Managing Placenta Accreta and Massive Hemorrhage: A Case Report on Anesthetic and Surgical Interventions.

Obstetric haemorrhage is a leading cause of maternal morbidity and mortality and is a common reason for intensive care unit (ICU) admission in the postpartum. Primary postpartum obstetric haemorrhage is associated with four main causes: tone, thrombin, trauma, and tissue. Regarding the last one, placenta accreta is an abnormal invasion of the placenta into the myometrium. Early diagnosis of placenta accreta allows for better perioperative management; however, it is sometimes only identified during caesarean delivery when the placenta cannot be removed. We report a case of a 37-year-old woman with a history of caesarean section due to placenta previa, who was admitted at 36 weeks and 1 day for an urgent caesarean section (c-section) due to cord presentation. A subarachnoid block (SAB) was used for anaesthesia. It was chosen over general anaesthesia because it allows the patient to experience the birth of her children, enhances pain control, and avoids complications associated with general anaesthesia. Besides our centre has expertise in neuraxial anaesthesia. During the procedure, placental accretism and massive haemorrhage occurred, and a life-saving abdominal hysterectomy was needed. The patient experienced hypotension, partially responsive to volume replacement and vasopressors, leading to norepinephrine infusion and conversion to general anaesthesia. The surgery lasted 2.5 hours with a blood loss of 3500 ml. The patient was extubated without complications and transferred to the post anaesthesia care unit (PACU). Risk factors for placenta accreta spectrum (PAS) include previous surgery and placenta previa with a prior c-section. Antenatal diagnosis is crucial, and women with risk factors should undergo imaging at experienced centres. Delivery centres must have protocols for unexpected PAS and major obstetric haemorrhage. Both general and neuraxial anaesthesia can be suitable for managing PAS, and caesarean hysterectomy is often required to control haemorrhage. Postoperatively, adequate monitoring and care is essential. PAS management should involve excellent communication between a multidisciplinary team in specialised centres.