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Paping A, Bluth A, Al Naimi A, Mhallem M, Kolak M, Jaworowski A, Huras H, Morlando M, Daskalakis G, Pinto PV, Sentilhes L, van Beekhuizen HJ, Stefanovic V, Fox KA, Morel O, Bertholdt C, Braun T. Advances in uterine-preserving surgical techniques for placenta accreta spectrum. Acta Obstet Gynecol Scand 2024. [PMID: 39344693 DOI: 10.1111/aogs.14967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2024] [Accepted: 08/26/2024] [Indexed: 10/01/2024]
Affiliation(s)
- Alexander Paping
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universitätzu Berlin, Berlin, Germany
| | - Anja Bluth
- Department of Gynecology and Obstetrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ammar Al Naimi
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University Hospital Frankfurt Goethe-University, Frankfurt am Main, Germany
- Department of Obstetrics and Gynecology, Buerger Hospital, Frankfurt, Germany
| | - Mina Mhallem
- Department of Obstetrics, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Magdalena Kolak
- Department of Obstetrics and Perinatology, Jagiellonian University, Medical College, Krakow, Poland
| | - Andrzej Jaworowski
- Department of Obstetrics and Perinatology, Jagiellonian University, Medical College, Krakow, Poland
| | - Hubert Huras
- Department of Obstetrics and Perinatology, Jagiellonian University, Medical College, Krakow, Poland
| | - Maddalena Morlando
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - George Daskalakis
- Department of Obstetrics and Gynecology, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Pedro Viana Pinto
- Departamento de Ginecologia, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Loïc Sentilhes
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Bordeaux, France
| | | | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of OB-GYN, Baylor College of Medicine, Houston, Texas, USA
| | - Olivier Morel
- Université de Lorraine, CHRU-NANCY, Pôle de la Femme, Nancy, France
- Université de Lorraine, Inserm, IADI, Nancy, France
| | - Charline Bertholdt
- Université de Lorraine, CHRU-NANCY, Pôle de la Femme, Nancy, France
- Université de Lorraine, Inserm, IADI, Nancy, France
| | - Thorsten Braun
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universitätzu Berlin, Berlin, Germany
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Nieto-Calvache AJ, Fox KA, Jauniaux E, Maya J, Stefanovic V, Weizsäcker K, van Beekhuizen H, Adu-Bredu T, Collins S, Siaulys M, Hussein AM, Duvekot J, Aryananda R, Nieto-Calvache AS, Pajkrt E, Rijken MJ. Is telehealth useful in the management of placenta accreta spectrum in low-resource settings? Results of an exploratory survey. Int J Gynaecol Obstet 2024; 166:1031-1039. [PMID: 38509726 DOI: 10.1002/ijgo.15474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/25/2024] [Accepted: 02/20/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVE The optimal management of placenta accreta spectrum (PAS) requires the participation of multidisciplinary teams that are often not locally available in low-resource settings. Telehealth has been increasingly used to manage complex obstetric conditions. Few studies have explored the use of telehealth for PAS management, and we aimed evaluate the usage of telehealth in the management of PAS patients in low-resource settings. METHODS Between March and April 2023, an observational, survey-based study was conducted, and obstetricians-gynecologists with expertise in PAS management in low- and middle-income countries were contacted to share their opinion on the potential use of telehealth for the diagnosis and management of patients at high-risk of PAS at birth. Participants were identified based on their authorship of at least one published clinical study on PAS in the last 5 years and contacted by email. This is a secondary analysis of the results of that survey. RESULTS From 158 authors contacted we obtained 65 responses from participants in 27 middle-income countries. A third of the participants reported the use of telehealth during the management obstetric emergencies (38.5%, n = 25) and PAS (36.9%, n = 24). Over 70% of those surveyed indicated that they had used "informal" telemedicine (phone call, email, or text message) during PAS management. Fifty-nine participants (90.8%) reported that recommendations given remotely by expert colleagues were useful for management of patients with PAS in their setting. CONCLUSION Telehealth has been successfully used for the management of PAS in middle-income countries, and our survey indicates that it could support the development of specialist care in other low resource settings.
