Experience of managing abnormally invasive placenta over an eight-year period in a UK centre

ABSTRACT

Introduction: Abnormally invasive placenta (AIP) has a significant risk of mortality and morbidity. International recommendations support management in specialist centres [1]. North Bristol Trust (NBT) is a large obstetric unit providing regional management since 2014 this service evaluation shows changing management over an eight year period, in line with local experience and published recommendations. Methods: Retrospective database analysis (with local audit approval) of AIP cases at NBT 2014–2021 were performed. Antenatal and perioperative management was reviewed via electronic patient records. Results: Sixty-one patients presented with AIP. Mean maternal age was 35.2 years and mean gestation at delivery was 34 + 2 weeks. Average paritywas 2.5 (range 0–7). No maternal deathswere recorded. Sixty women were identified pre-operatively and one unexpected intraoperatively. Postoperatively 60 cases were managed on our level- 2 obstetric critical care unit, one required level-3 critical care. Anaesthetic technique has evolved including general anaesthetic (GA) plus low-dose spinal 36%;GA alone 36%;combined spinalepidural (CSE) 23%;CSE converted to GA 3%;epidurals 1.5%;and spinals 1.5%. Forty-five cases (72%) delivered via elective CS and 28% required urgent CS. Invasive arterial blood pressure monitoring was used in 84%. The hysterectomy rate was 67% (59% elective vs 100% urgent cases). Of 16 cases in the hybrid theatre, only four internal iliac artery balloons (IAB) were inflated (25%), for a mean of 62 min. One complication occurred, a femoral artery thrombus requiring embolectomy at the end of case. Mean estimated blood loss for all cases was 3.5 L (range 0.5–14 L). No statistical differencewas noted in blood loss with or without IAB (3.6 vs 3.1 L), nor planned vs urgent surgery. Intraoperative cell salvagewas used 97%;mean volume of cell salvaged blood (CSB) reinfused was 0.7 L (range 0–3.3 L). Packed red blood cells were transfused in 44%, fresh frozen plasma in 34%, platelets in 18%, and cryoprecipitate in 44%. ROTEM was utilised in 56% of cases and TXA given in 82%. Discussion: IAB have not been used in AIP management for 2 years in our institution. This does not appear to affect blood loss, transfusion rate, or requirement for critical care. Our GA rate has remained high compared to other centres [2], due to hybrid theatre ergonomics and Covid-19 PPE requirements. Use of autologous blood transfusion via cell salvage with rapid processing is central to our care.