, 2 units; 95% CI, 0 to 4 units; P = 0.16). In neonates of women who received only RA before delivery vs those who received GA prior to delivery, significantly higher median [IQR] Apgar scores were observed at both one minute (8 [8-9] vs 3 [0-5], respectively; median difference, 5; 95% CI, 3 to 8; P < 0.001) and five minutes (9 [9-9] vs 7 [0-9], respectively; median difference, 2; 95% CI, 1 to 9; P < 0.001). Postoperative respiratory complications were more common with GA (6%) than with RA (0%) (P = 0.03).
  
  
  CONCLUSIONS
  Having safely performed two-thirds of our cases of CHyst under RA, our study suggests that RA, when compared with GA, is associated with no differences in blood loss or blood transfusion, superior neonatal outcome, and fewer respiratory complications. This suggests that RA can be considered a primary mode of anesthesia for such cases.
authors.affiliation: Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Room 19-104, Toronto, ON, M5G 1X5, Canada.
authors.forename: Nhathien
authors.initials: N
authors.lastname: Nguyen-Lu
authors.affiliation: Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Room 19-104, Toronto, ON, M5G 1X5, Canada.|Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Jose Carlos Almeida
authors.initials: JC
authors.lastname: Carvalho
authors.affiliation: Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: John
authors.initials: J
authors.lastname: Kingdom
authors.affiliation: Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Rory
authors.initials: R
authors.lastname: Windrim
authors.affiliation: Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Lisa
authors.initials: L
authors.lastname: Allen
authors.affiliation: Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Room 19-104, Toronto, ON, M5G 1X5, Canada. mrinalini.balki@uhn.ca.|Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada. mrinalini.balki@uhn.ca.
authors.forename: Mrinalini
authors.initials: M
authors.lastname: Balki
mesh_terms: D000328:Adult; D000765:Anesthesia, Conduction; D000767:Anesthesia, Epidural; D000768:Anesthesia, General; D000773:Anesthesia, Obstetrical / Q000379:methods*; D001034:Apgar Score; D002585:Cesarean Section / Q000379:methods*; D015331:Cohort Studies; D036861:Delivery, Obstetric; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D010922:Placenta Diseases / Q000601:surgery*; D011247:Pregnancy; D011256:Pregnancy Outcome; D012151:Resuscitation; D012189:Retrospective Studies