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Affiliation(s)
- Albaro José Nieto-Calvache
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Clínica de Espectro de Acretismo Placentario, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Karin A Fox
- University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Eric Jauniaux
- Faculty of Population Health Sciences, EGA Institute for Women's Health, University College London (UCL), London, UK
| | | | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Katharina Weizsäcker
- Department of Obstetrics and Division of Experimental Obstetrics, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Heleen van Beekhuizen
- Department of Gynecological Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Theophilus Adu-Bredu
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Sally Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Monica Siaulys
- Hospital e Maternidade Santa Joana, Centro de Ensino, Pesquisa e Inovação, São Paulo, São Paulo, Brazil
| | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Johannes Duvekot
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rozi Aryananda
- Maternal-Fetal Medicine Division, Obstetrics and Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | | | - Eva Pajkrt
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Marcus J Rijken
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Julius Global Health, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Nieto-Calvache AJ, Jauniaux E, Fox KA, Maya J, Stefanovic V, Weizsäcker K, van Beekhuizen H, Adu-Bredu T, Collins S, Siaulys M, Hussein AM, Duvekot J, Aryananda R, Pajkrt E, Rijken MJ. Are international guideline recommendations for the management of placenta accreta spectrum applicable in low- and middle-income countries? Int J Gynaecol Obstet 2024; 166:1047-1056. [PMID: 38488201 DOI: 10.1002/ijgo.15473] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/15/2024] [Accepted: 02/20/2024] [Indexed: 08/16/2024]
Abstract
OBJECTIVE The aim of this study was to explore how obstetricians-gynecologists in low- and middle-income countries (LMICs) can apply current international clinical practice guidelines (CPGs) for the management of placenta accreta spectrum (PAS) in limited resource settings. METHODS This was an observational, survey-based study. Clinicians with expertise in managing patients with PAS in LMICs were contacted for their evaluation of the recommendations included in four PAS clinical practice guidelines. RESULTS Out of the 158 clinicians contacted, we obtained responses from 65 (41.1%), representing 27 middle income countries (MICs). The results of this survey suggest that the care of PAS patients in middle income countries is very different from what is recommended by international CPGs. Participants in the survey identified that their practice was limited by insufficient availability of hospital infrastructure, low resources of local health systems and lack of trained multidisciplinary teams (MDTs) and this did not enable them to follow CPG recommendations. Two-thirds of the participants surveyed describe the absence of centers of excellence in their country. In over half of the referral hospitals with expertise in managing PAS, there are no MDTs. One-third of patients with intraoperative findings of PAS are managed by the team initially performing the surgery (without additional assistance). CONCLUSION The care of patients with PAS in middle income countries frequently deviates from established CPG recommendations largely due to limitations in local resources and infrastructure. New practical guidelines and training programs designed for low resource settings are needed.
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Affiliation(s)
- Albaro Jose Nieto-Calvache
- Clínica de Espectro de Acretismo Placentario, Fundacion Valle de Lili, Cali, Colombia
- Universidad ICESI, Cali, Colombia
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
| | - Karin A Fox
- University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Juliana Maya
- Programa de Medicina, Universidad ICESI, Cali, Colombia
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Katharina Weizsäcker
- Departments of Obstetrics and Division of Experimental Obstetrics Charité Universitäts Medizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Heleen van Beekhuizen
- Department of Gynecological Oncology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Theophilus Adu-Bredu
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Sally Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Monica Siaulys
- Hospital e Maternidade Santa Joana, Centro de Ensino, Pesquisa e Inovação, São Paulo, Brazil
| | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Johannes Duvekot
- Department of Obstetrics and Gynecology, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
| | - Rozi Aryananda
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Eva Pajkrt
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Marcus J Rijken
