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Flores-Mendoza H, Shehata N, Murji A, Allen LM, Kingdom JC, Windrim RC, Carvalho JCA, Ravi Chandran A, Papalia N, Hobson SR. Use of intraoperative red cell salvage in the contemporary management of placenta accreta spectrum disorders. Can J Anaesth 2023; 70:1544-1546. [PMID: 37308739 DOI: 10.1007/s12630-023-02490-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/07/2023] [Accepted: 02/07/2023] [Indexed: 06/14/2023] Open
Affiliation(s)
- Homero Flores-Mendoza
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Nadine Shehata
- Division of Hematology, Departments of Medicine, Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Ally Murji
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Lisa M Allen
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - John C Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Rory C Windrim
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Jose C A Carvalho
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Anjana Ravi Chandran
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Nicholas Papalia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Sebastian R Hobson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.
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Warrick CM, Sutton CD, Farber MM, Hess PE, Butwick A, Markley JC. Anesthesia Considerations for Placenta Accreta Spectrum. Am J Perinatol 2023; 40:980-987. [PMID: 37336215 DOI: 10.1055/s-0043-1761637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Anesthesiologists are critical members of the multidisciplinary team managing patients with suspected placenta accreta spectrum (PAS). Preoperatively, anesthesiologists provide predelivery consultation for patients with suspected PAS where anesthetic modality and invasive monitor placement is discussed. Additionally, anesthesiologists carefully assess patient and surgical risk factors to choose an anesthetic plan and to prepare for massive intraoperative hemorrhage. Postoperatively, the obstetric anesthesiologist hold unique skills to assist with postoperative pain management for cesarean hysterectomy. We review the unique aspects of peripartum care for patients with PAS who undergo cesarean hysterectomy and explain why these responsibilities are critical for achieving successful outcomes for patients with PAS. KEY POINTS: · Anesthesiologists are critical members of the multidisciplinary team planning for patients with suspected placenta accreta spectrum.. · Intraoperative preparation for massive hemorrhage is a key component of anesthetic care for patients with PAS.. · Obstetric anesthesiologists have a unique skill set to manage postpartum pain and postoperative disposition for patients with PAS who undergo cesarean hysterectomy..
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Affiliation(s)
- Christine M Warrick
- Department of Anesthesiology, School of Medicine, University of Utah Hospital, Salt Lake City, Utah
| | - Caitlin D Sutton
- Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Michaela M Farber
- Department of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Philip E Hess
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Alexander Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University Medical Center, Palo Alto, California
| | - John C Markley
- Department of Anesthesia and Perioperative Care, University of California San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
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3
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Ioscovich A, Weiss A, Shatalin D. The anesthetic approach to a patient with placenta accreta spectrum. Curr Opin Anaesthesiol 2023; 36:263-268. [PMID: 36745077 DOI: 10.1097/aco.0000000000001242] [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: 02/07/2023]
Abstract
PURPOSE OF REVIEW Placenta accreta poses significant risk of morbidity and mortality to a laboring patient. Here we review available treatment options, highlight trends in bleeding prevention and diagnosis that have been shown to improve patient outcome, and provide best practice suggestions. We also discuss the decision-making process for choice of anesthesia, as it is not based on a gold-standard paradigm. RECENT FINDINGS The use of resuscitative endovascular balloon occlusion of the aorta has been gaining popularity around the world. It has been shown to cause an equivocal reduction in perioperative bleeding in placenta accreta spectrum (PAS), reduce the rate of hysterectomies, and is a safe and relatively easy technique. There are other invasive radiology techniques that have also proven to be beneficial in bleeding prevention: balloon occlusion of hypogastric arteries intraoperatively, internal iliac artery embolization, and intraoperative ligation of the hypogastric or uterine arteries. SUMMARY Optimal management of PAS begins with early and definitive diagnosis. A multidisciplinary approach along with preparation of special equipment and the use of a check-list maximize the chance for success. Anesthesia could be done with all types of regional or under general, considering case-by-case factors but most importantly choosing according to the institution's best facility and skill.
