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Yu H, Diao J, Fei J, Wang X, Li D, Yin Z. Conservative management or cesarean hysterectomy for placenta accreta spectrum in middle-income countries: A systematic review and meta-analysis. Int J Gynaecol Obstet 2024; 167:92-104. [PMID: 38650462 DOI: 10.1002/ijgo.15558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 03/04/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Cesarean hysterectomy is a dominant and effective approach during delivery in patients with placenta accreta spectrum (PAS). However, as hysterectomy results in a loss of fertility, conservative management is an alternative approach. However, management selection may be affected by a country's overall economic level. Thus the preferred treatment for PAS generates controversy in middle-income countries. OBJECTIVES We aimed to compare conservative management and cesarean hysterectomy for managing PAS in middle-income countries. SEARCH STRATEGY China National Knowledge Infrastructure, Wanfang Med Online Databases, Cochrane Library, Ovid MEDLINE, PubMed, Web of Science, EMBASE, clinicaltrials.gov, and Scopus were searched from inception through to October 1, 2022. SELECTION CRITERIA We included studies that evaluated at least one complication comparing conservative management and hysterectomy. All cases were diagnosed with PAS prenatally and intraoperatively. DATA COLLECTION AND ANALYSIS The primary outcomes were blood loss, adjacent organ damage, and the incidence of hysterectomy. Descriptive analyses were conducted for studies that did not meet the meta-analysis criteria. A fixed-effects model was used for studies without heterogeneity and a random-effects model was used for studies with statistical heterogeneity. MAIN RESULTS In all, 11 observational studies were included, with 975 and 625 patients who underwent conservative management and cesarean hysterectomy, respectively. Conservative management was significantly associated with decreased blood loss and lower risks of adjacent organ injury and hysterectomy. Conservative management significantly reduced blood transfusions, hospitalization duration, operative time, intensive care unit admission rates, and infections. There were no significant differences in the risks of coagulopathy, thromboembolism, or reoperation. CONCLUSION Given short-term complications and future fertility preferences for patients, conservative management appears to effectively manage PAS in middle-income countries. Owing to low levels of evidence, high heterogeneity and insufficient long-term follow-up data, further detailed studies are warranted.
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Affiliation(s)
- Huihui Yu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jingyi Diao
- Department of Medical Administration, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jiajia Fei
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xingxing Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Dan Li
- Department of Scientific Research, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zongzhi Yin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- NHC Key Laboratory of the Study on abnormal gametes and the reproductive tract, Anhui Medical University, Hefei, China
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Futterman ID, Sher O, Saroff C, Cohen A, Doulaveris G, Dar P, Griffin MM, Limaye M, Owens T, Brustman L, Rosenberg H, Jessel R, Chudnoff S, Haberman S. Machine Learning for the Prediction of Surgical Morbidity in Placenta Accreta Spectrum. Am J Perinatol 2024. [PMID: 39288819 DOI: 10.1055/a-2405-3459] [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: 09/19/2024]
Abstract
OBJECTIVE We sought to create a machine learning (ML) model to identify variables that would aid in the prediction of surgical morbidity in cases of placenta accreta spectrum (PAS). STUDY DESIGN A multicenter analysis including all cases of PAS identified by pathology specimen confirmation, across five tertiary care perinatal centers in New York City from 2013 to 2022. We developed models to predict operative morbidity using 213 variables including demographics, obstetrical information, and limited prenatal imaging findings detailing placental location. Our primary outcome was prediction of a surgical morbidity composite defined as including any of the following: blood loss (>1,500 mL), transfusion, intensive care unit admission, vasopressor use, mechanical ventilation/intubation, and organ injury. A nested, stratified, cross-validation approach was used to tune model hyperparameters and estimate generalizability. Gradient boosted tree classifier models incorporated preprocessing steps of standard scaling for numerical variables and one-hot encoding for categorical variables. Model performance was evaluated using area under the receiver operating characteristic curve (AUC), positive and negative predictive values (PPV, NPV), and F1 score. Variable importance ranking was also determined. RESULTS Among 401 PAS cases, 326 (81%) underwent hysterectomy. Of the 401 cases of PAS, 309 (77%) had at least one event defined as surgical morbidity. Our predictive model had an AUC of 0.79 (95% confidence interval: 0.69, 0.89), PPV 0.79, NPV 0.76, and F1 score of 0.88. The variables most predictive of surgical morbidity were completion of a hysterectomy, prepregnancy body mass index (BMI), absence of a second trimester ultrasound, socioeconomic status zip code, BMI at delivery, number of prenatal visits, and delivery time of day. CONCLUSION By identifying social and obstetrical characteristics that increase patients' risk, ML models are useful in predicting PAS-related surgical morbidity. Utilizing ML could serve as a foundation for risk and complexity stratification in cases of PAS to optimize surgical planning. KEY POINTS · ML models are useful models are useful in predicting PAS-related surgical morbidity.. · Optimal management for PAS remains unclear.. · Utilizing ML can serve as a foundation for risk and complexity stratification in cases of PAS..