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Julius Global Health, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Lucidi A, Janiaux E, Hussein AM, Nieto-Calvache A, Khalil A, D'Amico A, Rizzo G, D'Antonio F. Emergency delivery in pregnancies at high probability of placenta accreta spectrum on prenatal imaging: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2024; 6:101432. [PMID: 39069207 DOI: 10.1016/j.ajogmf.2024.101432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/29/2024] [Accepted: 06/15/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Placenta accreta spectrum disorders are associated with a high risk of maternal morbidity, particularly when surgery is performed under emergency conditions. This study aimed to investigate the incidence of emergency cesarean delivery in patients with a high probability of placenta accreta spectrum disorders on prenatal imaging and to compare the maternal and neonatal outcomes between patients requiring emergency cesarean delivery and those not requiring emergency cesarean delivery. DATA SOURCES MEDLINE, Embase, Cochrane, and ClinicalTrials.gov databases were searched. STUDY ELIGIBILITY CRITERIA This study included case-control studies reporting the outcomes of pregnancies with a high probability of placenta accreta spectrum on prenatal imaging confirmed at birth delivered via unplanned emergency cesarean delivery vs those delivered via planned elective cesarean delivery for maternal or fetal indications. The outcomes observed were the occurrence of emergency cesarean delivery; incidence of placenta accreta and placenta increta/placenta percreta; preterm birth at <34 weeks of gestation; and indications for emergency delivery. This study analyzed and compared the outcomes between patients who underwent emergency cesarean delivery and those who underwent elective cesarean delivery, including estimated blood loss; number of packed red blood cell units transfused and blood products transfused; transfusion of more than 4 units of packed red blood cell; ureteral, bladder, or bowel injury; disseminated intravascular coagulation; relaparotomy after the primary surgery; maternal infection or fever; wound infection; vesicouterine or vesicovaginal fistula; admission to the neonatal intensive care unit; maternal death; composite neonatal morbidity; fetal or neonatal loss; Apgar score of <7 at 5 minutes; and neonatal birthweight. METHODS Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for case-control and cohort studies. Random-effect meta-analyses of proportions, risks, and mean differences were used to combine the data. RESULTS A total of 11 studies with 1290 pregnancies complicated by placenta accreta spectrum were included in the systematic review. Emergency cesarean delivery was reported in 36.2% of pregnancies (95% confidence interval, 28.1-44.9) with placenta accreta spectrum at birth, of which 80.3% of cases (95% confidence interval, 36.5-100.0) occurred before 34 weeks of gestation. The main indication for emergency cesarean delivery was antepartum bleeding, which complicated 61.8% of the cases (95% confidence interval, 32.1-87.4). Patients who underwent emergent cesarean delivery had higher estimated blood loss during surgery (pooled mean difference, 595 mL; 95% confidence interval, 116.10-1073.90; P<.001), higher number of packed red blood cells transfused (pooled mean difference, 2.3 units; 95% confidence interval, 0.99-3.60; P<.001), and higher number of blood products transfused (pooled mean difference, 3.0; 95% confidence interval, 1.10-4.90; P=.002) than patients who underwent scheduled cesarean delivery. Patients who underwent emergency cesarean delivery had a higher risk of requiring transfusion of more than 4 units of packed red blood cell (odds ratio, 3.8; 95% confidence interval, 1.7-4.9; P=.002), bladder injury (odds ratio, 2.1; 95% confidence interval, 1.1-4.0; P=.003), disseminated intravascular coagulation (odds ratio, 6.1; 95% confidence interval, 3.1-13.1; P<.001), and admission to the intensive care unit (odds ratio, 2.1; 95% confidence interval, 1.4-3.3; P<.001). Newborns delivered via emergency cesarean delivery had a higher risk of adverse composite neonatal outcomes (odds ratio, 2.6; 95% confidence interval, 1.4-4.7; P=.019), admission to the neonatal intensive care unit (odds ratio, 2.5; 95% confidence interval, 1.1-5.6; P=.029), Apgar score of <7 at 5 minutes (odds ratio, 2.7; 95% confidence interval, 1.5-4.9; P=.002), and fetal or neonatal loss (odds ratio, 8.2; 95% confidence interval, 2.5-27.4; P<.001). CONCLUSION Emergency cesarean delivery complicates approximately 35% of pregnancies affected by placenta accreta spectrum disorders and is associated with a higher risk of adverse maternal and neonatal outcomes. Large prospective studies are needed to evaluate the clinical and imaging signs that can identify patients with a high probability of placenta accreta spectrum at birth, patients at risk of requiring emergency cesarean delivery or peripartum hysterectomy, and patients at high risk of experiencing intrapartum hemorrhage.
