Comparison of maternal and neonatal outcomes between general anesthesia and combined spinal-epidural anesthesia in cesarean delivery for pregnancy complicated with placenta previa.

Background: 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.

Methods: 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.

Results: 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/m², 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.

Conclusion: 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.

Trial registration: ChiCTR2100052428, October 26^th, 2021.