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Affiliation(s)
- Itamar D Futterman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York
- Division of Complex Obstetrical Surgery, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York
| | - Olivia Sher
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York
| | | | - Alexa Cohen
- Division of Fetal Medicine and Ultrasound, Obstetrics, Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Georgios Doulaveris
- Division of Fetal Medicine and Ultrasound, Obstetrics, Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Pe'er Dar
- Division of Fetal Medicine and Ultrasound, Obstetrics, Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Myah M Griffin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York, New York
| | - Meghana Limaye
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York, New York
| | - Thomas Owens
- Division of Maternal Fetal Medicine, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lois Brustman
- Division of Maternal Fetal Medicine, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Henri Rosenberg
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rebecca Jessel
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Scott Chudnoff
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York
| | - Shoshana Haberman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York
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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, 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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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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Aguilera LR, Mojica-Palacios LM, Urquizu F, Gorena M, Tinajeros Guzmán F, Vergara Galliadi LM, Hidalgo A, Nieto-Calvache AJ. Difficulties in the Management of Placenta Accreta Spectrum in Hospitals with Limited Resources. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:467-474. [PMID: 35472821 PMCID: PMC9948092 DOI: 10.1055/s-0042-1742408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) is a serious diseases, and the recommendation is that the treatment is conducted in centers of excellence. Such hospitals are not easy to find in low- and middle-income countries. We seek to describe the process of prenatal diagnosis, surgical management, and postnatal histological analysis in a low-income country referral hospital with limited resources. METHODS A descriptive, retrospective study was carried out including patients with a pre- or intraoperative diagnosis of PAS. The clinical results of the patients were studied as well as the results of the prenatal ultrasound and the correlation with the postnatal pathological diagnosis. RESULTS In total, 129 patients were included. Forty-eight of them had a prenatal PAS ultrasound diagnosis (37.2%). In the remaining 81 (62.8%), the diagnosis was intraoperative.Although hysterectomy was performed in all cases, one-third of the patients (31%) did not have a histological study of the uterus. In 40% of the patients who had a histological study, PAS was not reported by the pathologist. CONCLUSION The frequency of prenatal diagnosis and the availability of postnatal histological studies were very low in the studied population. Surgical skill, favored by a high flow of patients, is an important factor to avoid complications in settings with limited resources.
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Affiliation(s)
| | | | - Federico Urquizu
- Hospital de la Mujer Percy Boland Rodríguez, Santa Cruz de la Sierra, Bolivia
| | - Mirko Gorena
- Hospital de la Mujer Percy Boland Rodríguez, Santa Cruz de la Sierra, Bolivia
| | | | | | - Alejandra Hidalgo
- Centro de Investigaciones Clínicas, Fundación Valle de Lili, Cali, Colombia
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Nieto-Calvache AJ, Velásquez P, Aguilera R, Aryananda RA, Hidalgo A. Placenta accreta spectrum: intraoperatory analysis for immediate tele-help. J Matern Fetal Neonatal Med 2022; 35:9299-9302. [DOI: 10.1080/14767058.2022.2029399] [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]
Affiliation(s)
| | | | - Rudy Aguilera
- Hospital de la Mujer Dr. Percy Bolland Rodríguez, Santacruz, Bolivia
| | | | - Alejandra Hidalgo
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
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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] [Key Words] [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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Affiliation(s)
- Albaro José Nieto-Calvache
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs AJ Nieto-Calvache and Burgos-Luna)
| | - José Miguel Palacios-Jaraquemada
- Hospital Universitario, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina (Dr Palacios-Jaraquemada)
| | | | | | - Maria Andrea Zambrano
- Facultad de Ciencias de la Salud, Programa de Ginecología y Obstetricia, Universidad Icesi, Cali, Colombia (Dr Zambrano)
| | - Juan Manuel 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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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Aguilera LR, Arriaga W, Colonia A, Aryananda RA, Nieto-Calvache AS, Maya J, Vergara-Galliadi LM, Messa Bryon A. Telemedicine facilitates surgical training in placenta accreta spectrum. Int J Gynaecol Obstet 2021; 158:137-144. [PMID: 34714947 DOI: 10.1002/ijgo.14000] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/19/2021] [Accepted: 10/27/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The training of groups responsible for managing patients with placenta accreta spectrum (PAS) is complex because of the lack of hospitals with a high flow of patients and absence of formal educational programs. We report here the results of a virtual training program (VTP) that implemented one-step conservative surgery (OSCS). METHODS A prospective observation study of OSCS VTP between three expert groups and PAS reference hospitals without experience in OSCS was performed. Accessible or cost-efficient web meeting platforms were used to implement the VTP components: baseline observation of the participant's prior knowledge; instructions about essential PAS surgery topics; case selection and joint planning of surgery; expert group "telepresence" during surgery and postoperative debriefing. RESULTS One-step conservative surgery was performed successfully at six hospitals. All patients had increta/percreta with a median intraoperative bleeding of 1300 ml (IQR 825-2325) and surgical time of 184 min (IQR 113-240). All groups considered the VTP very useful (n = 33, 97%) or useful (n = 1, 3%), they would use it again (definitely: n = 27, 81.8%; or probably: n = 6, 18.2%), and they would recommend it to other colleagues. CONCLUSION Tele education and telepresence during PAS surgery facilitates the implementation of OSCS in selected cases.
