Epidural anesthesia in a patient with placenta accreta for intra-aortic ballooning and cesarean section

Postpartum hemorrhage (PPH) is one of the main causes of maternal death besides cardiovascular disease. Among the causes of PPH is placenta accreta. Hysterectomy is usually performed in placenta accreta to save the mother's life. However, hysterectomy has a direct impact on fertility so that a new strategy was developed, namely the use of prophylaxis Intra-abdominal Aortic Balloon Occlusion (IABO). Anesthetic management plays an important role in ensuring the safety of placenta accreta patients.We present a case of a 34-year-old woman G3P1A1 38+3 weeks with a history of antepartum hemorrhage, complete placenta previa with moderate risk morbidly adherent placenta (MAP), oblique breech position, oligohydramnios, intrauterine growth restriction (IUGR), and previous cesarean section (CS) 4 y ago. She was ASA-II and planned cystoscopy and ureteral catheter insertion by a urologist. The aortic ballooning angioplasty was done through inguinal area by a cardiothoracic surgeon. Followed by CS for 120 minutes, and duration of arterial blockade that can be maintained for 20 min during CS. The operation was performed using epidural anesthesia. Induction with an initial epidural dose was carried out using levobupivacaine 0.5% 15 ml in 5 ml increments every 5 min. Placenta accreta can cause massive bleeding, disseminated intravascular coagulation (DIC), and damage to the liver and kidneys. Massive bleeding caused by placenta accreta significantly increases maternal morbidity and mortality. The latest technology called Intra-abdominal Aortic Balloon Occlusion (IABO) is an option to reduce bleeding and the need for transfusions during and after surgery. Epidural anesthesia is considered a favorable anesthetic option for these patients, as it can also be used as a good postoperative analgesia.