*RINI HARTATIK/P/35 tahun 10 bulan 18 hari/11569463/23146623*

*Keluhan Utama*
Pasien mengeluh keluar darah dari jalan lahir semakin banyak
Pasien rujukan RSIA Galeri Chandra dengan keluhan keluar darah dari jalan lahir
semakin banyak, riwayat terdiagnosa dengan plasenta akreta  diberikan
IMP inj dexamethasone 24 mg

KU ; tampak sakit sedang, GCS 456 TD : 84/52 mmHg N : 100 x/menit RR :

20x/menit SpO2 : 98% on room air TB : 151 cm BB sekarang : 54 kg BB
sebelum hamil : 49 jg BMI : 21,6kg/m2 K/L : anemis -/- ikt -/- Tho: C/ S1S2
tunggal, reg (+), murmur (-) P/ ves +/+ rh -/- whz -/- Abd : TFU 25 cm, Letak
U, TBJ 1860 gr, His (+) 10.2.20”, DJJ 158-175 x/menit GE : fluxus (+) fluor (-)
Insp : v/v fluxus (+), fluor (-) Portio terbuka 1 jari, tampak jaringan plasenta
VT : tidak dilakukan

G3P1101Ab000 34-36 minggu T/H + APB dt Plasenta previa totalis + Susp.

Placenta akreta (Probability 51%) + Fluxus aktif + Fluxus berulang + Bekas
SC 2x + Usia > 35 th + Post IMP (10/05/2023)

PDx : - USG FM jam kerja PTx : - pro perawatan konservatif - pro perawatan di
R. HCU Ranu Grati - IVFD 1500cc/24 jam - Terapi Injeksi : Gentamycin
2x80mg Asam Tranexamat 3x500mg - Drip Proterin 1amp dlm RL 500cc ~
20 tpm (bila MAP > 65) - Terapi Oral : Asam Mefenamat 3x500mg Asam
Folat 1x1 tab Histolan 2x1 tab - Tokolitik kaltrofen supp II

*Pasien Pindah ICU 20/5/2023*

S : Pasien Tiba di ICU
Tampon terlepas
O : Kenceng-kenceng
O : KU : tampak sakit sedang, GCS 456
TD : 95/67 mmhG
N : 99x/menit
RR : 20x/menit
SpO2 : 100% on room air
K/L : anemis -/- ikt -/-
Tho : C/ S1S2 tunggal reg , murmur (-)
P/ ves / rh -/- ikt -/-
Abd : TFU 25 cm, TBJ 1850 gr, His ( ) 10.2.20, DJJ 160-170x/menit
A : G3P1101Ab000 gr 34-36 mg T/H
APB dt Plasenta Previa Totalis
Susp Plasenta Akreta (prob 51%)
Fluxus Aktif
Fluxus Berulang
Bekas SC 2x
Usia > 35 th
Post IMP (10/5/2023)
P : PDx :
- USG FM jam kerja
PTx :
- Perawatan ICU ~ TS Anestesi
- O2 NRBM 10 lpm
IVFD 2 line : i : IVFD RL + Proterin 30 tpm, II : IVFD HES 20 tpm lanjut NS 20
tpm ~ TS Anestesi
- pasang tampon vagina (terpasang 2 ball tampon pkl 01.00, evaluasi 12 jam pkl
13.00)
Pro perawatan konservatif
- Terapi injeksi :
Gentamycin 2x80mg
Asam Tranexamat 3x1gr
Vit K 3X1 amp
Antrain 3x1 amp
- Drip Proterin 1 amp dlm RL 500cc ~ 20 tpm (bila MAP >65)
- Terapi Oral :
Histolan 2x1 tab
- Tokolitik kaltrofen supp II
- Terapi lain ~ TS Anestesi
- Obs. Flux, DJJ, His
*21/5/2023*
S : Pasien mengeluh kenceng-kenceng berkurang, masih terpasang 2 tampon
ball
O : KU : Tampak sakit berat, GCS 456
TD : 112/82 mmHg
N : 82 x/m
RR : 20 x/m
SpO2 : 98% on NRBM 10 lpm
Prod. Urine : 100 cc/jam