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Affiliation(s)
- Alexander Ioscovich
- Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Zedek Medical Center, affiliated with The Hebrew University, Jerusalem, Israel
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Detlefs SE, Goffman D, Buttle RA, Crump CM, Thornburg LL, Foley MR, Deering S. Correlation between medical management and teamwork in multidisciplinary high-fidelity obstetrics simulations. Am J Obstet Gynecol MFM 2022; 4:100626. [PMID: 35351671 DOI: 10.1016/j.ajogmf.2022.100626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/23/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Teamwork and communication gaps are consistently cited as contributors to adverse outcomes in obstetrics. The Critical Care in Obstetrics Course provides an innovative experience by combining brief interactive didactics with the opportunity to practice and implement the knowledge gained with hands-on simulation. Most participants have never worked together, which creates a unique environment to evaluate the importance of teamwork and communication. OBJECTIVE This study aimed to evaluate the association between teamwork and medical management in high-fidelity critical care simulations. STUDY DESIGN The participants were separated into multidisciplinary teams and taken through simulations, including placental abruption, hypertensive emergency, eclampsia, sepsis, cardiac arrest, venous thromboembolism, diabetic ketoacidosis, and thyroid storm. Facilitators completed a validated checklist assessment for each group's performance in medical care and teamwork. Each element was rated on a scale from 1 to 5, with 1 being unacceptable and 5 being perfect. We evaluated 5 communication measures, including the use of closed-loop communication and orientation of new team members. A Spearman correlation was used to evaluate the relationship between total medical management and total teamwork scores and specific measures of team communication. Receiver operating characteristic curves were created for total teamwork score as a predictor of good or perfect medical management. RESULTS A total of 354 multidisciplinary teams participated in 1564 high-fidelity simulations. There was a significant correlation between medical management and teamwork and communication scores for all scenarios. The strongest correlation was for the total teamwork score for all simulations (ρ=0.84). Teamwork scores were highly predictive of medical management scores with an area under the curve of at least 0.88 for all simulations, although this was not significant for diabetic ketoacidosis. CONCLUSION The quality of teamwork and communication correlated with the quality of clinical performance in newly formed multidisciplinary teams. This demonstrates the importance of teamwork training, with a focus on key communication tools and strategies, among medical providers to optimize the management of complex and emergent obstetrical conditions.
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Affiliation(s)
- Sarah E Detlefs
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Detlefs)
| | - Dena Goffman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY (Dr Goffman)
| | - Rae A Buttle
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX (Ms Buttle)
| | | | - Loralei L Thornburg
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY (Dr Thornburg)
| | - Michael R Foley
- Banner-University Medical Center Phoenix, The University of Arizona College of Medicine-Phoenix, Phoenix, AZ (Dr Foley)
| | - Shad Deering
- Department of Obstetrics and Gynecology, Christus Health, Baylor College of Medicine, San Antonio, TX (Dr Deering).
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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Vergara-Galliadi LM, Matera L, Sanín-Blair JE, Rivera EP, Rozo-Rangel AP, Burgos-Luna JM. All maternal deaths related to placenta accreta spectrum are preventable: a difficult-to-tell reality. AJOG GLOBAL REPORTS 2021; 1:100012. [PMID: 36277252 PMCID: PMC9563525 DOI: 10.1016/j.xagr.2021.100012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Most maternal deaths related to postpartum hemorrhage are preventable. In most cases, placenta accreta spectrum is the principal cause of severe postpartum hemorrhage; however, there are few studies about maternal deaths, probably because of the legal implications of “problems” in the management of patients who have died. OBJECTIVE This study aimed to identify the problems or “delays” in the care of patients who die because of placenta accreta spectrum in Latin America. STUDY DESIGN A retrospective, descriptive, observational multicentric study in Latin American hospitals was conducted. The care of patients who died from placenta accreta spectrum was investigated under a “delay” study model that included delays related to patients, institutions, and healthcare providers. Centers of excellence standards of care were taken into account, and 2 analysis moments were included: an initial analysis for each local care group in the place where maternal death occurred and another analysis that included the main researcher. All information were collected through a predesigned survey and discussed by telephone. RESULTS Overall, 52 patients in 10 Latin American countries were included, with options for improvement identified in all cases. The most prevalent type of delay was associated with health providers (98% of cases), followed by health institutions (96% of cases) and patients (63% of cases). Each hospital's analysis group defined maternal death as avoidable in all cases and determined that the interventions needed to improve the outcome would present low, moderate, and high difficulties in 28.8%, 48.1%, and 34.8% of cases, respectively. CONCLUSION All maternal deaths related to placenta accreta spectrum were potentially preventable, and 76.9% of cases were avoidable by low to moderate complexity interventions.
