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Ramachandran R, Nistor S, Gietzmann W, Symons N, Soleymani majd H. Radical total pelvic exenteration with concomitant right nephrectomy in the management of recurrent endometrioid ovarian adenocarcinoma: A case report and literature review. Clin Case Rep 2024; 12:e9148. [PMID: 38962465 PMCID: PMC11220455 DOI: 10.1002/ccr3.9148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 06/05/2024] [Accepted: 06/13/2024] [Indexed: 07/05/2024] Open
Abstract
Endometrioid ovarian adenocarcinoma is a common subtype of epithelial ovarian cancer that can arise on a background of endometriosis. Maximal cytoreductive effort with an aim to remove all macroscopic disease (achieve R0) is the single independent prognostic factor for survival. Complex multidisciplinary surgeries may be required in order to achieve this.
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Affiliation(s)
| | - Sabina Nistor
- Department of Gynaecology OncologyChurchill Hospital, Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - William Gietzmann
- Department of UrologyOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Nicholas Symons
- Department of Colorectal SurgeryOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Hooman Soleymani majd
- Department of Gynaecology OncologyChurchill Hospital, Oxford University Hospitals NHS Foundation TrustOxfordUK
- Nuffield Department of Women's and Reproductive HealthUniversity of OxfordOxfordUK
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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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Daggez M, Aslanca T, Dursun P. Intraoperative temporary internal iliac arterial occlusion (Polat's technique) for severe placenta accreta spectrum: A description of the technique and outcomes in 61 patients. Int J Gynaecol Obstet 2024; 164:99-107. [PMID: 37377184 DOI: 10.1002/ijgo.14968] [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: 03/16/2023] [Revised: 05/27/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVE To report the results of prophylactic use of intraoperative temporary internal iliac arterial occlusion by Bulldog clamps in patients clinically diagnosed with abnormally invasive placenta. METHODS This retrospective study included 61 patients diagnosed with FIGO grade 3 abnormally invasive placenta between January 2018 and March 2022. After transfundal incision and fetal delivery, bilateral temporary internal iliac arterial occlusion by Bulldog clamps was performed in all patients. The grades 3b and 3c group underwent cesarean hysterectomy whereas selected cases of grade 3a abnormally invasive placenta underwent fertility-preserving procedures. Preoperative and postoperative findings were compared. RESULTS Cesarean hysterectomy was performed in 50 (82%) patients and cesarean plus conservative procedures were performed in 11 (18%) patients. Intraoperative blood replacement was not performed in 83.6% of all patients. Mean blood loss was 1.37 ± 0.53 L (range 0.5-2.5) in all patients. Estimated blood loss was significantly higher in cesarean hysterectomy group. There was no statistically significant difference between two groups in terms of peroperative blood replacement, bladder, and ureteral injury. CONCLUSION Prophylactic bilateral temporary internal iliac arterial occlusion by Bulldog clamps should be performed in cases of grade 3 abnormally invasive placenta. Fertility-preserving steps may be undertaken safely in selected cases with this approach.