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Affiliation(s)
- Alessandro Lucidi
- Department of Obstetrics and Gynecology, Center for Fetal Cand High-Risk Pregnancy, University of Chieti, Chieti, Italy (Lucidi, D'Amico, and D'Antonio)
| | - Eric Janiaux
- Faculty of Population Health Sciences, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom (Janiaux)
| | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt (Hussein)
| | - Albaro Nieto-Calvache
- Placental Accreta Spectrum Clinic, Fundación Valle del Lili, Cali, Colombia (Nieto-Calvache)
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, London, United Kingdom (Khalil); Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, England, United Kingdom (Khalil)
| | - Alice D'Amico
- Department of Obstetrics and Gynecology, Center for Fetal Cand High-Risk Pregnancy, University of Chieti, Chieti, Italy (Lucidi, D'Amico, and D'Antonio)
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Tor Vergata University of Rome, Rome, Italy (Rizzo)
| | - Francesco D'Antonio
- Department of Obstetrics and Gynecology, Center for Fetal Cand High-Risk Pregnancy, University of Chieti, Chieti, Italy (Lucidi, D'Amico, and D'Antonio).
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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Fox KA, Benavides JP, Sarria-Ortiz D, Muñoz-Córdoba L, Galindo-Velasco V, Maya J, Meade P, Romero E, Mostajo D, Delgado J, de la Cruz A, Valladares A, Sánchez A, Fernández J, Pavón N, Solo-Nieto A, Burgos JM, Messa-Bryon A, Hussein AM. Usefulness of low-cost simulation models to learning surgical techniques for placenta accreta spectrum: An observational educational study. Int J Gynaecol Obstet 2024. [PMID: 39016241 DOI: 10.1002/ijgo.15788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 05/14/2024] [Accepted: 07/02/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVE To evaluate the utility of low-cost simulation models to teach surgical techniques for placenta accreta spectrum (PAS), included in a multimodal education workshop for PAS. METHODS This was an observational, survey-based study. Participants were surveyed before and after the use of low-fidelity mannequins to simulate two surgical techniques for PAS (one-step conservative surgery [OSCS] and modified subtotal hysterectomy [MSTH]), within a multimodal educational workshop. The workshops included pre-course preparation, didactics, simulated practice of the techniques using low-cost models, and viewing live surgery. RESULTS Six OSCS/MSTH training workshops occurred across six countries and a total of 270 participants were surveyed. The responses of 127 certified obstetricians and gynecologists (OB-GYNs) were analyzed. Participants expressed favorable impressions of all components of the simulated session. Perceived anatomical simulator fidelity, scenario realism, educational component effectiveness, and self-assessed performance improvement received ratings of 4-5 (positive end of the Likert scale) from over 90% of respondents. When asked about simulation's role in technique comprehension, comfort level in technique performance, and likelihood of recommending this workshop to others, more than 75% of participants rated these aspects with a score of 4-5 (positively) on the five-point scale. CONCLUSION Low-cost simulation, within a multimodal education strategy, is a well-accepted intervention for teaching surgical techniques for PAS.