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Affiliation(s)
- Albaro J. Nieto-Calvache
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs AJ Nieto-Calvache and Burgos-Luna)
- Corresponding author: Albaro J. Nieto-Calvache, MD.
| | | | - Lina M. Vergara-Galliadi
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia (Dr Vergara-Galliadi)
| | - Lía Matera
- Placenta Accreta Spectrum Team, Clínica Santa Cruz de Bocagrande, Cartagena, Colombia (Dr Matera)
| | - José E. Sanín-Blair
- Maternal Fetal Medicine Unit, Clinica Universitaria Bolivariana/Clinica el Rosario, Medellín, Colombia (Dr Sanín-Blair)
| | | | - Adda P. Rozo-Rangel
- Hospital San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia (Dr Rozo-Rangel)
| | - Juan M. Burgos-Luna
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs AJ Nieto-Calvache and Burgos-Luna)
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6
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Advances in anesthetic and obstetric management of patients with placenta accreta spectrum. Curr Opin Anaesthesiol 2021; 34:260-268. [PMID: 33935172 DOI: 10.1097/aco.0000000000000985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The incidence of placenta accreta spectrum is increasing and it is a leading cause of peripartum hysterectomy and massive postpartum hemorrhage. The purpose of the present article is to provide a contemporary overview of placenta accreta spectrum pertinent to the obstetric anesthesiologist. RECENT FINDINGS Recent changes in the terminology used to report invasive placentation were proposed to clarify diagnostic criteria and guidelines for use in clinical practice. Reduced morbidity is associated with scheduled preterm delivery in a center of excellence using a multidisciplinary team approach. Neuraxial anesthesia as a primary technique is increasingly being used despite the known risk of major bleeding. The use of viscoelastic testing and endovascular interventions may aid hemostatic resuscitation and improve outcomes. SUMMARY Accurate diagnosis and early antenatal planning among team members are essential. Obstetric anesthesiologists should be prepared to manage a massive hemorrhage, transfusion, and associated coagulopathy. Increasingly, viscoelastic tests are being used to assess coagulation status and the ability to interpret these results is required to guide the transfusion regimen. Balloon occlusion of the abdominal aorta has been proposed as an intervention that could improve outcomes in women with placenta accreta spectrum, but high-quality safety and efficacy data are lacking.
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Hobson SR, Kingdom JCP, Windrim RC, Murji A, Milligan N, Pacheco JF, Lu C, Steckham KE, Kajal D, Pantazi S, Carvalho JCA, Parks WT, Allen LM. Safer outcomes for placenta accreta spectrum disorders: A decade of quality improvement. Int J Gynaecol Obstet 2021; 157:130-139. [PMID: 33890292 DOI: 10.1002/ijgo.13717] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/13/2021] [Accepted: 04/19/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To describe the evolution and evaluation of protocol-based multidisciplinary quality improvement (QI) in women undergoing cesarean hysterectomy for radiologically suspected and pathologically confirmed placenta accreta spectrum (PAS) disorders. METHODS A single-center, retrospective cohort study was conducted of all patients undergoing cesarean hysterectomy for PAS disorders between March 2009 and June 2018. Two distinct periods were defined to compare outcomes: 2009-2011 (initial period) and 2017-2018 (current period). Primary outcomes included blood loss and administration of blood products. Secondary outcomes included perioperative levels of hemoglobin, adverse events and complications, time to mobilization, and length of hospitalization. RESULTS Among the 105 consecutive patients identified, there were 26 in the initial period and 32 in the current period. With the implementation of all QI care bundles, median estimated surgical blood loss halved from 2000 ml in the initial period to 1000 ml in the current period, and fewer patients required allogenic blood transfusion (61.5% vs 25%). Patients in the current period demonstrated improved postoperative levels of hemoglobin compared to those in the initial period (101 g/L vs 89 g/L) and had a shorter median postoperative hospital stay (3 days vs 5 days). CONCLUSION These results support the implementation of a multifaceted QI and patient care initiative for women with PAS disorders.