K/L : an +/+, ict -/-

Tho : C/ S1S2 tunggal, m (-), g (-)
P/ ves/ves, Rh Ξ|Ξ, Wh Ξ|Ξ
Abd : TFU 25 cm, letak bujur U, TBJ 1860 gr, DJJ 160 x/m, his (+) 10.1.20"
GE : flux (+) minimal, terpasang ball tampon 2 buah sejak pukul 01.00

Laboratorium :
DL : 6,8/25.310/20/219.000
A : G3P1101Ab000 gr 34-36 minggu T/H (35W5D)
+ APB dt. Placenta previa totalis
+ Susp. Placenta akreta (probability 51%)
+ Riwayat fluksus aktif
+ Riwayat fluksus berulang
+ Riwayat hematuria
+ Bekas SC 2x
+ Usia > 35 th
+ Post IMP (10/5/2023)
+ Anemia (6,8)
P : PDx :
- USG FM jam kerja (Senin, 22 Mei 2023)
- DL post transfusi
PTx :
- Perawatan ICU lanjut ~ TS Anestesi
- Perawatan konservatif lanjut
- O2 NRBM 10 lpm
- IVFD double line :
I : IVFD RL 500 cc + Proterin 1 amp 30 tpm (jika MAP > 65)
II : MgSO4 full dose → inj. MgSO4 20% 4 gr bolus pelan lanjut drip MgSO4 40%
10 gr dalam RD5 500 cc ~ 1 gr/jam s/d 24 jam
- Terapi injeksi :
Gentamycin 2x80 mg (1x24 jam)
Kalnex 3x1 gr
Vit K 3x1 amp
Paracetamol 3x1 gr ~ TS Anestesi
- Transfusi PRC & WB s/d target Hb > 10 gr/dL ~ TS Anestesi (premedikasi :
Kaltrofen supp II)
- Kaltrofen supp II k/p his
- Evaluasi & aff 2 ball tampon/12 jam (pukul 13.00)
- Terapi lain ~ TS Anestesi
- Tranfusi WB 1 labu dan PRC 1 labu (+)
- Simpanan WB 1 labu, PRC 3 labu
- Rencana Operasi tunggu jadwal

*Pre Op 23/5/2023*
S : A : (-)
M : O2 NRBM 10 lpm
- IVFD RL 500 cc + Proterin 1 amp 20 tpm (jika MAP > 65)
- Terapi injeksi :
Kalnex 3x1 gr
Vit K 3x1 amp
Paracetamol 3x1 gr
- Terapi oral :
Histolan 2x1 tab
As folat 1x 1 tab
- Transfusi PRC ~ TS Anestesi (target Hb >8g/dl untuk persiapan operasi)
(premedikasi : Kaltrofen supp II)
- Tokolitik : Kaltrofen supp II k/p his
P : HT(-), DM (-), Asma (-), Penyakit jantung (-), riwayat operasi (+), CVA (-)
1. SC, RS dr soedono trenggalek RA SAB 2010
2. SC, RS manu husada, RA SAB 2013
L: direncanakan minimal puasa 6 jam preop
E: Pasien dengan kehamilan dan keluhan perdarahan dari jalan lahir, sejak 4 hari
yll dan kencang kencang semakin lama semakin sering. Sudah 2 hari ini
perdarahan aktif tidak didapatkan, gerak bayi masih dirasakan. Saat ini Hb
terakhir 7,9 sudah dilakukan transfusi.
O : B1. Airway paten, nafas spontan, RR 17-19 x/menit, SpO2 100% NRBM
10lpm , vesikuler+/+, wheezing -/-, Rhonki -/-
B2. AHKM (+), CRT < 2 detik, N : 98x/mnt, reguler (+), kuat angkat (+) TD
112/68mmHg S1-S2 tunggal, reguler, murmur (-)
B3. GCS 456, Pupil bulat isokor 3mm/3mm
B4. BAK (+) on DC PU 800cc/6jam kuning terang
B5. BU (+) distended abdomen (-) TFU 25 cm, letak U, TBJ 1850 gr, DJJ
158x/menit
B6. Edema (-), sianosis (-) ikterik (-)