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Affiliation(s)
- Mine Daggez
- Department of Gynecologic Oncology, University of Health Sciences Tekirdag City Hospital, Tekirdag, Turkiye
| | - Tufan Aslanca
- Department of Gynecologic Oncology, University of Health Sciences Ankara City Hospital, Ankara, Turkiye
| | - Polat Dursun
- Private Gynecologic Oncology Clinic, Ankara, Turkiye
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Palacios-Jaraquemada JM, Nieto-Calvache Á, Aryananda RA, Basanta N. Placenta accreta spectrum into the parametrium, morbidity differences between upper and lower location. J Matern Fetal Neonatal Med 2023; 36:2183764. [PMID: 36966802 DOI: 10.1080/14767058.2023.2183764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
Abstract
OBJECTIVE To demonstrate the surgical and morbidity differences between upper and lower parametrial placenta invasion (PPI). MATERIALS AND METHODS Forty patients with placenta accreta spectrum (PAS) into the parametrium underwent surgery between 2015 and 2020. Based on the peritoneal reflection, the study compared two types of parametrial placental invasion (PPI), upper or lower. Surgical approach to PAS follows a conservative-resective method. Before delivery, surgical staging by pelvic fascia dissection established a final diagnosis of placental invasion. In upper PPI cases, the team attempted to repair the uterus after resecting all invaded tissues or performing a hysterectomy. In cases of lower PPI, experts performed a hysterectomy in all cases. The team only used proximal vascular (aortic occlusion) control in cases of lower PPI. Surgical dissection for lower PPI started finding the ureter in the pararectal space, ligating all the tissues (placenta and newly formed vessels) to create a tunnel to release the ureter from the placenta and placenta suppletory vessels. Overall, at least three pieces of the invaded area were sent for histological analysis. RESULTS Forty patients with PPI were included, 13 in the upper parametrium and 27 in the lower parametrium. MRI indicated PPI in 33/40 patients; in three, the diagnosis was presumed by ultrasound or medical background. The intrasurgical staging categorizes 13 cases of PPI performed and finds diagnosis in seven undetected cases. The expertise team completed a total hysterectomy in 2/13 upper PPI cases and all lower PPI cases (27/27). Hysterectomies in the upper PPI group were performed by extensive damage of the lateral uterine wall or with a tube compromise. Ureteral injury ensued in six cases, corresponding to cases without catheterization or incomplete ureteral identification. All aortic vascular proximal control (aortic balloon, internal aortic compression, or aortic loop) was efficient for controlling bleeding; in contrast, ligature of the internal iliac artery resulted in a useless procedure, resulting in uncontrollable bleeding and maternal death (2/27). All patients had antecedents of placental removal, abortion, curettage after a cesarean section, or repeated D&C. CONCLUSIONS Lower PAS parametrial involvement is uncommon but associated with elevated maternal morbidity. Upper and lower PPI has different surgical risks and technical approaches; consequently, an accurate diagnosis is needed. The clinical background of manual placental removal, abortion, and curettage after a cesarean or repeated D&C could be ideally studied to diagnose a possible PPI. For patients with high-risk antecedents or unsure ultrasound, a T2 weight MRI is always recommended. Performing comprehensive surgical staging in PAS allows the efficient diagnosis of PPI before using some procedures.
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Teixeira B, Pinto PV, Realista R, Silva M, Costa A, Machado AP, Moucho M. Placenta Accreta Spectrum Disorders - The Impact of the Creation of a Multidisciplinary Team on Maternal Outcomes in Portugal. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:e747-e753. [PMID: 38141594 DOI: 10.1055/s-0043-1772482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2023] Open
Abstract
OBJECTIVE To describe a cohort of placenta accreta spectrum (PAS) cases from a tertiary care institution and compare the maternal outcomes before and after the creation of a multidisciplinary team (MDT). METHODS Retrospective study using hospital databases. Identification of PAS cases with pathological confirmation between 2010 and 2021. Division in two groups: standard care (SC) group - 2010-2014; and MDT group - 2015-2021. Descriptive analysis of their characteristics and maternal outcomes. RESULTS During the study period, there were 53 cases of PAS (24 - SC group; 29 - MDT group). Standard care group: 1 placenta increta and 3 percreta; 12.5% (3/24) had antenatal suspicion; 4 cases had a peripartum hysterectomy - one planned due to antenatal suspicion of PAS; 3 due to postpartum hemorrhage. Mean estimated blood loss (EBL) was 2,469 mL; transfusion of packed red blood cells (PRBC) in 25% (6/24) - median 7.5 units. Multidisciplinary team group: 4 cases of placenta increta and 3 percreta. The rate of antenatal suspicion was 24.1% (7/29); 9 hysterectomies were performed, 7 planned due to antenatal suspicion of PAS, 1 after intrapartum diagnosis of PAS and 1 after uterine rupture following a second trimester termination of pregnancy. The mean EBL was 1,250 mL, with transfusion of PRBC in 37.9% (11/29) - median 2 units. CONCLUSION After the creation of the MDT, there was a reduction in the mean EBL and in the median number of PRBC units transfused, despite the higher number of invasive PAS disorders.