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Affiliation(s)
- Sebastian R Hobson
- Department of Obstetrics & Gynaecology, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada
| | - John C P Kingdom
- Department of Obstetrics & Gynaecology, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada.,Department of Diagnostic Imaging, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada
| | - Rory C Windrim
- Department of Obstetrics & Gynaecology, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada
| | - Ally Murji
- Department of Obstetrics & Gynaecology, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada
| | - Natasha Milligan
- Department of Obstetrics & Gynaecology, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada
| | - Jessica F Pacheco
- Department of Obstetrics & Gynaecology, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada
| | - Catherine Lu
- Department of Obstetrics & Gynaecology, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada
| | - Katherine E Steckham
- Department of Obstetrics & Gynaecology, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada
| | - Dilkash Kajal
- Department of Diagnostic Imaging, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada
| | - Sophia Pantazi
- Department of Diagnostic Imaging, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada
| | - Jose C A Carvalho
- Department of Obstetrics & Gynaecology, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada.,Department of Anaesthesia, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada
| | - W Tony Parks
- Department of Pathology & Laboratory Medicine, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada
| | - Lisa M Allen
- Department of Obstetrics & Gynaecology, University of Toronto & Mount Sinai Hospital, Toronto, ON, Canada
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Einerson BD, Weiniger CF. Placenta accreta spectrum disorder: updates on anesthetic and surgical management strategies. Int J Obstet Anesth 2021; 46:102975. [PMID: 33784573 DOI: 10.1016/j.ijoa.2021.102975] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 01/31/2021] [Accepted: 02/24/2021] [Indexed: 12/15/2022]
Abstract
Placenta accreta spectrum (PAS) is a leading contributor to major obstetric hemorrhage and severe maternal morbidity in the developed world. In the United States, PAS has become the most common cause of peripartum hysterectomy. Over the last 40 years, clinicians have also witnessed a dramatic increase in the incidence of PAS. In the 1950s, the incidence of PAS was reported to be 0.03 per 1000 pregnancies. Recent epidemiological studies estimate that the PAS incidence is between 0.79 and 3.11 in 1000 pregnancies. As a consequence, obstetric anesthesiologists are increasingly likely to be called upon to manage women with suspected PAS for delivery. Given the increasing incidence and the morbidity burden associated with PAS, anesthesiologists play a vital role in optimizing maternal outcomes for women with PAS. This review will provide up-to-date information on nomenclature, pathophysiology, risk factors, antenatal detection, systemic preparations (includes timing of delivery, location of surgery, pre-operative evaluation and patient positioning), surgical and anesthetic approach, intra-operative management, invasive radiology and postoperative plans.
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Affiliation(s)
- B D Einerson
- University of Utah Health Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Salt Lake City, Utah, USA.
| | - C F Weiniger
- Division of Anesthesia, Critical Care and Pain, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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Nieto-Calvache AJ, Hidalgo-Cardona A, Lopez-Girón MC, Rodriguez F, Ordoñez C, Garcia AF, Mejia M, Pabón-Parra MG, Burgos-Luna JM. Arterial thrombosis after REBOA use in placenta accreta spectrum: a case series. J Matern Fetal Neonatal Med 2020; 35:4031-4034. [PMID: 33207992 DOI: 10.1080/14767058.2020.1846178] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The use of resuscitative endovascular balloon of the aorta (REBOA) is a useful strategy for bleeding control in placenta accreta spectrum (PAS) management. The incidence of complications associated with this procedure is variable. We report three cases of arterial thrombosis associated with REBOA, and we also analyze the factors that facilitated its occurrence. CASE REPORT Three women with PAS, presented common femoral and external iliac arterial thrombosis after REBOA use. Among the contributing factors probably associated with thrombosis, we identified the absence of ultrasound guidance for vascular access and the not using of heparin during aortic occlusion. CONCLUSIONS REBOA use is not exempt from complications and must be performed by experienced groups applying strategies to reduce the risks of complications.
