title: Anaesthesia for abnormally invasive placenta: a single-institution case series.
abstract: BACKGROUND
  Abnormally invasive placenta describes a spectrum of disorders resulting in pathological placental implantation. It is associated with the potential for severe maternal haemorrhage and poor fetal outcome. Increasing numbers of women are at risk owing to the rising incidence of uterine surgery and increasing maternal age. We report data over a five-year period describing anaesthetic management of cases of abnormally invasive placenta in a UK tertiary-referral maternity unit and assess how management has developed.
  
  
  METHODS
  Surgically confirmed cases of abnormally invasive placenta were identified from January 2011 to January 2016. Cases were identified using standard ICD-10 codes and by review of departmental records, with surgically-confirmed cases included following review of medical records.
  
  
  RESULTS
  Forty cases of abnormally invasive placenta were identified. Eighteen (40%) women had significant medical co-morbidity. All parturients were delivered by caesarean delivery. Caesarean hysterectomy occurred in 24 (60%) cases, delayed hysterectomy in two (5%) and the uterus was preserved in the remaining 14 (35%). Thirty-eight (95%) caesarean deliveries were commenced under neuraxial anaesthesia with 17 (45%) converted to general anaesthesia intraoperatively. Interventional radiology was undertaken in 23 (58%) cases. Median [range] estimated blood loss was 1700mL [500-12000mL]. Intraoperative transfusion of packed red cells occurred in 14 (35%) cases. Intraoperative cell salvage was used in 26 (65%) cases. Four (10%) women were admitted to critical care postoperatively. There were no maternal deaths.
  
  
  CONCLUSIONS
  Our data illustrate the burden on healthcare resources associated with management of abnormally invasive placenta, underlining the continued need for centralised services for treatment of these complex cases. An integrated multidisciplinary approach to case planning, case management and service provision is key to a successful outcome in these cases.
authors.affiliation: Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK. Electronic address: njtaylor@doctors.org.uk.
authors.forename: N J
authors.initials: NJ
authors.lastname: Taylor
authors.affiliation: Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
authors.forename: R
authors.initials: R
authors.lastname: Russell
mesh_terms: D000328:Adult; D000765:Anesthesia, Conduction; D000768:Anesthesia, General; D000773:Anesthesia, Obstetrical / Q000379:methods*; D016063:Blood Loss, Surgical; D001803:Blood Transfusion / Q000706:statistics & numerical data; D002585:Cesarean Section; D015897:Comorbidity; D003422:Critical Care; D005260:Female; D006801:Humans; D007044:Hysterectomy; D016343:Monitoring, Intraoperative; D010348:Patient Care Team; D010921:Placenta Accreta / Q000000981:diagnostic imaging / Q000601:surgery*; D011247:Pregnancy; D012189:Retrospective Studies; D006113:United Kingdom
keywords: Abnormally invasive placenta; Placenta accreta; Placenta increta; Placenta percreta