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Affiliation(s)
- Beatriz Teixeira
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Pedro Viana Pinto
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Anatomy, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Department of Obstetrics and Gynecology, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Rodrigo Realista
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Manuela Silva
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Antónia Costa
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Obstetrics and Gynecology, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Ana Paula Machado
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Marina Moucho
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
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Lucidi A, Jauniaux E, Hussein AM, Coutinho CM, Tinari S, Khalil A, Shamshirsaz A, Palacios-Jaraquemada JM, D'Antonio F. Urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:633-643. [PMID: 37401769 DOI: 10.1002/uog.26299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/16/2023] [Accepted: 04/21/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To report on the occurrence of urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders (PAS). METHODS MEDLINE, EMBASE and the Cochrane databases were searched electronically up to 1 November 2022. Studies reporting on the urological outcome of women undergoing Cesarean section for PAS were included. Two independent reviewers performed data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with disagreements resolved by consensus.The primary outcome was the overall occurrence of urological complications. Secondary outcomes were the occurrence of any cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula and vesicovaginal fistula. All outcomes were explored in the overall population of women undergoing surgery for PAS. In addition, we performed subgroup analyses according to the type of surgery (Cesarean hysterectomy, or conservative surgery or management), severity of PAS at histopathology (placenta accreta/increta and placenta percreta), type of intervention (planned vs emergency) and number of cases per year. Random-effects meta-analyses of proportions were used to analyze the data. RESULTS There were 62 studies included in the systematic review and 56 were included in the meta-analysis. Urological complications occurred in 15.2% (95% CI, 12.9-17.7%) of cases. Cystotomy complicated 13.5% (95% CI, 9.7-17.9%) of surgical operations. Intentional cystotomy was required in 7.7% (95% CI, 6.5-9.1%) of cases, while unintentional cystotomy occurred in 7.2% (95% CI, 6.0-8.5%) of cases. Urological complications occurred in 19.4% (95% CI, 16.3-22.7%) of cases undergoing hysterectomy and 12.2% (95% CI, 7.5-17.8%) of those undergoing conservative treatment. In the subgroup analyses, urological complications occurred in 9.4% (95% CI, 5.4-14.4%) of women with placenta accreta/increta and 38.5% (95% CI, 21.6-57.0%) of those described as having placenta percreta, and included mainly cystotomy (5.5% (95% CI, 0.6-15.1%) and 22.0% (95% CI, 5.4-45.5%), respectively). Urological complications occurred in 15.4% (95% CI, 8.1-24.6%) of cases undergoing a planned procedure and 24.6% (95% CI, 13.0-38.5%) of those undergoing an emergency intervention. In subanalysis of studies reporting on ≥ 12 cases per year, the incidence of urological complication was similar to that reported in the primary analysis. CONCLUSIONS Women undergoing surgery for PAS are at high risk of urological complication, mainly cystotomy. The incidence of these complications was particularly high in women described as having placenta percreta at birth and in those undergoing emergency surgical intervention. The high heterogeneity between the included studies highlights the need for a standardized protocol for the diagnosis of PAS to identify prenatal imaging signs associated with the increased risk of urological morbidity at delivery. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Lucidi
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - E Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - A M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - C M Coutinho
- Department of Gynecology and Obstetrics, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paolo, Brazil
| | - S Tinari
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
| | - A Shamshirsaz
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - J M Palacios-Jaraquemada
- CEMIC University Hospital and School of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
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Mousa A, Elkhateb IT, Gaafar HM, Elsherbini MM, Mousa H, Abdalla M, Abdelbar A, Rida D, Majd HS, Collins SL. Kasr Alainy simplified uterine preserving surgery for conservative management of placenta accreta spectrum (PAS): A modified surgical approach. Eur J Obstet Gynecol Reprod Biol 2023; 284:150-161. [PMID: 37001252 DOI: 10.1016/j.ejogrb.2023.03.026] [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: 10/15/2022] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVE The incidence of placenta accreta spectrum (PAS) is rising rapidly due to the global surge in Caesarean delivery. It is associated with significant maternal morbidity and mortality. It is usually managed with Caesarean hysterectomy. However, uterine preserving surgeries can have advantages over Caesarean hysterectomy and intentional placental retention techniques. STUDY DESIGN We present a modified technique of uterine preserving surgery that uses a safe approach for placental bed surgical devascularization. This is followed by resection of the invaded uterine segment and uterine wall reconstruction. RESULTS The technique was used in the management of 20 patients with antenatally suspected PAS that were confirmed at laparotomy. It was successful in preserving the uterus in 18/20 (90 %) women. The mean intraoperative blood loss in was 1305 CC (SD: +361.6) with a mean operative time of 123 min (SD: ±38.7). There was only one urinary bladder injury and no other maternal morbidity. CONCLUSION Our surgical technique is safe and may be useful for conservative surgical management of PAS, particularly in low- and middle-income countries, where access to complex resources, such as interventional radiology, is limited.