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Affiliation(s)
- Albaro Jose Nieto-Calvache
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia.,Latin American Group for the Study of Placenta Accreta Spectrum, Cali, Colombia
| | | | - Lorgio Rudy Aguilera
- Latin American Group for the Study of Placenta Accreta Spectrum, Cali, Colombia.,Hospital de la Mujer Dr Percy Boland, Santacruz, Bolivia
| | - William Arriaga
- Latin American Group for the Study of Placenta Accreta Spectrum, Cali, Colombia.,Hospital Regional de Occidente, Quetzaltenango, Guatemala
| | - Alejandro Colonia
- Latin American Group for the Study of Placenta Accreta Spectrum, Cali, Colombia.,Hospital General de Medellín, Medellín, Colombia
| | | | | | - Juliana Maya
- Facultad de Ciencias de la Salud, Programa de Medicina, Universidad Icesi, Cali, Colombia
| | | | - Adriana Messa Bryon
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia.,Latin American Group for the Study of Placenta Accreta Spectrum, Cali, Colombia
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11
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Miller P, Owolabi E, Chu K. We Asked the Experts: The Promises and Challenges of Surgical Telehealth in Low Resourced Settings. World J Surg 2021; 46:45-46. [PMID: 34568971 PMCID: PMC8475306 DOI: 10.1007/s00268-021-06318-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2021] [Indexed: 10/28/2022]
Affiliation(s)
- Phoebe Miller
- School of Medicine, University of California-San Francisco, 1400 Parnassus Avenue, San Francisco, CA, USA
| | - Eyitayo Owolabi
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie Van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Kathryn Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie Van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa. .,Department of Surgery, University of Botswana, Plot 4775 Notwane Rd, Gaborone, Botswana.
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12
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Nieto-Calvache AJ, Nieto-Calvache AS, Aguilera LR. Telemedicine as a strategy to facilitate placenta accreta spectrum treatment. J Matern Fetal Neonatal Med 2021; 35:8284-8285. [PMID: 34486453 DOI: 10.1080/14767058.2021.1971646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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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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14
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Nieto-Calvache AJ, Vergara-Galliadi LM, Rodríguez F, Ordoñez CA, García AF, López MC, Manzano R, Velásquez J, Carbonell JP, Bryon AM, Echavarría MP, Escobar MF, Carvajal J, Benavides-Calvache JP, Burgos JM. A multidisciplinary approach and implementation of a specialized hemorrhage control team improves outcomes for placenta accreta spectrum. J Trauma Acute Care Surg 2021; 90:807-816. [PMID: 33496549 DOI: 10.1097/ta.0000000000003090] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The main complication of placenta accreta spectrum (PAS) is massive bleeding. Endoarterial occlusion techniques have been incorporated into the management of this pathology. Our aim was to examine the endovascular practice patterns among PAS patients treated during a 9-year period in a low-middle income country in which an interdisciplinary group's technical skills were improved with the creation of a PAS team. METHODOLOGY A retrospective cohort study including all PAS patients treated from December 2011 to November 2020 was performed. We compared the clinical results obtained according to the type of endovascular device used (group 1, internal iliac artery occlusion balloons; group 2, resuscitative endovascular balloons of the aorta; group 3, no arterial balloons due to low risk of bleeding) and according to the year in which they were attended (reflects the PAS team level of experience). A fourth group of comparisons included the woman diagnosed during a cesarean delivery and treated in a nonprotocolized way. RESULTS A total of 113 patients were included. The amount of blood loss decreased annually, with a median of 2,500 mL in 2014 (when endovascular occlusion balloons were used in all patients) and 1,394 mL in 2020 (when only 38.5% of the patients required arterial balloons). Group 3 patients (n = 16) had the lowest bleeding volume (1,245 mL) and operative time (173 minutes) of the entire population studied. Group 2 patients (n = 46) had a bleeding volume (mean, 1,700 mL) and transfusions frequency (34.8%) slightly lower than group 1 patients (n = 30) (mean of 2,000 mL and 50%, respectively). They also had lower hysterectomy frequency (63% vs. 76.7% in group 1) and surgical time (205 minutes vs. 275 in group 1) despite a similar frequency of confirmed PAS and S2 compromise. CONCLUSION Endovascular techniques used for bleeding control in PAS patients are less necessary as interdisciplinary groups improve their surgical and teamwork skills. LEVEL OF EVIDENCE Therapeutic care management, level III.
