Anesthesia
The choice of anesthesia technique for cesarean delivery where there is a suspected PAS disorder with high risk of significant hemorrhage must be made by the attending anesthesia team. This decision between general and neuraxial/regional anesthesia can be aided through active consultation with the wider MDT.
There are several factors to consider that can influence this decision (Box 1). Historically, most patients with PAS disorders were managed conservatively with general anesthesia, as described in a retrospective study of 26 maternity hospitals in Israel.37 Recently, greater experience has permitted more frequent use of epidural with or without spinal. When managed appropriately and in an elective situation, most patients can tolerate both prolonged and extensive surgery with significant associated blood loss using these techniques.38-40
Box 1. Factors to consider in selection of anesthesia for placenta accreta spectrum (PAS) disorders.
Criteria for consideration
Patient preference
Body habitus (body mass index, potentially difficult patient airway)
American Society of Anesthesiologists Score
Available resources
Anesthetist experience
Regional anesthesia effectiveness
State of emergency
Hemodynamic stability
Ability to manage patient in hypovolemic shock
Ability to perform a rapid emergent tracheal intubation
Patient co‐morbidities
Potential complications
Secondary benefits, i.e. patient‐controlled epidural anesthesia for postoperative pain management with midline laparotomy