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Affiliation(s)
- Abdalla Mousa
- University Department of Obstetrics and Gynecology, Faculty of Medicine, Kasr Alainy Hospital, Cairo University, Cairo, Egypt.
| | - Islam T Elkhateb
- University Department of Obstetrics and Gynecology, Newgiza University School of Medicine, Giza, Egypt
| | - Hassan M Gaafar
- University Department of Obstetrics and Gynecology, Faculty of Medicine, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
| | - Moutaz M Elsherbini
- University Department of Obstetrics and Gynecology, Faculty of Medicine, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
| | - Hatem Mousa
- Leicester Obstetrics and Midwifery Centre for Women's Health Research, University Department of Obstetrics and Gynecology, University Hospital of Leicester NHS Trust, United Kingdom
| | - Mostafa Abdalla
- Department of Gynecological Oncology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Ahmed Abdelbar
- University Department of Obstetrics and Gynecology, Faculty of Medicine, Kasr Alainy Hospital, Cairo University, Cairo, Egypt; Department of Gynecological Oncology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Dana Rida
- Department of Radiology, Jordan University, Jordan
| | - Hooman Soleymani Majd
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom; Department of Gynecological Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom; Fetal Medicine Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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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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Safe Service Delivery of a Complex Early Pregnancy Problem: Caesarean Scar Pregnancy. J Clin Med 2022; 11:jcm11237063. [PMID: 36498640 PMCID: PMC9741336 DOI: 10.3390/jcm11237063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/14/2022] [Accepted: 11/25/2022] [Indexed: 12/02/2022] Open
Abstract
Caesarean Scar Pregnancy (CSP) is an ectopic pregnancy with implantation into the niche of the uterine scar. We aimed to describe the local management of consecutive cases of CSP to develop a standard operating procedure (SOP). Between December 2019 and June 2022, there were 19,100 maternities. Of these, 23 were CSPs in 19 patients. Median BMI was 29 (range 20.5-52), median number of Caesarean deliveries (CS) was 2 (range 1-4) and 7/23 (30%) were cigarette smokers. At diagnosis, 9/23 were live pregnancies, 3/23 were retained products of conception (RPOC), 9/23 were pregnancies of uncertain viability (PUV), and 2/23 were non-viable. In six, the initial management was expectant, surgical suction evacuation with transrectal ultrasound guidance in 16, and one had a hysterectomy. The median blood loss was 100 mL (range 50-2000 mL). Two patients (9%) required a blood transfusion. Median hospital stay was 1 day (range 0-4). At follow-up after 10 weeks, no patients had an ongoing haematoma, and one had significant RPOC electing hysterectomy. Eight women were known to have 9 subsequent pregnancies (recurrent CSP n = 4, livebirth n = 2, miscarriage n = 2, tubal ectopic n = 1). Outcomes as rated by low blood loss, short hospital stay, and rare need for further intervention were favorable. Factors associated included prompt ultrasonographic diagnosis, availability of transrectal ultrasound guided surgery, and specialist follow-up, which form the basis of the SOP.
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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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11
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Li C, Duan W, Zhu Y, Li G, Gao M, Weng Z, Zhu Y, Bu Y. Cohesion Design-Led Tough Sealants with Controllably Dissolvable Properties. ACS APPLIED MATERIALS & INTERFACES 2022; 14:34415-34426. [PMID: 35857427 DOI: 10.1021/acsami.2c08328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Leakage is a common complication of surgeries and injuries, causing pain and increasing the economic burden on patients. Although there are commercially available sealants for leakage prevention, few of them are entirely satisfactory due to disease transmission, high cost, and poor biocompatibility. In addition, none of them can be controllably removed for further healthcare. In this paper, by using cohesion design, a sealant based on amino-modified gelatin (AG) and bi-polyethylene glycol N-hydroxysuccinimide active ester (Bi-PEG-SS) was fabricated. To increase the bursting pressure, the cohesion strength was enhanced by increasing the cross-linking density of the sealant. To endow the sealant with controllably dissolvable properties, the smart succinic ester units were introduced into the cohesion network. Both the in vitro and in vivo experiments showed that this sealant processed high bursting pressure with efficient hemorrhage control. Moreover, no side effects were observed after 7 days of in vivo sealing, including little inflammation and fibrogenesis. These results, together with the easy availability of the raw materials, revealed that this sealant might be a promising alternative for leakage sealing.
