Background and Aims Placenta accreta(PA) remains as one of the leading causes of peripartum hemorrhage. Regional anesthesia and hypervolemic hemodilution techniques remain controversial in the PA case. We aim to describe the use of combined spinal epidural(CSE) anesthesia with hypervolemic hemodilution technique and fetomaternal outcomes in our patients.

Methods We present four cases of parturient with a median age of 32 years old, who have a history of section cesarean surgery and are suspected of placenta accreta in their current pregnancy.

Results Physical examination and laboratory results show no abnormalities in all patients. The probability of PA using placenta accreta index(PAI) was about 19-69%. Two large 18G calibers of intravenous line and arterial line were inserted, then hypervolemic hemodilution calculated using formula: Estimated Blood Volume(EBV)×[(Initial hematocrit(HO)-targeted hematocrit(Hf))/Hf] given around 1,5-2,5 liters of fluid before we conducted CSE anesthesia. The placenta accreta was documented and hysterectomy was done in all patients. Intra-operative hypotension was quickly resolved with fluid loading and vasopressor drugs. The bleeding was around 2-4 liters replaced by a<50% red pack cell transfusion. Post-operative hematocrit level was 28-30%. The APGAR score was good in all the babies. The patients are then transferred to the intensive care unit(ICU) in a stable condition without vasopressor drugs. We used epidural analgesia for post-operative pain management. They were moved to a regular ward after 24 hours of monitoring with uneventful adverse effects.

Conclusions CSE anesthesia with hypervolemic hemodilution technique showed good fetomaternal outcomes with uneventful adverse effects, acceptable post- operative hematocrit level and excellent post-operative pain management in our patients.