This document describes the anaesthetic management of a 37-year-old pregnant woman with central placenta praevia and percreta undergoing caesarean section. Preoperatively, the patient was assessed and preparations were made for potential massive bleeding including establishing IV access and blood product availability. General anaesthesia was induced and the baby delivered quickly. However, massive bleeding occurred requiring extensive resuscitation efforts and ligation of arteries to control bleeding. The patient required a hysterectomy and extensive blood transfusion but was stabilized after 4 hours of surgery. Central placenta praevia with percreta carries high risks requiring a multidisciplinary approach to optimize outcomes.

1. WELCOME

2. ANAESTHESIA FOR LUCS OF A
PATIENT WITH CENTRAL
PLACENTA PRAEVIA & PERCRETA

3. PARTICULARS OF THE PATIENT
● Name : W/O an Officer
● Age : 37 years
● Gender : Female
● Religion : Islam
● Marital Status : Married
● Hailing from : Staff Road, Dhaka Cantt.
● Date of Admission : 5th September 2016

4. CHIEF COMPLAINTS
● Pregnancy for 36+ weeks
● Lower abdominal pain for 3
days
● A known case of central
placenta praevia.

5. H/O PRESENT ILLNESS
The patient was pregnant for 36+ weeks. She
also complaints of lower abdominal pain for last
3 days which was intermittent in nature, no
radiation. She was a known case of central
placenta praevia. With these complaints, she
got admitted to this CMH in Officers’ Family
Gynae ward.

6. H/O PAST ILLNESS
● GDM since 30th week of
pregnancy
● Hypothyroidism for 2 years
● Hb-E trait
● No H/O of HTN, Bronchial
asthma

7. DRUG HISTORY
● Tab. Thyroxin and Metformin
TREATMENT HISTORY
● Iron, Vit B complex & Ca++ supplementation
● She was on regular Antenatal check-up
SOCIO-ECONOMIC HISTORY
● High middle class
FAMILY HISTORY
● Nothing contributory

8. OBSTETRIC HISTORY
● Married for : 9 years
● Para : 1 (C/S) + 1 (Abortion)
● Gravida : 3rd
● ALC : 7 years
MENSTRUAL HISTORY
● Menstrual cycle : Irregular
● EDD : 4th October 2016

9. GENERAL EXAMINATION
● Appearance : Anxious
● Built : Average
● Nutritional status : Average
● Decubitus : On choice
● Anaemia : Mild
● Pulse : 88 beats/min
● BP : 110/70 mm Hg
● Temperature : 98.4˚F

10. SYSTEMIC EXAMINATION
Respiratory system (on admission):
Inspection Palpation Percussion Auscultation
● Shape: Normal
● Chest movement:
Symmetrical on
both side
● No visible scar
mark
● No visible
engorged vein
● Respiratory rate:
16 breaths/min
● Trachea:
centrally
placed
● Apex beat:
normal
● Chest
expansibility:
Symmetrical
on both side
● Vocal fremitus:
Normal
● Percussion:
Resonant
● Cardiac
dullness:
Normal
● Vesicular
breath
sound

11. SYSTEMIC EXAMINATION
(Continued)
Cardiovascular system:
● 1st & 2nd heart sound were audible
● There was no added sound
● Nothing abnormality detected

12. LOCAL EXAMINATION
Per-abdominal examination (on admission):
Inspection Palpation Auscultation
● Globular in
shape
● Umbilicus:
Centrally
placed,
everted.
● Symphysio-fundal height:
Revealed 36 weeks of
pregnancy
● Abdominal girth: 120 cm
● Foetal movement: Present
● Fundal grip: Head felt
● Lateral grip: Back felt on right
side and the limbs on the left
side and foetal parts were
easily palpable
● Fetal heart
rate: 148
beats/min

13. SALIENT FEATURES
A 37-years-old lady reported to Gynae OPD with
pregnancy for 36+ weeks. She also complaints
of lower abdominal pain for last 3 days which
was intermittent in nature. She was diagnosed
as a case of central placenta praevia during
routine antenatal check-up. Her antenatal period
was uneventful upto 36 weeks.