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Affiliation(s)
- Chaowei Li
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian 350108, China
- Institute of Medical Engineering, Department of Biophysics, School of Basic Medical Sciences, Health Science Center, Xi'an Jiaotong University, Xi'an 710061, China
| | - Wanglin Duan
- Institute of Medical Engineering, Department of Biophysics, School of Basic Medical Sciences, Health Science Center, Xi'an Jiaotong University, Xi'an 710061, China
| | - Ye Zhu
- Institute of Medical Engineering, Department of Biophysics, School of Basic Medical Sciences, Health Science Center, Xi'an Jiaotong University, Xi'an 710061, China
| | - Guanying Li
- Institute of Medical Engineering, Department of Biophysics, School of Basic Medical Sciences, Health Science Center, Xi'an Jiaotong University, Xi'an 710061, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education of China, Xi'an 710061, China
| | - Min Gao
- Institute of Molecular and Translational Medicine, Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University, Xi'an 710061, China
| | - Zuquan Weng
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Yuan Zhu
- Department of Gynecology, The Affiliated Maternal and Child Healthcare Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
- Department of Gynecology, Jiangxi Provincial Maternal and Child Health Hospital, Nanchang, Jiangxi 330006, China
| | - Yazhong Bu
- Institute of Medical Engineering, Department of Biophysics, School of Basic Medical Sciences, Health Science Center, Xi'an Jiaotong University, Xi'an 710061, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education of China, Xi'an 710061, China
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12
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McCall SJ, Deneux-Tharaux C, Sentilhes L, Ramakrishnan R, Collins SL, Seco A, Kurinczuk JJ, Knight M, Kayem G. Placenta accreta spectrum - variations in clinical practice and maternal morbidity between the UK and France: a population-based comparative study. BJOG 2022; 129:1676-1685. [PMID: 35384244 PMCID: PMC9544707 DOI: 10.1111/1471-0528.17169] [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: 01/20/2022] [Revised: 03/15/2022] [Accepted: 03/28/2022] [Indexed: 11/30/2022]
Abstract
Objective To compare the management and outcomes of women with placenta accreta spectrum (PAS) in France and the UK. Design Two population‐based cohorts. Setting All obstetrician‐led hospitals in the UK and maternity hospitals in eight French regions. Population A cohort of 219 women with PAS in France and a cohort of 154 women with PAS in the UK. Methods The management and outcomes of women with PAS were compared between the UK and France. Main outcome measures Median blood loss, severe postpartum haemorrhage (≥3 l), postpartum infection and damage to surrounding organs. Results The management of PAS differed between the two countries: a larger proportion of women with PAS in the UK had a caesarean hysterectomy compared with France (43% vs 26%, p < 0.001), whereas in France a larger proportion of women with PAS received a uterus‐preserving approach compared with the UK (36% vs 19%, p < 0.001). The total median blood loss in the UK was 3 l (IQR 1.7–6.5 l), compared with 1 l (IQR 0.5–2.5 l) in France; more women with PAS had a severe postpartum haemorrhage (PPH) in the UK compared with women with PAS in France (58% vs 21%, p < 0.001) [Correction added on 06 May 2022, after first online publication: ‘24 hour’ has been changed to ‘total’ in the preceding sentence]. There was no difference between the UK and French populations for postpartum infection or organ damage. Conclusions The UK and France have very different approaches to managing PAS, with more women in France receiving a uterine‐conserving approach and more women in the UK undergoing caesarean hysterectomy. A life‐threatening haemorrhage was more common in the UK than in France, which may be the result of differential management and/or the organisation of the healthcare systems. In women with placenta accreta spectrum, severe haemorrhage was more common in the UK than in France. Tweetable abstract In women with placenta accreta spectrum, severe haemorrhage was more common in the UK than in France. In women with placenta accreta spectrum, severe haemorrhage was more common in the UK than in France. Linked article: This article is commented on by Amarnath Bhide, pp. 1686 in this issue. To view this minicommentary visit https://doi.org/10.1111/1471-0528.17170.