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Affiliation(s)
- Albaro José Nieto-Calvache
- From the Placenta Accreta Spectrum Clinic (A.J.N.-C., F.R., C.A.O., A.F.G., J.V., J.P.C., A.M.B., M.P.E., M.F.E., J.C., J.P.B.-C., J.M.B.), Clinical Research Center (L.M.V.-G., M.C.L., R.M.); Division of Trauma and Acute Care Surgery, Department of Surgery (F.R., C.A.O., A.F.G.); and Interventional Radiology Department (J.V., J.P.C.), Fundación Valle del Lili, Cali, Colombia
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15
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Üstünyurt E. Local uterine resection with Bakri balloon placement in placenta accreta spectrum disorders. Turk J Obstet Gynecol 2020; 17:108-114. [PMID: 32850185 PMCID: PMC7406901 DOI: 10.4274/tjod.galenos.2020.82652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/18/2020] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) is a potentially life-threatening condition characterized by the abnormal adherence of the placenta to the implantation site. We sought to evaluate the efficacy, surgical feasibility, risks, and advantages of local uterine resection in cases complicated with PAS. MATERIALS AND METHODS This study included 97 patients with PAS, which was confirmed during surgery and by histopathological examination between January 2013 and December 2019. The patients were divided into two groups based on operative approach. The study population (local resection group) consisted of 30 cases in whom total resection of adherent placenta and myometrium was performed, whereas the control group (hysterectomy group) of 67 cesarean hysterectomy cases. RESULTS Patients who underwent hysterectomy had significantly more bleeding than the local resection group (1180±160 mL vs 877±484 mL; p=0.002). The mean number of transfused packed red blood cells (pRBCs) was greater in the hysterectomy group (4.5±2.3) than in the local resection group (2.6±3.1; p=0.001). Transfusion rate of four and/or more pRBCs was 67.2% in the hysterectomy group and 33.3% in the local resection group, which indicated a statistically significant difference (p=0.002). Of patients, 29.6% required intensive care unit in the hysterectomy group and 6.7% in the local resection group (p=0.023). CONCLUSION Local resection can be performed safely in selected PAS cases. In these cases, using a standardized protocol in terms of patient selection and surgical procedure will reduce morbidity and mortality.
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Affiliation(s)
- Emin Üstünyurt
- University of Health Sciences Turkey, Bursa Yüksek İhtisas Training and Research Hospital, Clinic of Gynecology, Bursa, Turkey
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16
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Nieto-Calvache AJ, López-Girón MC, Nieto-Calvache AS. The usefulness of inter-institutional collaboration (teleconsultation, eHealth) in the management of placenta accreta. J Matern Fetal Neonatal Med 2020; 35:1081-1087. [PMID: 32202177 DOI: 10.1080/14767058.2020.1742692] [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: 10/24/2022]
Abstract
Introduction: The availability of interdisciplinary groups trained in morbidly adherent placenta (MAP) is limited. Telemedicine can be a useful strategy to bring patients affected by MAP to institutions specialized in its management. We sought to assess how useful an informal teleconsultation is for MAP cases among users who contacted a reference center for this pathology in a low middle-income country.Methodology: Likert-type surveys were conducted among specialist physicians who carried out teleconsultation with a MAP experienced institution, for assessing how useful the remote assistance was.Results: In 15-month period, 21 teleconsultations associated with MAP were recorded. Teleconsultation was considered "very useful" by 100% of obstetricians. Among the physicians, 90.5% said they would "definitely use the service again" if they had a new case of MAP and 85.7% said that they would "always recommend" the service to other groups of specialists.Conclusion: Teleconsultation in MAP cases is perceived by service users as a useful tool in the management of affected patients. In a context with few specialized centers in the management of this condition, telemedicine must be taken into account when designing comprehensive care strategies for this rare and highly morbid disease.