14. SALIENT FEATURES (Continued)
She was admitted for elective Caesarean
section. On general examination, she was
anxious looking and mildly anaemic. Per-
abdominal examination revealed that her uterus
was corresponding to the period of gestation.
Foetal heart rate was 148 beats/min. There was
no active per vaginal bleeding .

15. PROVISIONAL DIAGNOSIS
A case of 36+ weeks
pregnancy with GDM
with hypothyroidism
with central placenta
praevia and previous
one C/S.

16. INVESTIGATIONS
● Hb conc. : 10.5 gm/dl
● Total Red Blood cells : 05 X 1012/L
● Hct : 38.10%
● Total White blood cells : 10 X 109/L
● Differential leucocyte count:
● Neutrophils - 70%
● Eosinophils - 01%
● Basophils - 00%
● Lymphocytes - 25%
● Monocytes - 04%
● Others - 00%
Complete blood count:

17. INVESTIGATIONS (CONTINUED)
● Platelets : 411.00×109/L
● ESR (Westergren) : 25 mm in 1st hour
Complete blood count:
● Prothrombin Time (PT):
● Patient : 12 seconds
● Control : 12 seconds
● INR : 1.00
● Activated Partial thromboplastin time (APTT):
● Patient : 31 seconds
● Control : 31 seconds
Coagulation profile:

18. INVESTIGATIONS (CONTINUED)
Urine routine & microscopic examination:
Physical and Chemical
examination
Microscopic Examination
Appearance:
Sp. Gravity:
Reaction:
Protein:
Glucose:
Bile salt:
Bile pigments:
Light amber
Not done
Acidic
Nil
Nil
Not done
Not done
WBCs:
RBCs:
Epithelial
cells:
Casts:
Crystals:
Others:
2-3/HPF
Nil/HPF
4-6/HPF
Nil
Nil
Nil

19. INVESTIGATIONS (CONTINUED)
● Plasma glucose (fasting) : 4.6 mmol/L
● Plasma Glucose 2 hrs after
75 mg oral glucose : 6.0 mmol/L
Blood sugar:
● O (OOO) Negative
Blood group (ABO and Rh typing):

20. INVESTIGATIONS (CONTINUED)
● Uterus was gravid containing single live foetus
with regular cardiac pulsations and normal foetal
movement
● Foetal presentation:
Breech
● Placenta: completely
covering the os.
● Gestational age:
36+ weeks
Ultrasonogram of Pregnancy profile per abdominal:

21. INVESTIGATIONS (CONTINUED)
● Serum Creatinine : 0.7 mg/dl
● LFT: Serum Bilirubin : 0.6 mg/dl
ALT : 92 IU
● Serum TSH : 1.77 µIU/dl
● ECG : Within normal limit

22. INVESTIGATIONS (CONTINUED)
● The placenta penetrated the myometrium and
also invaded the bladder.
Colour Doppler study of uterus:

23. CONFIRMATORY DIAGNOSIS
A case of 36+ weeks
pregnancy with GDM
with hypothyroidism
with central placenta
praevia with percreta
with Rh negative
mother with Hb-E trait
and previous one C/S

24. SURGICAL PLAN
ELECTIVE LOWER UTERINE
CAESAREAN SECTION

25. ANAESTHETIC MANAGEMENT

26. PREANAESTHETIC ASSESSMENT
● Pre-anaesthetic check-up was done with detail
history, proper clinical examination and
assessment of the investigation reports
● Airway Assessment : Mallampati class – II
● ASA Grading : ASA Grade- II
● Procedure was explained to the patient and her
attendants. Informed written consent was
obtained for operation and anaesthesia

27. PREANAESTHETIC ADVICES
● Fasting for 6 hours before operation
● Arrange minimum 4 units of whole blood.
● Keep ‘O’ negative blood donors stand by.
● Do not take oral hypoglycaemic agents in the
morning on the day of operation
● Continue Tab. Thyroxin