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Affiliation(s)
- Stephen J McCall
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Université de Paris, CRESS U1153, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Paris, France.,Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Catherine Deneux-Tharaux
- Université de Paris, CRESS U1153, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Paris, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Rema Ramakrishnan
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK.,Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK
| | - Aurélien Seco
- Clinical Research Unit, Paris-Descartes Necker/Cochin, Paris, France
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Gilles Kayem
- Université de Paris, CRESS U1153, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Paris, France.,Hôpital Trousseau, Assistance Publique -Hôpitaux de Paris (APHP), Sorbonne Université, Paris, France
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13
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Internal manual compression of the aorta-an effective way to temporarily control pelvic bleeding in obstetrical hemorrhage. Am J Obstet Gynecol 2022; 227:96-97. [PMID: 35248574 DOI: 10.1016/j.ajog.2022.02.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/15/2022] [Accepted: 02/15/2022] [Indexed: 11/22/2022]
Abstract
Obstetrical hemorrhage is the leading cause of maternal death, and its treatment frequently involves surgical procedures. In the most serious cases, regardless of the etiology, the priority is to stop the bleeding and obtain the conditions to definitively repair the injury that generates the bleeding. Multiple options for achieving hemostasis have been described, but most of them require extensive training or technological resources that are not available in all hospitals. Internal manual aortic compression is a procedure that is widely used in the management of massive pelvic bleeding; it was first described more than 50 years ago in obstetrics but is rarely used by obstetricians today. We describe in detail the technique for internal manual aortic compression and highlight the simplicity and effectiveness of the procedure, especially as an initial measure, to avoid the metabolic consequences of massive blood loss. We hope that internal manual aortic compression is taken into account by each obstetrician when caring for a pregnant woman with massive bleeding.
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14
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Lumbreras-Marquez MI, Villela-Franyutti D, Reale SC, Farber MK. Coagulation Management in Obstetric Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00517-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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15
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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Vergara-Galliadi LM, Nieto-Calvache AS, Zambrano MA, Burgos-Luna JM. Training facilitated by interinstitutional collaboration and telemedicine: an alternative for improving results in the placenta accreta spectrum. AJOG GLOBAL REPORTS 2021; 1:100028. [PMID: 36277461 PMCID: PMC9563901 DOI: 10.1016/j.xagr.2021.100028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 11/27/2022] Open
Abstract
Placenta accreta spectrum is a severe condition that requires trained, interdisciplinary group intervention. However, achieving the level of training that is required is difficult without academic programs or hospitals dedicated to teaching the necessary skills to deal with placenta accreta spectrum. We describe an interinstitutional collaboration process focused on improving placenta accreta spectrum treatment, which is facilitated by telemedicine. Lastly, we propose a replicable model for other centers. This was a retrospective, descriptive study that included placenta accreta spectrum patients treated over a 10-year period in a low-middle income country hospital (local hospital). We evaluated the clinical results and impact of interinstitutional collaboration with a placenta accreta spectrum expert group at another low-middle income country hospital. Virtual strategies of continuous communication between the local hospital and expert group were used, such as telemedicine, teleradiology, and telepresence during surgeries. A total of 89 placenta accreta spectrum patients were included. We observed a progressive improvement in the clinical outcomes (intraoperative bleeding, transfusion frequency, postoperative length of stay, and frequency of complications) as the fixed interdisciplinary group at the local hospital gained experience by treating more cases. Interinstitutional collaboration (through telemedicine and remote supervision) and placenta accreta spectrum team formation were the 2 factors associated with the best outcomes in the most recent years of observation. Thus, ongoing placenta accreta spectrum team training, facilitated by interinstitutional collaboration and telemedicine, is a valid strategy for improving the clinical outcomes in placenta accreta spectrum.