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Affiliation(s)
| | | | | | - Juan Pablo Benavides
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia
| | | | - Laura Muñoz-Córdoba
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | | | - Juliana Maya
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | | | | | | | - Jorge Delgado
- Facultad de Medicina de León, Universidad de Guanajuato, Guanajuato, Mexico
| | | | | | | | | | - Néstor Pavón
- Hospital Nacional Bertha Calderón Roque, Managua, Nicaragua
| | - Alejandro Solo-Nieto
- Universidad Santiago de Cali, Cali, Colombia
- Universidad Nacional Abierta y a Distancia (UNAD), Palmira, Colombia
| | - Juan Manuel Burgos
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia
| | - Adriana Messa-Bryon
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia
| | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
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Yalınkaya A, Oğlak SC. A Novel Approach for Conservative Management of Placenta Accreta Spectrum Disorder Cases: Experience of a Single Surgeon: PAS Disorders and Conservative Management. J Pregnancy 2024; 2024:9910316. [PMID: 38961859 PMCID: PMC11221975 DOI: 10.1155/2024/9910316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/18/2024] [Accepted: 05/14/2024] [Indexed: 07/05/2024] Open
Abstract
Background: This study is aimed at evaluating the conservative surgical treatment of patients with placenta accreta spectrum (PAS) disorder and at presenting the experience of a single surgeon. Materials and Methods: This retrospective study included 245 patients with placenta previa accompanied by PAS disorders operated at a university hospital between June 2013 and December 2023. The diagnosis of PAS was made by a single perinatologist using a combination of transvaginal and transabdominal ultrasonography. All patients were operated with conservative surgical technique by the same surgeon. The demographic and clinical characteristics of the patients, the anesthesia and incision types used, and the details of the surgical technique were evaluated. Results: Of the patients, 165 were operated on at the scheduled time, 80 were operated on under emergency conditions, and 232 (94.69%) of them were operated on under spinal anesthesia. All patients were operated on with a Pfannenstiel incision followed by a transverse incision to the upper border of the placenta to enter into the uterus. An average of 0.52 units of red blood cells per patient was transfused to all patients. Spontaneous intra-abdominal bleeding developed in five patients, and surgical complications occurred in eight patients. No cesarean hysterectomy was performed, and no maternal mortality was detected in any of the cases. The mean time duration of surgery was 54.44 ± 11.37 (30-90) min, and the mean length of hospital stay was 1.71 ± 1.30 (1-9) days. Conclusions: We recommend this procedure as a novel technique and a robust and safe alternative to peripartum hysterectomy and other conservative surgical management procedures for cases with complete PP accompanied with PAS. This technique preserves the uterus as well as reduces blood loss, and transfusion requirement, and thus maternal morbidity and mortality in PAS cases.
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Affiliation(s)
- Ahmet Yalınkaya
- Department of Obstetrics and GynecologyDicle University Faculty of Medicine, Diyarbakır, Türkiye
| | - Süleyman Cemil Oğlak
- Department of Obstetrics and GynecologyHealth Sciences UniversityGazi Yaşargil Training and Research Hospital, Diyarbakır, Türkiye
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Palacios-Jaraquemada JM, Nieto-Calvache AJ, Savukyne E, Pellegrinelli JM, de Tejada BM. Why isn't one-step conservative surgery used more frequently to treat women with placenta accreta spectrum? Acta Obstet Gynecol Scand 2024. [PMID: 38856302 DOI: 10.1111/aogs.14897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/11/2024]
Affiliation(s)
| | - Albaro Jose Nieto-Calvache
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia
- Amsterdam University Medical Center, Doctoral School, Amsterdam, The Netherlands
| | - Egle Savukyne
- Department of Obstetrics and Gynecology, Medicine Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jean-Maria Pellegrinelli
- Obstetrics Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Begoña Martinez de Tejada
- Obstetrics Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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8
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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Hussein AM, Jauniaux E, Milani Coutinho C, Rijken M. Management of placenta accreta spectrum in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 94:102475. [PMID: 38452606 DOI: 10.1016/j.bpobgyn.2024.102475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/16/2024] [Accepted: 02/05/2024] [Indexed: 03/09/2024]
Abstract
Placenta accreta spectrum (PAS) can be associated massive intra- and post-operative hemorrhage which when not controlled can lead to maternal death. Important advances have occurred in understanding the pathophysiology and therapeutic options for this condition. The prevalence of PAS at birth is direct association with the cesarean delivery (CD) rate in the corresponding population and is increasing worldwide. Limited health infrastructure in low- and middle-income countries increases the morbidity and mortality of patients with PAS at birth. In many cases, obstetricians working in limited resources settings cannot follow some of the international guideline's recommendations and have to opt for low-cost management procedures. In this review, we describe the particularities of managing PAS care in low- and middle-income countries from of prenatal evaluation of patients at risk of PAS at birth, therapeutic options, and inter-institutional collaboration. We also propose a management protocol based on training of the local obstetric teams rather than on sophisticated technological resources that are almost never available in low-resource scenarios.
