Anesthetic Management for Placenta Percreta

Preoperative Considerations

The American College of Obstetricians and Gynecologists recommends preoperative consultation with anesthesiology as part of the multidisciplinary planning team, which includes maternal-fetal medicine, gynecologic oncology, interventional radiology, and neonatology 2
Thorough evaluation of airway, hemoglobin levels, and coagulation status should be performed, with optimization of hemoglobin values through iron supplementation when indicated 3
Delivery timing should be planned for 34 0/7-35 6/7 weeks of gestation in stable patients to balance maternal hemorrhage risk with neonatal outcomes 3, 4
Notification and collaboration with the blood bank is essential given the frequent need for large-volume transfusion 3

The American College of Obstetricians and Gynecologists notes that neuraxial anesthesia (combined spinal-epidural) has benefits including maternal awareness during delivery 3

Prepare for massive transfusion protocol with a 1:1:1 to 1:2:4 ratio strategy of packed red blood cells:fresh frozen plasma:platelets 5
Cell salvage technology should be available when possible 6, 7
Consider use of tranexamic acid to reduce blood loss 6, 7

Patients with placenta percreta are at high risk for ongoing abdominopelvic bleeding and other complications 6
Monitor for complications including renal failure, liver failure, infection, unrecognized injuries, pulmonary edema, and disseminated intravascular coagulation 6
Be vigilant for Sheehan syndrome (postpartum pituitary necrosis) in cases with significant hypoperfusion 6

Delayed recognition of placenta percreta intraoperatively can lead to catastrophic hemorrhage; if suspected, the case should be temporarily paused until optimal surgical and anesthetic expertise arrives 6, 7
Transfer to a higher level of care facility should be considered if the diagnosis is made at a center without appropriate resources, assuming maternal and fetal stability 6, 7