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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Aryananda RA, Rodriguez F, Ordoñez CA, Messa Bryon A, Calvache JPB, Lopez J, Campos CI, Mejia M, Rengifo M, Galliadi LMV, Maya J, Zambrano MA, Aguayo IP, Carabalí IG, Burgos JM. How to identify patients who require aortic vascular control in placenta accreta spectrum disorders? Am J Obstet Gynecol MFM 2021; 4:100498. [PMID: 34610485 DOI: 10.1016/j.ajogmf.2021.100498] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The placenta accreta spectrum disorder may lead to severe complications. Helpful interventions to prevent placenta accreta spectrum bleeding include vascular control procedures in the aorta or pelvic vessels. Although these procedures are related to lower intraoperative bleeding, they are associated with complications, so the possibility of selecting patients at highest risk of bleeding while avoiding vascular procedures for all cases is attractive. OBJECTIVE We describe an intraoperative staging protocol whose objective is to identify the need to use vascular control procedures in patients with placenta accreta spectrum. We also describe the results of its application in a placenta accreta spectrum referral hospital. STUDY DESIGN This descriptive, retrospective study included patients with suspected prenatal placenta accreta spectrum treated at a referral center for placenta accreta spectrum between April 2016 and June 2020. The use of the resuscitative endovascular balloon occlusion of the aorta allowed the prevention and treatment of excessive bleeding; its application was performed according to 3 approaches: (1) presurgical use in all placenta accreta spectrum patients (Group 1), (2) according to the prenatal placenta accreta spectrum topography (Group 2), and (3) according to the "intraoperative staging" (Group 3). In addition, the frequency of use of resuscitative endovascular balloon occlusion of the aorta and the clinical results in the management of placenta accreta spectrum were described in the 3 groups. RESULTS Seventy patients underwent surgery for a prenatal suspicion of placenta accreta spectrum. Of these, 16 underwent intraoperative staging (Group 3); in 20 cases, resuscitative endovascular balloon occlusion of the aorta was used based on the prenatal imaging topographic classification (Group 2), and in the remaining 34 patients (Group 1), it was always used before the laparotomy. The frequency of use of resuscitative endovascular balloon occlusion of the aorta was progressively lower in Groups 1 (32 patients, 94.1% of cases), 2 (11 patients, 75% of cases), and 3 (4 patients, 25% of cases). Similarly, resuscitative endovascular balloon occlusion of the aorta went from being applied predominantly before the laparotomy (all cases in Group 1) to being applied after intraoperative staging (all cases in Group 3). The percentage of endovascular devices applied but not used, decreased from 23.5% in Group 1 to 0% in Group 3. Complications related to the resuscitative endovascular balloon occlusion of the aorta were seen in 4 patients (2 women in Group 1, and 1 woman each in Groups 2 and 3). CONCLUSION The "intraoperative staging" of placenta accreta spectrum allows the optimization of the use of resuscitative endovascular balloon occlusion of the aorta, which decreases the frequency of its use without increasing the volume of blood loss.
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Affiliation(s)
- Albaro José Nieto-Calvache
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos).
| | | | - Rozi Aditya Aryananda
- Dr Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia (Dr Aryananda)
| | - Fernando Rodriguez
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); División de Trauma y Emergencias, Departamento de Cirugía General, Fundación Valle del Lili, Cali, Colombia (Drs Rodriguez and Ordoñez)
| | - Carlos A Ordoñez
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); División de Trauma y Emergencias, Departamento de Cirugía General, Fundación Valle del Lili, Cali, Colombia (Drs Rodriguez and Ordoñez)
| | - Adriana Messa Bryon
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
| | - Juan Pablo Benavides Calvache
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
| | - Jaime Lopez
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
| | - Clara Ivette Campos
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Patología y Laboratorio Clínico, Fundación Valle del Lili, Cali, Colombia (Dr Campos)
| | - Mauricio Mejia
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Radiología e Imágenes Diagnósticas, Fundación Valle del Lili, Cali, Colombia (Drs Mejia and Rengifo)
| | - Martin Rengifo
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Radiología e Imágenes Diagnósticas, Fundación Valle del Lili, Cali, Colombia (Drs Mejia and Rengifo)
| | | | - Juliana Maya
- Programa de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Drs Maya, Aguayo, and Carabalí)
| | - Maria Andrea Zambrano
- Programa de Ginecología y Obstetricia, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Dr Zambrano)
| | - Isabella Prado Aguayo
- Programa de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Drs Maya, Aguayo, and Carabalí)
| | - Isabella Gutierrez Carabalí
- Programa de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Drs Maya, Aguayo, and Carabalí)
| | - Juan Manuel Burgos
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
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