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Affiliation(s)
- Albaro José Nieto-Calvache
- Fundación Valle Del Lili, Departamento de Ginecología y Obstetricia, Cra 98 No. 18 - 49, Cali, 760032, Colombia; Amsterdam University Medical Center, Amsterdam, 1007, the Netherlands.
| | | | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, 12613, Egypt; Faculty of Medicine, Department of Obstetrics and Gynecology, University of Cairo, Cairo, 12613, Egypt
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, WC1E 6AU, UK
| | - Conrado Milani Coutinho
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, 14040-900, SP, Brazil
| | - Marcus Rijken
- Amsterdam University Medical Center, Amsterdam, 1007, the Netherlands; Vrouw & Baby, University Medical Centre Utrecht, Utrecht University, Utrecht, 3584, the Netherlands; Antoni van Leeuwenhoek hospital, Amsterdam, the Netherlands
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Fernandes RD, Ghasroddashti A, Sorefan-Mangou F, Williams E, Choi K, Fasola L, Szasz P, Zevin B. Educational Effectiveness of Telementoring as a Continuing Professional Development Intervention for Surgeons in Practice: A Systematic Review. ANNALS OF SURGERY OPEN 2023; 4:e341. [PMID: 38144497 PMCID: PMC10735140 DOI: 10.1097/as9.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/26/2023] [Indexed: 12/26/2023] Open
Abstract
Objective We performed a systematic review to determine the educational effectiveness of telementoring as a continuing professional development (CPD) intervention for surgeons in practice. Background Surgeons can mentor their peers in remote locations using videoconferencing communication, referred to as telementoring. Methods We searched MEDLINE and EMBASE and included studies assessing the educational effectiveness of telementoring interventions used by surgeons in practice. We excluded studies involving only trainees and those not evaluating educational effectiveness. Two reviewers independently screened, extracted data, and assessed study quality using the Medical Education Research Study Quality Instrument (MERSQI; maximum score 18). Educational outcomes were categorized using Moore's Outcomes Framework. Results We retrieved a total of 1351 records, and 252 studies were selected for full-text review. Twenty-eight studies were included with 1 randomized controlled trial, 19 cohort studies, 5 qualitative studies, and 3 case studies, totaling 178 surgeons and 499 cases. The average MERSQI score was 10.21 ± 2.2 out of 18. Educational outcomes included surgeons' satisfaction with telementoring interventions (Moore's Level 2) in 12 studies, improvement in surgeons' procedural knowledge (Level 3b) in 3 studies, improvements in surgeons' procedural competence in an educational setting (Level 4) in 4 studies, performance in a workplace-based setting (Level 5) in 23 studies, and patient outcomes (Level 6) in 3 studies. No studies reported community health outcomes (Level 7). Conclusions Moderate-level evidence demonstrates the use of telementoring as effective in changing surgeons' knowledge and competence in both educational and workplace-based settings. Its use is also associated with changes in patient outcomes.
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Affiliation(s)
| | | | | | - Erin Williams
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
| | - Ken Choi
- From the The School of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Laurie Fasola
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
| | - Peter Szasz
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
| | - Boris Zevin
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
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Bao Vuong AD, Thi Pham XT, Nguyen PN. The modified one-step conservative uterine surgery (MOSCUS) in the management of placenta accreta spectrum disorders: Which, where, when, and who. Taiwan J Obstet Gynecol 2023; 62:621-622. [PMID: 37407211 DOI: 10.1016/j.tjog.2023.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 07/07/2023] Open
Affiliation(s)
- Anh Dinh Bao Vuong
- Department of High-risk Pregnancy, Tu Du Hospital, Ho Chi Minh City, Viet Nam
| | - Xuan Trang Thi Pham
- Department of High-risk Pregnancy, Tu Du Hospital, Ho Chi Minh City, Viet Nam
| | - Phuc Nhon Nguyen
- Department of High-risk Pregnancy, Tu Du Hospital, Ho Chi Minh City, Viet Nam; Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Viet Nam.