28. ANTICIPATED CHALLENGES IN
ANAESTHETIC MANAGEMENT
● Difficult intubation
● Anticipated massive blood loss & challenges
of resuscitation
● Possibility of Wide ranges of hemodynamic
instability
● Maintenance of vital organ perfusion
● Prevention of DIC

29. PREPARATION FOR ANAESTHESIA
● 4 units of whole blood were kept ready as there
was high risk of massive bleeding and blood
group was O(-ve)
● O2 inhalation @ 4 l/min
● Airway management eqpt
● Different sized ET tube
● Gum elastic bougie
● Breathing circuits
● Drugs for GA & emergency carts

30. PREPARATION FOR ANAESTHESIA
(Continued)
● Defibrillator
● Syringe pumps
● Large-bore 16 gauze I/V line
was established through left
cephalic vein
● Urinary catheterization was
done
● Paediatric team and
Urologists were present in
the OT.

31. PREPARATION FOR ANAESTHESIA
(Continued)
● A 20 cm, 7 Fr. central venous catheter was
established through the right internal jugular vein
(IJV).

32. PREPARATION FOR ANAESTHESIA
(Continued)
● An intra-arterial line was established in the right
radial artery to monitor the continuous invasive
blood pressure.

33. PREMEDICATIONS
Medications those were given to the patient on
the OT table before operation:
● Inj. Metoclopramide (10 mg)
● Inj. Ranitidine (50 mg)

34. INDUCTION & INTUBATION
● Rapid sequence Induction
was done by TPS (300 mg)
● Intubation was done
after adequate muscle
relaxation with
Suxamethonium (100 mg)

35. DELIVERY OF BABY &
RESUSCITATION
● Surgery was proceeded very quickly
● A male baby with 3 kg
body wt was delivered
per-abdominally
within 3 min of incision
● Immediate resuscitation was conducted by the
attending Paediatric Team
● The baby was shifted to NICU for further
evaluation and management

36. MAINTENANCE OF ANAESTHESIA
● Anaesthesia was maintained with 0.2%
halothane initially + 100% O2 then only100%
O2
● Analgesia was ensured with intravenous
Fentanyl (100 mcg) after the per-abdominal
delivery of the baby
● Muscle relaxation was provided with
intermittent NMBA (Inj. Vecuronium Bromide)
● The patient was on controlled ventilation

37. INTRA-OPERATIVE MONITORING
● Routine monitoring of ECG
and SpO2.
● Continuous ETCO2 was
monitored and kept below 30
mmHg .
● CVP was monitored to restore
normal volume status.
● Urine output was monitored
(850 ml in 4 hrs)

38. INTRA-OPERATIVE MONITORING
(Continued)
● Beat-to-beat IBP was monitored through arterial
line
● Per-operative ABG was done and correction was
provided according to the reports

39. MEASURES TAKEN TO COMBAT
PEROPERATIVE EVENTS
● Just after delivery of the baby
sudden massive bleeding
started from lower uterine
segment and other placental
adherent sites like bladder and
parametrium
● Then, the help of Adviser
Gynaecologist was sought
● Meanwhile, resuscitation was
started with HES, whole blood,
crystalloid solution & inotropes
to maintain BP
PLACENT
A
UTERUS

40. MEASURES TAKEN TO COMBAT
PEROPERATIVE EVENTS
(Continued)
● Urologist was also
present in OT. He also
tried to stop the
bleeding & separate
the placenta from
bladder.
● Still then profuse
bleeding was continued
and specific bleeding
source could not be
identified.