Pemeriksaan Penunjang:
Lab 23/5/2023
SE 141/3.42/114
Alb 2.38
Ur/Cr 20.4/0.68
eGFR 113.327

Lab 22/5/2023
DL 7.90/10.47/23.50/158.000

Lab 21/5/2023
DL 7.90/14.10/23.60/182.000
20/5/2023 (19.22)
10,2/22.470/30,7/314.000

20/5/2023 (17.42)
SE 136/4.37/115
DL ; 11,9/19.180/35,6/287.000
PPT : 9,8/11/0.94
APTT 25.6/25.3
OT/PT : 20/13
Alb : 3,83
GDS : 101
Ur/Cr : 18,4/0,67
SE : 136/4,37/115
Swab antigen : negative

CXR 12/5/2023
Pneumonia
Cardiomegaly

MRI Abdomen 3/4/2023

Menyokong gambaran placenta previa type IV (complete previa) disertai placenta
inkreta
Fetus tunggal intrauterine posisi melintang

USG FM
TBJ : 1860 gr
EFW : 1637 gr
AFI : 8,03
DJJ : 170 x/m
Plasenta implantasi di anterior meluas menutupi OUI
Maturasi grade II
Bridging vein (-)
Lacuna patologis (-)
Myometrium tertipis > 0,5 cm

PAI Score
Bekas SC 2x : 3
Plasenta previa anterior : 1
Bridging vein : 0
Lacuna : 0
Myometrium tertipis : 0
--------------------------------- +
Total : 4 ~ Probability 51%
MRI Abdomen UK 24-26 minggu
- Tampak fetus intrauterine dengan posisi melintang, kepala di sisi kiri atas
- Tampak plasenta implantasi pada segmen bawah rahim sisi
anteroinferoposterior yang menutupi seluruh ostium uteri interna.
- Tampak bulging dari uterus dengan placenta menempel dan mengaburkan
miometrium sisi anterior dan inferior, dengan heterogenous placenta dan T2-
hypointense placental band (+).Tidak tampak fat antara uterus dan vesika
urinaria. Tampak placenta sebagian berbatas tegas dengan dinding vesika
urinaria.
- Ren D/S: ukuran normal, tidak tampak pelebaran sistem pelviocalyceal, tidak
tampak batu
- Kesimpulan :
Menyokong gambaran plasenta previa tipe IV (complete previa) disertai plasenta
inkreta
Fetus T/H/I posisi melintang
A : ASA 3E
Gravida G3P1101A0 gr 34-36 mgg T/H
APB dt plasenta previa totalis dengan riwayat fluksus aktif
Susp Placenta Akreta (probability 51%)
Riwayat BSC 2x
Anemia Hb 7.9 on transfusi
Hipoalbuminemia 2.38 on transfusi
P : 1. Informed consent
2. Pastikan CVC dan ABP di ICU sebelum operasi, pastikan paten dan lancar
3. IVFD RL 90cc/jam selama puasa
4. Puasa minimal 8 jam pre op makanan padat, 2 jam clear water
5. Premedikasi ranitidine 50mg + metoclotpramide 10mg IV (1 jam pre op)
6. Sedia darah 4 WB, 4 PRC, 600cc FFP, 600cc TC --> rencana bawa PRC 4
labu ke OK
8. Cek DL dan albumin post tranfusi
9. Post Op kembali ke ICU

*Post Op*
S : Post op
O : KU : tampak sakit sedang, GCS 456
TD : 126/71 mmHg
N : 63 x/m
RR : 20x/m
SpO2 : 96 % on ventilator