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How to perform the one-step conservative surgery for placenta accreta spectrum move by move. Am J Obstet Gynecol MFM 2023; 5:100802. [PMID: 36372188 DOI: 10.1016/j.ajogmf.2022.100802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/01/2022] [Accepted: 11/05/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND There are 3 treatment options for placenta accreta spectrum: cesarean delivery with hysterectomy, expectant management, and uterine-sparing surgical techniques. One-step conservative surgery is the most extensively described conservative surgical technique, and it has extensive evidence supporting its usefulness; however, few groups apply it, most likely because of the misconception that it is a complex procedure that requires extensive training and is applicable to only a few patients. OBJECTIVE This study aimed to evaluate the clinical outcomes of patients undergoing one-step conservative surgery in 4 placenta accreta spectrum reference hospitals and provided detailed steps for successfully applying this type of surgery. STUDY DESIGN This was a multicenter, descriptive, prospective study that described the outcomes of patients with placenta accreta spectrum treated in 4 reference hospitals for this condition. The patients were divided into those managed with one-step conservative surgery and those managed with cesarean delivery and hysterectomy. RESULTS Overall, 75 patients were included. One-step conservative surgery was possible in 85.3% of placenta accreta spectrum cases (64 patients). Intraoperative staging and placenta accreta spectrum topographic classification allowed for the selection of one-step conservative surgery candidates. The clinical outcomes of the 2 groups were similar, except for the frequency of transfusions (81.8% in the cesarean delivery and hysterectomy group vs 67.2% in the one-step conservative surgery group) and vascular interventions (27.3% in the cesarean delivery and hysterectomy group vs 4.7% in the one-step conservative surgery group), which were both higher in patients who underwent hysterectomy. In addition, the operation time was shorter in the one-step conservative surgery group (164.4 minutes vs 216.5 minutes). CONCLUSION One-step conservative surgery is a valid procedure in most patients with placenta accreta spectrum. It is an applicable technique even in scenarios with limited resources. However, its safe application requires knowledge of the topographic classification and the application of intraoperative staging.
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Nieto-Calvache AJ, Sanín-Blair JE, Buitrago-Leal HM, Benavides-Serralde JA, Maya-Castro J, Rozo-Rangel AP, Messa-Bryon A, Colonia-Toro A, Gómez-Castro AR, Cardona-Ospina A, Caicedo-Cáceres CE, Dorado-Roncancio EF, Silva JL, Carvajal-Valencia JA, Velásquez-Penagos JA, Niño-González JE, Burgos-Luna JM, Rincón-García JC, Matera-Torres L, Villamizar-Galvis OA, Olaya-Garay SX, Medina-Palmezano VP, Castañeda J. Colombian Consensus on the Treatment of Placenta Accreta Spectrum (PAS). REVISTA COLOMBIANA DE OBSTETRICIA Y GINECOLOGIA 2022; 73:283-316. [PMID: 36331304 PMCID: PMC9674383 DOI: 10.18597/rcog.3877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/14/2022] [Indexed: 06/16/2023]
Abstract
Introduction Placenta accreta spectrum (PAS) is a condition associated with massive postpartum bleeding and maternal mortality. Management guidelines published in high income countries recommend the participation of interdisciplinary teams in hospitals with sufficient resources for performing complex procedures. However, some of the recommendations contained in those guidelines are difficult to implement in low and medium income countries. Objectives The aim of this consensus is to draft general recommendations for the treatment of PAS in Colombia. Materials and methods Twenty-three panelists took part in the consensus with their answers to 31 questions related to the treatment of PAS. The panelists were selected based on participation in two surveys designed to determine the resolution capabilities of national and regional hospitals. The modified Delphi methodology was used, introducing two successive discussion rounds. The opinions of the participants, with a consensus of more than 80%, as well as implementation barriers and facilitators, were taken into consideration in order to issue the recommendations. Results The consensus draftedfive recommendations, integrating the answers of the panelists. Recommendation 1. Primary care institutions must undertake active search of PAS in patients with risk factors: placenta praevia and history of myomectomy or previous cesarean section. In case of ultrasound signs suggesting PAS, patients must be immediately referred, without a minimum gestational age, to hospitals recognized as referral centers. Online communication and care modalities may facilitate the interaction between primary care institutions and referral centers for PAS. The risks and benefits of telemedicine modalities must be weighed. Recommendation 2. Referral hospitals for PAS need