J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

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Case Report

Volume 17, Number 1, January 2026, pages 21-27

Anesthetic and Transfusion Management in Placenta Accreta Spectrum: Lessons From a Resource-Limited Setting and Mini-Review

Figure 2. Doppler ultrasound examination showing placental tissue invading the myometrium and extending to the serosa. Increased vascular flow was demonstrated on color Doppler ultrasound (arrow).

**Table 1.** Complications Associated With PAS
Category	Complications
DIC: disseminated intravascular coagulation; DVT: deep venous thrombosis; ICU: intensive care unit; NICU: neonatal intensive care unit; PAS: placenta accreta spectrum; PE: pulmonary embolism.
Hemorrhagic	Massive obstetric hemorrhage; transfusion requirement; DIC; hypovolemic shock
Surgical	Urologic injury (bladder, ureter); gastrointestinal injury; vascular injury; nerve injury
Postoperative	Infection (wound, pelvic abscess, sepsis); venous thromboembolism (DVT/PE); wound dehiscence
Reproductive/long-term	Loss of fertility (hysterectomy); intra-abdominal adhesions; chronic pelvic pain
Maternal outcome	Increased morbidity: prolonged ICU stay; increased mortality risk
Neonatal outcome	Preterm birth; low birth weight; NICU admission; neonatal mortality

Table 1. Complications Associated With PAS

Category

Complications

DIC: disseminated intravascular coagulation; DVT: deep venous thrombosis; ICU: intensive care unit; NICU: neonatal intensive care unit; PAS: placenta accreta spectrum; PE: pulmonary embolism.

Hemorrhagic

Massive obstetric hemorrhage; transfusion requirement; DIC; hypovolemic shock

Surgical

Urologic injury (bladder, ureter); gastrointestinal injury; vascular injury; nerve injury

Postoperative

Infection (wound, pelvic abscess, sepsis); venous thromboembolism (DVT/PE); wound dehiscence

Reproductive/long-term

Loss of fertility (hysterectomy); intra-abdominal adhesions; chronic pelvic pain

Maternal outcome

Increased morbidity: prolonged ICU stay; increased mortality risk

Neonatal outcome

Preterm birth; low birth weight; NICU admission; neonatal mortality

**Table 2.** Anesthetic Management of Massive Bleeding [21-28]
Step	Intervention	Description
GA: general anesthesia; ICU: intensive care unit; IV: intravenous; RBC: red blood cell; FFP: fresh frozen plasma.
1	Monitoring and access	Establish large-bore IV access (two lines), arterial line, and central venous access if needed. Continuous hemodynamic and urine output monitoring.
2	Airway and oxygenation	Early airway control with intubation if patient unstable or anticipated rapid deterioration. Provide 100% oxygen.
3	Volume resuscitation	Start with balanced crystalloids, transition quickly to blood products. Apply massive transfusion protocol (1:1:1 ratio of RBC/FFP/platelets).
4	Hemostatic agents	Administer tranexamic acid early (within 3 h), consider fibrinogen concentrate or cryoprecipitate if hypofibrinogenemia present.
5	Anesthetic technique	GA in unstable patients; regional may be used in selected stable cases (but be prepared to convert to GA).
6	Adjunctive measures	Maintain normothermia, correct acidosis, optimize calcium levels during transfusion, permissive hypotension
7	Team communication	Close coordination with obstetricians, blood bank, and ICU team. Activate massive transfusion protocol early.
8	Postoperative care	Transfer to ICU for ongoing resuscitation, monitoring, and correction of coagulopathy.

Table 2. Anesthetic Management of Massive Bleeding [21-28]

Step

Intervention

Description

GA: general anesthesia; ICU: intensive care unit; IV: intravenous; RBC: red blood cell; FFP: fresh frozen plasma.

Monitoring and access

Establish large-bore IV access (two lines), arterial line, and central venous access if needed. Continuous hemodynamic and urine output monitoring.

Airway and oxygenation

Early airway control with intubation if patient unstable or anticipated rapid deterioration. Provide 100% oxygen.

Volume resuscitation

Start with balanced crystalloids, transition quickly to blood products. Apply massive transfusion protocol (1:1:1 ratio of RBC/FFP/platelets).

Hemostatic agents

Administer tranexamic acid early (within 3 h), consider fibrinogen concentrate or cryoprecipitate if hypofibrinogenemia present.

Anesthetic technique

GA in unstable patients; regional may be used in selected stable cases (but be prepared to convert to GA).

Adjunctive measures

Maintain normothermia, correct acidosis, optimize calcium levels during transfusion, permissive hypotension

Team communication

Close coordination with obstetricians, blood bank, and ICU team. Activate massive transfusion protocol early.

Postoperative care

Transfer to ICU for ongoing resuscitation, monitoring, and correction of coagulopathy.

**Table 3.** Our Practice to Reduce Massive Bleeding in Obstetrics
Intervention	Description
FFP: fresh frozen plasma.
Uterotonics and uterine massage	First-line measures to stimulate uterine contraction and reduce bleeding.
Tranexamic acid	Early administration (within 3 h) to reduce fibrinolysis and improve survival.
Volume replacement	Use crystalloids and initiate massive transfusion protocols (1:1:1 ratio).
Surgical interventions	Balloon tamponade, compression sutures, arterial ligation, or hysterectomy if conservative methods fail.
Correction of coagulopathy	Administer FFP, platelets, cryoprecipitate, or fibrinogen concentrate as indicated.
Hemodynamic	Permissive hypotension
Multidisciplinary approach	Close coordination between obstetric, anesthetic, surgical, and blood bank teams.

Table 3. Our Practice to Reduce Massive Bleeding in Obstetrics

Intervention

Description

FFP: fresh frozen plasma.

Uterotonics and uterine massage

First-line measures to stimulate uterine contraction and reduce bleeding.

Tranexamic acid

Early administration (within 3 h) to reduce fibrinolysis and improve survival.

Volume replacement

Use crystalloids and initiate massive transfusion protocols (1:1:1 ratio).

Surgical interventions

Balloon tamponade, compression sutures, arterial ligation, or hysterectomy if conservative methods fail.

Correction of coagulopathy

Administer FFP, platelets, cryoprecipitate, or fibrinogen concentrate as indicated.

Hemodynamic

Permissive hypotension

Multidisciplinary approach

Close coordination between obstetric, anesthetic, surgical, and blood bank teams.