Anesthetic Management for Manual Removal of Retained Placenta in Parturients Without Labor Epidural Analgesia: A Retrospective Multicenter Real-World Study.

Abstract

Background: Manual removal of placenta (MRP) is required in 0.1%-3.3% of vaginal births. For patients who give birth without labor epidural analgesia, the choice between neuraxial or general anesthesia (GA) with or without tracheal intubation presents unique challenges. This study describes anesthetic management practices for these cases.

Methods: This multicenter retrospective cohort study analyzed 423 patients undergoing MRP at two tertiary centers in Israel (Soroka and Rabin Medical Centers) from 2016 to 2022. We collected data on anesthetic techniques, patient characteristics, and clinical outcomes, comparing patients managed with and without tracheal intubation during GA.

Results: GA was used in 409 (96.7%) cases, with 269 (65.8%) patients managed with tracheal intubation and 140 (34.2%) receiving tubeless GA. Patients who received tubeless GA had lower rates of intraoperative complications, including hypotension (16.4% vs. 26.0%, p = 0.034), vasopressor use (10.0% vs. 20.8%, p = 0.006), and blood product transfusions (3.6% vs. 11.9%, p = 0.006). Multivariable analysis revealed associations between higher body mass index (aOR = 2.19), elevated heart rate (aOR = 1.86), and tracheal intubation. Tracheal intubation rates significantly declined from 2016 to 2022 following the introduction of gastric ultrasound in our practice.

Conclusion: Anesthetic management for MRP should be individualized based on clinical factors. In our cohort, tubeless GA was preferred for fasted, lower BMI, and hemodynamically stable patients, with tracheal intubation typically reserved for more complex cases, reflecting inherent selection bias. This study was descriptive in nature and was not designed to establish the safety of any particular technique. Further high-quality research is needed to validate these findings and refine anesthetic guidelines for MRP.

Editorial comment: MRP is a rare obstetric procedure that can be challenging to manage without prior epidural analgesia. A retrospective study of 423 patients in two Israeli hospitals (2016-2022) found that most cases (96.7%) used GA, with about two-thirds involving tracheal intubation and one-third using tubeless techniques. Tubeless anesthesia was associated with less hypotension, reduced need for vasopressors, and fewer blood transfusions. Patients with higher BMI and heart rate were more likely to be intubated. Intubation rates decreased over time after gastric ultrasound was introduced in this cohort. Overall, the study suggests tailoring anesthesia choice to the patient, with no endotracheal intubation approaches safe for selected stable cases, though more research is needed.