to be defined in each region of Colombia, ensuring coverage throughout the national territory. It is advisable to concentrate the flow of patients affected by this condition in a few hospitals with surgical teams specifically trained in PAS, availability of specialized resources, and institutional efforts at improving quality of care with the aim of achieving better health outcomes in pregnant women with this condition. To achieve this goal, participants recommend that healthcare regulatory agencies at a national and regional level should oversee the process of referral for these patients, expediting administrative pathways in those cases in which there is no prior agreement between the insurer and the selected hospital or clinic. Recommendation 3. Referral centers for patients with PAS are urged to build teams consisting of a fixed group of specialists (obstetricians, urologists, general surgeons, interventional radiologists) entrusted with the care of all PAS cases. It is advisable for these interdisciplinary teams to use the “intervention bundle” model as a guidance for building PAS referral centers. This model comprises the following activities: service preparedness, disease prevention and identification, response to the occurrence of the disease, and debriefing after every event. Telemedicine facilitates PAS treatment and should be taken into consideration by interdisciplinary teams caring for this disease. Recommendation 4. Obstetrics residents must be instructed in the performance of maneuvers that are useful for the prevention and treatment of massive intraoperative bleeding due to placenta praevia and PAS, including manual aortic compression, uterine tourniquet, pelvic packing, retrovesical bypass, and Ward maneuver. Specialization Obstetrics and Gynecology programs in Colombia must include the basic concepts of the diagnosis and treatment of PAS. Referral centers for PAS must offer online and in-person training programs for professionals interested in improving their competencies in PAS. Moreover, they must offer permanent remote support (telemedicine) to other hospitals in their region for patients with this condition. Recommendation 5. Patients suspected of having PAS and placenta praevia based on imaging, with no evidence of active vaginal bleeding, must be delivered between weeks 34 and 36 6/7. Surgical treatment must include sequential interventions that may vary depending on the characteristics of the lesion, the clinical condition of the patient and the availability of resources. The surgical options (total and subtotal hysterectomy, one-stage conservative surgical management and watchful waiting) must be included in a protocol known by the entire interdisciplinary team. In situations in which an antepartum diagnosis is lacking, that is to say, in the face of intraoperative finding of PAS (evidence of purple bulging or neovascularization of the anterior aspect of the uterus), and the participation of untrained personnel, three options are considered: Option 1: In the absence of indication of immediate delivery or of vaginal delivery, the recommendation is to postpone the cesarean section (close the laparotomy before incising the uterus) until the recommended resources for safe surgery are secured. Option 2: If there is an indication for immediate delivery (e.g., non-reassuring fetal status) but there is absence of vaginal bleeding or indication for immediate PAS management, a two-stage management is suggested: cesarean section avoiding placental incision, followed by uterine repair and abdominal closure, until the availability of the recommended resources for safe surgery is ascertained. Option 3: In the event of vaginal bleeding that prevents definitive PAS management, the fetus must be delivered through the uterine fundus, followed by uterine repair and reassessment of the situation. Sometimes, fetal delivery diminishes placental flow and vaginal bleeding is reduced or disappears, enabling the possibility to postpone definitive management of PAS. In case of persistent significant bleeding, hysterectomy should be performed, using all available resources: manual aortic compression, immediate call to the surgeons with the best available training, telemedicine support from expert teams in other hospitals. If a patient with risk factors for PAS (e.g., myomectomy or previous cesarean section) has a retained placenta after vaginal delivery, it is advisable to confirm the possibility of such diagnosis (by means of ultrasound, for example) before proceeding to manual extraction of the placenta. Conclusions It is our hope that this first Colombian consensus on PAS will serve as a basis for additional discussions and collaborations that can result in improved clinical outcomes for women affected by this condition. Additional research will be required in order to evaluate the applicability and effectiveness of these recommendations.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jimmy Castañeda
- Federación Colombiana de Obstetricia y Ginecología (FECOLSOG), Bogotá (Colombia)..
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