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Affiliation(s)
| | | | | | - Fernando Rodriguez
- Fundación Valle del Lili, Trauma and Emergency Surgery Department, Cali, Colombia
| | - Carlos Ordoñez
- Fundación Valle del Lili, Trauma and Emergency Surgery Department, Cali, Colombia
| | - Alberto F Garcia
- Fundación Valle del Lili, Trauma and Emergency Surgery Department, Cali, Colombia
| | - Mauricio Mejia
- Radiology Department, Fundación Valle del Lili, Cali, Colombia
| | | | - Juan M Burgos-Luna
- Fundación Valle del Lili, Abnormally Invasive Placenta Clinic, Cali, Colombia
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Fratto VM, Conturie CL, Ballas J, Pettit KE, Stephenson ML, Truong YN, Henry D, Afshar Y, Murphy A, Kim L, Field N, Wing DA, Norton ME, Ramos GA. Assessing the multidisciplinary team approaches to placenta accreta spectrum across five institutions within the University of California fetal Consortium (UCfC). J Matern Fetal Neonatal Med 2019; 34:2971-2976. [PMID: 31645153 DOI: 10.1080/14767058.2019.1676411] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To describe the multidisciplinary approaches to placenta accreta spectrum (PAS) across five tertiary care centers that comprise the University of California fetal Consortium (UCfC) and to identify potential best practices. MATERIALS AND METHODS Retrospective review of all cases of pathologically confirmed invasive placenta delivered from 2009 to 2014 at UCfC. Differences in intraoperative management and outcomes based on prenatal suspicion were compared. Interventions assessed included ureteral stent use, intravascular balloon use, anesthetic type, gynecologic oncology (Gyn Onc) involvement, and cell saver use. Intervention variation by institution was also assessed. Analyses were adjusted for final pathologic diagnosis. Chi-square, Fisher's exact, Student's t-test, and Mann-Whitney's U-test were used as appropriate. Binary logistic regression and multivariable linear regression were used to adjust for confounders. RESULTS One hundred and fifty-one cases of pathologically confirmed invasive placenta were identified, of which 82% (123) were suspected prenatally. There was no correlation between the degree of invasion on prenatal imaging and use of each intervention. Ureteral stents were placed in 33% (41) of cases and did not reduce GU injury. Intravascular balloons were placed in 29% (36) of cases and were associated with shorter OR time (161 versus 236 min, p < .01) and lower estimated blood loss (EBL) (1800 versus 2500 ml, p < .01). General endotracheal anesthesia (GETA) was used in 70% (86). EBL did not differ between GETA and regional anesthesia. Gyn Onc was involved in 58% (71) of cases and EBL adjusted for final pathology was reduced with their involvement (2200 versus 2250 ml, p = .02) while OR time and intraoperative complications did not differ. Cell saver was used in 20% (24) and was associated with longer OR time (296 versus 200 min, p < .01). Use of cell saver was not associated with a difference in EBL or number of units of packed red cells transfused. All analyses were adjusted for pathologic severity of invasion. CONCLUSIONS Intravascular interventions such as uterine artery balloons and the inclusion of Gynecologic Oncologists as part of a multidisciplinary approach to treating PAS reduce EBL. Additionally, the placement of intravascular balloons may reduce OR time. No significant differences were seen in outcomes when comparing the use of ureteral stents, general anesthesia, or institutions. A team of experienced operators with a standard approach may be more significant than specific practices.