K/L : an -/- ikt -/-

Th : c/p dbn
Abd : soepl, luka op tertutup kassa kering, terpasang drain intraabdomen
GE : flux (-)
A : P1202Ab000 PP SCTP + TAH dg GA epidural H-0 ai APB dt Placenta previa
totalis + Placenta akreta PASD S2 diffuse + Riw. Fluxus aktif + Riw. Fluxus
berulang + Severe Oligohidramnion + IUGR + Bekas SC 2x + Usia > 35 th +
Post IMP (10/5/2023) + Anemia + Hipoalbuminemia
P : PDx: DL & Alb post op
PTx:
- Pro perawatan ICU ~ TS Anestesi
- O2, ventilator, IVFD, syringe, diet ~ TS Anestesi
- Tidak angkat kepala s/d 12 jam post op
- Puasa s/d BU (+)/ flatus
- Terapi injeksi:
Cefazoline 2x1 gr
Metoclopramide 3x10 mg
Ranitidine 2x50 mg
Ketorolac 3x30 mg
Asam tranexamat 3x1000 mg
- Bila Hb < 10 gr/dL pro transfusi PRC 2 labu/hari s/d Hb > 10 gr/dL
- Bila Alb < 2,5 gr/dL pro transfusi Alb 20% 1 flash/hari s/d Alb > 2,5 gr/dL
- Pertahankan DC urine sd H-5 post op
- Pertahankan drain sd prod drain < 50 cc/ 24 jam

S : S : flatus (+)
O : KU : Tampak sakit sedang GCS 456
TD : 114/55 mmHg
N : 86 x/m
RR : 20 x/m
SpO2 : 100% on NC 4 lpm
Prod. urine : 120 cc/jam
Prod. drain : 100 cc/24 jam, serohemoragik

K/L : an -/- ict -/-

Tho : Cor : S1-S2 tunggal, murmur (-), gallop (-)
Pulmo : ves/ves, Rh ≡/≡ Wh ≡/≡
Abd : soefl, tampak luka post op tertutup kassa kering, terpasang drain (+)
GE : flux (-)
A : P1202Ab000 PP SCTP + TAH dgn GA epidural H-2 ai APB dt Placenta previa
totalis + Placenta akreta Spectrum Disorder S2 diffuse + Riw. Fluxus aktif +
Riw. Fluxus berulang + Severe Oligohidramnion + IUGR + Bekas SC 2x +
Usia > 35 th + Post IMP (10/5/2023) + Anemia + Hipoalbuminemia
P : PDx :
PTx ;
- ACC pindah ke R. HCU Ranu Grati
Anesthesia Management in Pregnant Women with Placenta Accreta Undergoing
Cesarean Section with Transarterial Ballooning Catheter

I. INTRODUCTION
Bleeding, both before delivery (antepartum) and after delivery (postpartum),
still holds the primary position in perinatal mortality and maternal morbidity
worldwide. Antepartum bleeding is estimated to occur in 1 out of 80
pregnancies, and postpartum bleeding occurs in approximately 1%-6% of
pregnancies worldwide.1 One type of antepartum bleeding is placenta previa,
defined as the placenta's position partially or entirely within the lower
segment of the uterus.1 Although rare in normal pregnancies, about 9.3% of
mothers with placenta previa are at risk of encountering placenta accreta,
where the placenta grows too deeply into the uterine wall.

Placenta accreta is a cause of maternal morbidity and mortality, recently

becoming the most common reason for emergency postpartum hysterectomy.
The incidence of placenta accreta increased fourfold from 1994 to 2002 in
correlation with the rising rates of Cesarean sections (CS). Placenta previa and a
history of Cesarean section are crucial factors in the occurrence of placenta
accreta, with its prevalence increasing up to tenfold in the United States over the
past 50 years. This is primarily due to the rising percentage of pregnant patients
undergoing Cesarean sections and those with previous Cesarean sections.

Among patients diagnosed with abnormal placental invasion histologically, 78%

have placenta accreta, 17% have placenta increta, and 5% have placenta percreta.
Placenta accreta is a type of abnormal placentation where chorionic villi attach
directly and penetrate the myometrium. As a result, a portion of the placenta
cannot detach after delivery, leading to severe bleeding, necessitating emergency
cesarean hysterectomy.21 There are three grades of abnormal placental
attachment defined by the depth of invasion: Placenta accreta, where chorionic
villi attach to the endometrium beyond the decidua basalis; Placenta increta,
where chorionic villi invade the entire myometrium; and Placenta percreta, where
chorionic villi penetrate the myometrium to the serosa and abdominal organs.

