Mode of Anesthesia for Patients with Placenta Accreta Spectrum Undergoing Cesarean Hysterectomy

Authors: Padilla A et al.

Anesthesiology 144(3):535–545, March 2026

Summary

This retrospective cohort study used the Multicenter Perioperative Outcomes Group (MPOG) database to characterize anesthetic practice patterns for cesarean hysterectomy in patients with placenta accreta spectrum (PAS) across 43 U.S. institutions from 2015–2021.

A total of 1,257 PAS cases were analyzed. The primary outcome was anesthetic modality, categorized as:

• General anesthesia (GA)

• Neuraxial anesthesia (NA)

• Neuraxial anesthesia with conversion to general anesthesia

Distribution of anesthetic technique:

• General anesthesia alone: 33.3%

• Neuraxial anesthesia alone: 26.5%

• Neuraxial anesthesia with conversion to GA: 40.3% (most common)

Thus, although GA alone remains common, the predominant pattern nationally was neuraxial with eventual conversion to general anesthesia.

The investigators also modeled the intended anesthetic for the hysterectomy portion in suspected PAS. Factors associated with higher odds of selecting general anesthesia included:

• Placenta increta vs. accreta (OR 2.04)

• Placenta percreta vs. accreta (OR 2.14)

• Unscheduled vs. scheduled cases (OR 3.28)

• ASA Physical Status III vs. II (OR 1.57)

• ASA Physical Status IV vs. II (OR 2.95)

There was substantial inter-institutional variability in practice. Over time, neuraxial-only approaches increased in frequency, suggesting a shift in national practice patterns.

The authors conclude that while general anesthesia has traditionally been favored due to hemorrhage risk and urgency, contemporary practice reflects a hybrid model in many centers, often initiating with neuraxial anesthesia and converting as clinically required. They call for future studies evaluating maternal morbidity and recovery across anesthetic strategies.

What You Should Know

1. The hybrid approach dominates. Neuraxial with conversion to general anesthesia was the most frequent pattern (40%), reflecting a pragmatic balance between maternal awareness for delivery and readiness for massive hemorrhage.

2. Disease severity drives GA selection. Increta and percreta significantly increased the likelihood of choosing general anesthesia.

3. Urgency matters. Unscheduled cases tripled the odds of general anesthesia selection.

4. Sicker patients receive GA. Higher ASA status independently increased the likelihood of general anesthesia.

5. Practice is not uniform. Substantial variation exists across institutions, highlighting the absence of a universally accepted standard.

For anesthesia leadership models or large obstetric programs—particularly in centers managing complex PAS referrals—these data support individualized anesthetic planning driven by invasiveness, hemodynamic risk, urgency, and institutional resources rather than dogma favoring a single approach.

Key Points

• 1,257 PAS cesarean hysterectomies analyzed across 43 U.S. hospitals.

• Most common technique: neuraxial followed by conversion to general anesthesia (40.3%).

• Increta/percreta, unscheduled cases, and higher ASA status increased odds of GA.

• Significant between-hospital variability exists.

• Neuraxial-only use increased over time.

Thank you to Anesthesiology for allowing us to summarize and share this important multicenter analysis guiding anesthetic decision-making for placenta accreta spectrum.