Case scenario: perioperative management of a multigravida at 34-week gestation diagnosed with abnormal placentation.

P ERIPARTUM hemorrhage is responsible for 150,000 maternal deaths worldwide each year. Although the risk of maternal death has decreased over the preceding century, there has recently been a concerning suggestion of an increase in the overall incidence of hemorrhage. Despite multiple advances in medical and surgical care, a steady rise in hemorrhage has been noted within the developed world. Statistically significant increases in the incidence of maternal hemorrhage have been reported in retrospective studies in Canada (from 4.1% to 5.1%) and Australia (from 4.9% to 6.3%). Similarly, there was an increase in maternal deaths secondary to hemorrhage in the United Kingdom during the years 2000– 2002. This new uptick in the rate of peripartum hemorrhage has been attributed to increasing maternal age, multiple gestations, and the rise in the rate of cesarean sections. The most common cause of postpartum hemorrhage remains uterine atony. Disorders of placentation can be associated with either uterine atony or retained placenta. Importantly, in the developed world abnormal placentation is commonly diagnosed before delivery; with proper medical management and multidisciplinary planning, the associated morbidity and mortality can be minimized. During the past decade the rate of cesarean section has increased for multiple reasons, including an increase in maternal age, in vitro fertilization, multiple gestation, a decrease in vaginal breech delivery, and less frequent vaginal birth after cesarean section. A systematic review of 30 studies from 1997–2002 showed that nearly 90% of women chose to have a cesarean section after a previous cesarean section despite recent evidence for increased neonatal mortality. Repeated cesarean sections are a risk factor for abnormal placentation. Diagnosis of placenta previa is an indication of abnormal placentation. It is associated with an increased risk of postpartum hemorrhage due to inability of the lower uterine segment site of placental implantation to contract after placental delivery. In patients with placenta previa who have had previous cesarean delivery, each surgery is associated with an increased risk of placenta accreta. Placenta accreta, an abnormally deep attachment of the placenta into the endometrium and myometrium (the middle layer of the uterine wall), complicates 3% of primary, 11% of secondary, 40% of tertiary, 61% of quaternary, and 67% of higher-order cesarean sections for placenta previa. In this case scenario, a patient with suspected placenta accreta who required cesarean hysterectomy is presented. The risks and benefits of various anesthetic treatments and transfusion strategies are discussed with a multidisciplinary approach to delivery.