Placenta accreta spectrum with placenta previa: anaesthetic challenges in a planned caesarean hysterectomy with emergency conversion to general anaesthesia

Abstract

Placenta accreta spectrum (PAS) encompasses abnormal placental adherence and invasion (accreta, increta, percreta) and is strongly associated with placenta previa and prior uterine surgery. It remains a major cause of life-threatening obstetric haemorrhage. Antenatal diagnosis, delivery in a tertiary centre, multidisciplinary planning and meticulous anaesthetic preparation are essential for optimal outcomes. We report a 32-year-old gravida 3 para 2 abortion 1 at 35 weeks with placenta previa and antenatally confirmed PAS, scheduled for elective caesarean delivery with planned hysterectomy. Given her history of bronchial asthma, neuraxial anaesthesia was preferred, with full preparedness for immediate conversion to general anaesthesia. After establishing invasive monitoring and arranging adequate blood products, a subarachnoid block was performed using 2 mL of 0.5% hyperbaric bupivacaine with fentanyl 25 µg. Tranexamic acid 1 g IV was administered before incision. Following delivery, massive haemorrhage with haemodynamic instability occurred, necessitating urgent conversion to general anaesthesia. Induction was achieved with ketamine 2 mg/kg and atracurium, and aggressive resuscitation with vasopressors and transfusion was initiated. Haemostasis was secured by internal iliac artery ligation followed by hysterectomy. Estimated blood loss was 1.8 L; 4 units packed red blood cells and 2 units fresh frozen plasma were transfused. Postoperatively, the patient was electively ventilated in ICU suspecting airway oedema and extubated the next day. She was discharged on postoperative day 3. The neonate (3.1 kg) had Apgar scores of 8 and 10 at 1 and 5 minutes. This case underscores the need for individualised anaesthetic planning and readiness for rapid conversion in PAS.