Liu Tianjiao, Wang Yangyang, Xiao Xinyu, Chen Zhi, Li Xin, Liu Chunmei
Department of Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu Municipality, Sichuan Province, China.
Department of Gynecology and Obstetrics, Chengdu Xinjin District Maternal and Child Health Care Hospital, Chengdu Municipality, Sichuan Province, China.
BMC Anesthesiol. 2025 Jun 9;25(1):294. doi: 10.1186/s12871-025-03149-0.
Placenta previa (PP) involves abnormal placental implantation in the lower uterine segment, partially or completely covering the internal cervical os, and is linked to severe maternal hemorrhage and fetal complications. The optimal anesthetic method between general anesthesia (GA) and combined spinal-epidural anesthesia (CSEA) for cesarean delivery (CD) with PP remains controversial.
We retrospectively analyzed 550 PP-complicated CD cases from the Longitudinal Placenta Previa Study (LoPPS) conducted in Southwest China between January 2018 and December 2024. Patients received either GA (n = 170) or CSEA (n = 380). Sociodemographic, obstetric, perioperative, and neonatal data were compared. Multivariate linear and logistic regression was employed to assess the association between anesthetic methods and other perioperative factors, and intraoperative blood loss, or neonatal asphyxia while adjusting for potential confounders.
Patients undergoing GA had a higher age (32.4 vs 31.5 years, p = 0.020), higher body mass index (BMI) (26.5 vs 23.5 kg/m, p < 0.001), and greater parity (91.8% vs 78.4%, p < 0.001) compared to those under CSEA. Complete PP was more common in the GA group (47.1% complete PP vs 19.0%, p < 0.001). There were also more placenta accreta spectrum (PAS) (48.8% vs 15.8%, p < 0.001) and hysterectomy (12.9% vs 0.3%, p < 0.001) in the GA group. In accordance with the huge differences in anesthesia indications, the GA group experienced significantly greater intraoperative blood loss (1131.77 ± 77.29 mL vs. 707.50 ± 16.87 mL, p < 0.001), along with correspondingly higher rates of transfusion, including red cell suspension, plasma, and autologous blood (p < 0.001). The incidence of neonatal asphyxia was also significantly higher in the GA group (26.5% vs. 3.7%, p < 0.001), and the rate of preterm birth was notably higher (81.8% vs. 46.3%, p < 0.001). Among CSEA patients, increased blood loss was associated with placenta covering the uterine incision (HR = 58.49, p = 0.017), PAS type (HR = 29.02, p = 0.036), PP type (HR = 34.72, p = 0.048), and surgical duration (HR = 9.35, p < 0.001), while aortic balloon occlusion reduced blood loss (HR = -115.08, p = 0.009). In GA patients, similar risk factors were identified: placenta covering the incision (HR = 71.88, p = 0.015), PAS type (HR = 103.01, p = 0.042), PP type (HR = 106.16, p = 0.046), and surgical duration (HR = 13.83, p < 0.001). Aortic balloon occlusion remained protective in the GA group (HR = -300.01, p = 0.015), while GA (Exp(B) = 1.75, p = 0.002) and types of PAS are associated with increased risks of neonatal asphyxia.
CSEA is a safe option for selected cases of PP-related CD, particularly in the absence of PAS or in cases with milder forms of PP. Though the GA group exhibited greater intraoperative blood loss, due to the significant differences in the indications for anesthesia methods and the observational nature of current study, this should not be simply interpreted as a causative effect of GA on higher intraoperative blood loss. Thorough antenatal ultrasound assessment of placental status is critical. For complex cases, such as those involving severe PAS subtypes or complete PP, coordinated multidisciplinary perioperative management is essential.
ChiCTR2100052428, October 26, 2021.
前置胎盘（PP）是指胎盘在子宫下段异常植入，部分或完全覆盖宫颈内口，与严重的产妇出血和胎儿并发症相关。对于前置胎盘合并剖宫产（CD）患者，全身麻醉（GA）和腰麻-硬膜外联合麻醉（CSEA）哪种麻醉方法最佳仍存在争议。
我们回顾性分析了2018年1月至2024年12月在中国西南部进行的前置胎盘纵向研究（LoPPS）中的550例前置胎盘合并剖宫产病例。患者接受GA（n = 170）或CSEA（n = 380）。比较了社会人口统计学、产科、围手术期和新生儿数据。采用多变量线性和逻辑回归评估麻醉方法与其他围手术期因素之间的关联，以及术中失血或新生儿窒息情况，并对潜在混杂因素进行校正。
与接受CSEA的患者相比，接受GA的患者年龄更大（32.4岁对31.5岁，p = 0.020），体重指数（BMI）更高（26.5对23.5kg/m²，p < 0.001），产次更多（91.8%对78.4%，p < 0.001）。完全性前置胎盘在GA组更常见（47.1%的完全性前置胎盘对19.0%，p < 0.001）。GA组胎盘植入谱系（PAS）也更多（48.8%对15.8%，p < 0.001），子宫切除术更多（12.9%对0.3%，p < 0.001）。由于麻醉适应证存在巨大差异，GA组术中失血量显著更多（1131.77±77.29mL对707.50±16.87mL，p < 0.001），相应的输血率更高，包括红细胞悬液、血浆和自体血（p < 0.001）。GA组新生儿窒息发生率也显著更高（26.5%对3.7%，p < 0.001），早产率也显著更高（81.8%对46.3%，p < 0.001）。在接受CSEA的患者中，失血量增加与胎盘覆盖子宫切口（HR = 58.49, p = 0.017）、PAS类型（HR = 29.02, p = 0.036）、前置胎盘类型（HR = 34.72, p = 0.048）和手术时间（HR = 9.35, p < 0.001）有关，而主动脉球囊阻断可减少失血量（HR = -115.08, p = 0.009）。在接受GA的患者中，也发现了类似的危险因素：胎盘覆盖切口（HR = 71.88, p = 0.015）、PAS类型（HR = 103.01, p = 0.042）、前置胎盘类型（HR = 106.16, p = 0.046）和手术时间（HR = 13.83, p < 0.001）。主动脉球囊阻断在GA组仍具有保护作用（HR = -300.01, p = 0.015），而GA（Exp(B)=1.75, p = 0.002）和PAS类型与新生儿窒息风险增加有关。
对于部分前置胎盘合并剖宫产病例，CSEA是一种安全的选择，特别是在无胎盘植入或前置胎盘程度较轻的情况下。尽管GA组术中失血量更多，但由于麻醉方法适应证存在显著差异以及本研究的观察性质，不应简单地将其解释为GA导致术中失血量增加的因果效应。产前对胎盘状况进行全面的超声评估至关重要。对于复杂病例，如涉及严重胎盘植入亚型或完全性前置胎盘的病例，围手术期多学科协调管理至关重要。
ChiCTR2100052428，2021年10月26日。