41. MEASURES TAKEN TO COMBAT
PEROPERATIVE EVENTS
(Continued)
● Then, Cardiovascular surgeon
also joined the operation to
stop the bleeding
● But, still specific sources
could not be indentified
● In that time the patient was
gradually deteriorating
● Her pulse was not palpable &
IBP was only 40/20 mmHg on
monitor which deemed
incompatible to life

42. MEASURES TAKEN TO COMBAT
PEROPERATIVE EVENTS
(Continued)
● At last, the abdominal aorta had
to be clamped for 5 min to stop
bleeding
● Before clamping Heparin 5,000
IU was given I/V
● After clamping, the BP raised to
90/55 mmHg & then the heparin
was reversed by Protamin
● Unfortunately, the ligation of
both internal iliac arteries
became life-saving and it was
done.

43. MEASURES TAKEN TO COMBAT
PEROPERATIVE EVENTS
(Continued)

44. MEASURES TAKEN TO COMBAT
PEROPERATIVE EVENTS
(Continued)
● To control further
haemorrhage Total
Abdominal Hysterectomy
with bilateral
Salpingectomy had to do
● Consultant Surg Gen also
rushed to attend this
moribund case and gave
his valuable opinions &
advices

45. MEASURES TAKEN TO COMBAT
PEROPERATIVE EVENTS
(Continued)
● Total blood loss was 5500 ml
● Eight units of whole blood was transfused during per-
operative period and 4 bags of FFP was also given
● Due to massive bleeding, the patient was in severe
hypotension for quite a long period. It was a great
challenge to minimize the effects of hypoperfusion on
brain. Therefore TPS 1 gm I/V infusion was given to
reduce the CMRO2.
● ABG assessment & correction was done accordingly

46. ISSUE OF REVERSAL
● The patient remained haemodynamically unstable for a
long period and the operation time was 4 hours
● Considering the haemodynamic status, duration of
anaesthesia and operation, the patient was not
reversed on OT table
● She was kept on elective mechanical ventilation and
was shifted to CCC
● The patient was extubated on 2nd POD

47. DISCUSSION

48. DEFINITION OF PLACENTA
PRAEVIA
When the
placenta is
implanted
partially or
completely over
the lower uterine
segment is
called placenta
praevia

49. INCIDENCE
● Frequently, low lying placenta is observed
before 20th week of pregnancy
● But, only 10% persist in later pregnancy
● The incidence of clinically significant placenta
praevia is:
4/5 per 1,000 pregnancies at term

50. HIGH RISK FACTORS
● Multiparity
● Older age pregnancies (> 35 years)
● H/O previous C/S or scar in uterus
● Abnormalities in placental size
● Multiple gestation
● Recurrent abortions & prior curettage
● Infertility treatment
● Smoking & Cocaine use

51. CLASSIFICATION
Low lying
Major part of
placenta is
attached to
upper
segment only.
Lower margin
encroaches
into lower
segment not
upto internal
os
Marginal
The placenta
reaches the
margin of
internal os but
does not
cover it
Incomplete
central
The placenta
covers the
internal os
when closed
but does not
entirely when
fully dilated
Complete
central
The placenta
completely
cover the
internal os
even when
fully dilated

52. CLASSIFICATION (Continued)
Abnormal attachment of Placenta
• Placenta is adherent to
the myometrium, passing
through the decidua
Accreta
• Placenta invades the
myometrium deeplyIncreta
• Placenta penetrates
through the myometrium to
perimetrium or even may
perforate the uterus
Percreta

53. COMPLICATIONS
● Haemorrhage
● DIC
● Transfusion reactions
● Other complications accompanying
blood transfusions (HIV and Hepatitis)
● Surgical complications
● Pulmonary embolism
● ARDS

54. CHOICE OF ANAESTHESIA
The preferred technique is GA due to:
● Anticipated massive bleeding
● Potential requirement of massive blood
transfusion
● Prolongation of the duration of operation
● Possibility of salvage removal of some essential
organs
● Predicted wide ranges of haemodynamic
instability
● Provides effective control over the airway and
ventilation

55. CONCLUSION
Central placenta praevia with percreta carries
a high mortality for mother and foetus. Prior
multidisciplinary consultation, strategy ,skill
and expert anaesthesiologist and surgeon
can provide a good outcome and a healthy
baby.