Authors: Padilla, Andrew et al.
Anesthesiology October 2025 | DOI: 10.1097/ALN.0000000000005788
This multicenter retrospective cohort study examined anesthetic practices for cesarean hysterectomy in patients with placenta accreta spectrum (PAS) using data from the Multicenter Perioperative Outcomes Group (MPOG) database. Placenta accreta, increta, and percreta represent progressively invasive forms of abnormal placentation associated with massive hemorrhage and surgical morbidity, yet hospital-level data on anesthesia patterns for these complex cases have been limited.
The analysis included 1,257 PAS cases performed between 2015 and 2021 across 43 U.S. hospitals. Overall, 33.3% of patients underwent general anesthesia, 26.5% neuraxial anesthesia, and 40.3% neuraxial anesthesia with subsequent conversion to general anesthesia. Multivariable modeling identified several predictors of general anesthesia use during the hysterectomy phase of surgery: placenta percreta versus accreta (OR 2.14, 95% CI 1.33–3.44), increta versus accreta (OR 2.04, 95% CI 1.25–3.34), unscheduled surgery (OR 3.28, 95% CI 2.04–5.26), and higher ASA status—ASA 3 (OR 1.57, 95% CI 1.02–2.40) and ASA 4 (OR 2.95, 95% CI 1.51–5.74).
Neuraxial anesthesia with planned or unplanned conversion to general anesthesia was the most frequently employed approach, reflecting the need for flexibility as surgical complexity and hemodynamic instability evolve intraoperatively. The study underscores that anesthesia choice for PAS is influenced more by patient acuity and surgical urgency than by institutional preference.
The authors recommend further investigation into maternal outcomes, recovery metrics, and transfusion requirements across anesthesia modalities to better inform clinical guidelines and optimize perioperative management for PAS.
What You Should Know
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Among 1,257 PAS cesarean hysterectomies, 40% began under neuraxial anesthesia and required conversion to general anesthesia.
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Higher-grade placental invasion, unscheduled procedures, and greater ASA status were key predictors of general anesthesia use.
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Future research should correlate anesthesia modality with maternal morbidity and recovery to refine best practices for PAS management.
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