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Affiliation(s)
- Victoria M Fratto
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Charlotte L Conturie
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Jerasimos Ballas
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Kate E Pettit
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Megan L Stephenson
- Department of Obstetrics and Gynecology, University of California Irvine, Irvine, CA, USA
| | - Yen N Truong
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Dana Henry
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Yalda Afshar
- Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Aisling Murphy
- Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Lena Kim
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Nancy Field
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Deborah A Wing
- Department of Obstetrics and Gynecology, University of California Irvine, Irvine, CA, USA
| | - Mary E Norton
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Gladys A Ramos
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
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Hobson SR, Kingdom JC, Murji A, Windrim RC, Carvalho JC, Singh SS, Ziegler C, Birch C, Frecker E, Lim K, Cargill Y, Allen LM. No 383 – Dépistage, diagnostic et prise en charge des troubles du spectre du placenta accreta. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1050-1066. [DOI: 10.1016/j.jogc.2019.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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Hobson SR, Kingdom JC, Murji A, Windrim RC, Carvalho JC, Singh SS, Ziegler C, Birch C, Frecker E, Lim K, Cargill Y, Allen LM. No. 383-Screening, Diagnosis, and Management of Placenta Accreta Spectrum Disorders. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1035-1049. [DOI: 10.1016/j.jogc.2018.12.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Placenta accreta spectrum is becoming more common and is the most frequent indication for peripartum hysterectomy. Management of cesarean delivery in the setting of a morbidly adherent placenta has potential for massive hemorrhage, coagulopathies, and other morbidities. Anesthetic management of placenta accreta spectrum presents many challenges including optimizing surgical conditions, providing a safe and satisfying maternal delivery experience, preparing for massive hemorrhage and transfusion, preventing coagulopathies, and optimizing postoperative pain control. Balancing these challenging goals requires meticulous preparation with a thorough preoperative evaluation of the parturient and a well-coordinated multidisciplinary approach in order to optimize outcomes for the mother and fetus.
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Mitric C, Desilets J, Balayla J, Ziegler C. Surgical Management of the Placenta Accreta Spectrum: An Institutional Experience. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1551-1557. [PMID: 30948337 DOI: 10.1016/j.jogc.2019.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The incidence of placenta accreta spectrum (PAS) has risen over the past decades, primarily in response to increasing Caesarean section rates. The surgical management of PAS is associated with significant morbidity, including hemorrhage and intensive care unit (ICU) admission. This study sought to evaluate the surgical outcomes of a PAS operative approach. METHODS A single-centre retrospective chart review of all Caesarean hysterectomies for PAS by an assigned surgeon over a 16-year period was performed. Surgical outcomes were described (Canadian Task Force Classification II-2). RESULTS The described surgical approach involves a midline skin incision, high midline hysterotomy, a rapid single-layer uterine closure with no placental removal attempt, constant cephalad uterine traction, and liberal choice of subtotal hysterectomy. A total of 47 patients were included: 19 (40.4%) with placenta accreta, 14 (29.8%) with placenta increta, and 14 (29.8%) with placenta percreta. Mean estimated blood loss was 1416 ± 699 mL, and mean operative time was 112 ± 49 minutes. Overall, 16 patients (34.0%) required blood transfusion, and 4 patients (8.5%) required ICU admission. The average hospitalization was 5.2 days, with no re-admission within 30 days. The use of internal iliac balloons did not result in a difference in blood loss or operative time (P > 0.05). Patients with placenta percreta had significantly more blood loss (P = 0.02) and longer operative time (P = 0.007) compared with those with placenta accreta and increta. CONCLUSION The current surgical model for planned Caesarean hysterectomy for PAS exhibits a low complication rate. Further research is needed for developing a standardized approach to the management of PAS.
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Affiliation(s)
- Cristina Mitric
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montréal, QC
| | - Jade Desilets
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montréal, QC
| | - Jacques Balayla
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montréal, QC
| | - Cleve Ziegler
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montréal, QC.
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15
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Allen L, Jauniaux E, Hobson S, Papillon-Smith J, Belfort MA. FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management. Int J Gynaecol Obstet 2018; 140:281-290. [PMID: 29405317 DOI: 10.1002/ijgo.12409] [Citation(s) in RCA: 171] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Lisa Allen
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Sebastian Hobson
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | | | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Pavilion for Women, Texas Medical Center, Houston, TX, USA
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