Most cases of placenta accreta are observed as placenta previa in the third
trimester, with an incidence of 9.3% compared to normally inserted placentas.
Among women with placenta previa, the risk factors include age ≥ 35 years and a
history of previous Cesarean section (CS). The incidence is 2% in women <35
years without a history of previous CS and increases to 38% in women aged ≥ 35
years with ≥ 2 previous CS.22 Most patients with placenta accreta do not exhibit
symptoms. Symptoms associated with placenta accreta include vaginal bleeding
and cramps. Although rare, cases with acute abdominal pain and hypotension
due to hypovolemic shock from uterine rupture, secondary to placenta percreta,
can occur. Abnormal placental implantation, leading to invasive placenta
penetrating the uterine wall, can result in placental retention due to incomplete
detachment or bleeding at the placental bed.

Complications of placenta accreta include damage to local organs, postoperative

bleeding, amniotic fluid embolism, disseminated intravascular coagulation (DIC),
blood transfusions, acute respiratory distress syndrome, postoperative
thromboembolism, morbidity due to infection, multisystem organ failure, and
death. The average blood loss during delivery in women with placenta accreta is
3,000–5,000 ml. About 90% of patients with placenta accreta require blood
transfusions, and 40% may need more than 10 units of packed red blood cells
(PRC).24 Genital complications, common in the urinary tract, include cystotomy in
approximately 15% of cases and ureteral injury in around 2% of cases.

The anesthesia management of placenta accreta presents numerous challenges,

including optimizing surgical conditions, ensuring a safe delivery process,
preparing for massive bleeding and transfusions, preventing coagulopathy, and
optimizing postoperative pain control. To achieve these goals, meticulous
preparation is required, involving a comprehensive preoperative assessment of
the mother and a well-coordinated multidisciplinary approach to optimize
outcomes for both the mother and the fetus.2 This serial case report discusses
the comparative differences in anesthesia management for two patients both
diagnosed with suspected placenta accreta in the context of total placenta previa.

The use of bilateral balloon catheter occlusion in the internal iliac arteries
aims to prevent and reduce intraoperative blood loss, the need for blood
transfusions, and the requirement for ICU admission. The presence of
collateral blood vessels in the gravid uterus may explain some failures of
balloon occlusion, and overall blood loss may be attributed to collateral
circulation from the cervical, ovarian, rectal, femoral, lumbar, and sacral
arteries.

There is an opinion that occluding the common iliac vessels might be a

better option to decrease the amount of blood loss by adding the
blockade of supply from the external iliac vessels.

Discussion
A 35-year-old woman with a weight of 55 kg, height of 151 cm, G3P1101Ab000 at
a gestational age of 34-36 weeks. She reported vaginal bleeding four days before
admission and experienced contractions at home. The patient had a history of
surgeries in 2010 and 2013 with regional anesthesia – spinal block (RA-SAB).
There were no other significant medical history or comorbidities. The patient was
referred for follow-up to the RSSA clinic due to suspicion of placenta accreta with
a diagnosis of total placenta previa from the ultrasound. At the clinic, there were
no contractions or bleeding. The patient was admitted for observation of
bleeding, and a planned termination of pregnancy via cesarean section (C-
section) was scheduled.
In the case of this patient, the decision was made to use general anesthesia due
to a history of bleeding in the third trimester and a high probability index score of
51% for accreta. Before the surgery, a transarterial ballooning catheter was placed
in the interventional radiology suite. The balloon was inserted to occlude the left
common iliac artery, right internal iliac artery, and left internal iliac artery. The
patient experienced massive bleeding, amounting to 10,000 cc. For postoperative
management, the patient has the potential to be admitted to the Intensive Care
Unit (ICU).

Conclusion
To obtain a more comprehensive comparison and understanding of estimated
blood loss, comparing with other cases involving balloon catheter procedures
before or after surgery can provide better insights. Evaluating outcomes from
similar cases can assist in detailing the effectiveness of this method in reducing
bleeding and its impact on postoperative management.