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Affiliation(s)
- Albaro José Nieto-Calvache
- Abnormally Invasive Placenta Clinic, Fundación Valle del Lili, Cali, Colombia.,Department of Clinical Postgraduate Program, Universidad ICESI, Cali, Colombia
| | | | - Alejandro Solo Nieto-Calvache
- Universidad Nacional Abierta y a Distancia, Bogotá, Colombia.,Department of Public Health, Universidad Santiago de Cali, Cali, Colombia
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17
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Mohamed MA. Lower segment folding as novel technique to control bleeding in cases of morbidly adherent placenta. J Matern Fetal Neonatal Med 2019; 34:3397-3401. [PMID: 31722580 DOI: 10.1080/14767058.2019.1685971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIM To evaluate the effectiveness of lower segment folding in controlling lower segment bleeding and conserving uterus in cases with morbidly adherent placenta. METHODS This study was conducted on OB/GYN emergency unit of Sohag University hospital. The upper edge of lower segment was sutured to the internal os in continuous purse-string manner using delayed absorbable sutures "N0 2 vicryl (polyglactin 910)." The sutures incude both anterior and lateral aspects of lower uterine segment. Care was taken to maintain patency of endocervix. The folded lower segment was sutured to upper segment as ordinary closure of hysterectomy. RESULTS Thirty-two cases were included. The procedure was successful in all studied group to achieve good hemostasis and preservation of uterus. The estimated intraoperative blood loss was (1645 ± 318), there was no need for massive blood transfusion in all cases as number of blood units transfused ranged from 1 to 4 with mean (2.1 ± 0.53). Time required to perform lower segment folding was ranged from 3 to 8 min with mean (4.9 ± 1.1). CONCLUSION Lower segment folding is a good option for saving the uterus in cases of morbidly adherent placenta. The technique is rapid, easy to be performed without a need of special expertise nor special equipment's.
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Affiliation(s)
- Magdy A Mohamed
- Obstetrics and Gynecology Department, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
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18
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Nieto-Calvache AJ, López-Girón MC, Messa-Bryon A, Ceballos-Posada ML, Duque-Galán M, Ríos-Posada JGD, Plazas-Córdoba LA, Chancy-Castaño MM. Urinary tract injuries during treatment of patients with morbidly adherent placenta. J Matern Fetal Neonatal Med 2019; 34:3140-3146. [PMID: 31631730 DOI: 10.1080/14767058.2019.1678135] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Urinary tract injuries (UTI) are a frequent complication of morbidly adherent placenta (MAP) management. In this study, we aim to characterize the type of UTI that occurs and to define if their incidence varies after establishing a fixed interdisciplinary group for the protocolized management of patients with MAP. METHODOLOGY All patients with confirmed MAP attended between 2011 and 2019 in our institution, were included. We analyzed the effect of a change in the surgical protocol including rigid ureteral catheters, vesicouterine dissection before hysterotomy and interdisciplinary planning, in the bladder or ureteral injuries incidence. RESULTS The study included 65 women. UTI was identified in 27.7% of patients and was associated with a greater volume of blood loss, transfusion requirement, hospital stay, and the need for additional surgeries. There was a high frequency of UTI in patients without protocolized management. The use of rigid ureteral catheters and retrovesical dissection before hysterotomy were associated with a less ureteral injury. CONCLUSIONS Developing expertise among the members of the surgical team is essential to improve results. Using rigid ureteral catheters, performing retrovesical dissection before hysterotomy, and performing less extensive surgeries in selected patients are associated with a low frequency of ureteral injuries.
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Affiliation(s)
- Albaro José Nieto-Calvache
- Tertiary Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia.,Abnormally Invasive Placenta Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia
| | - María Camila López-Girón
- Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia.,Clinical Research Center, Fundación Valle del Lili, Cali, Colombia
| | - Adriana Messa-Bryon
- Tertiary Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia.,Abnormally Invasive Placenta Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia
| | - M Lili Ceballos-Posada
- Tertiary Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia.,Abnormally Invasive Placenta Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia.,Department Urology, Fundación Valle del Lili, Cali, Colombia
| | - Manuel Duque-Galán
- Tertiary Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia.,Abnormally Invasive Placenta Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia.,Department Urology, Fundación Valle del Lili, Cali, Colombia
| | - Juan Gabriel de Ríos-Posada
- Tertiary Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia.,Abnormally Invasive Placenta Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia.,Department Urology, Fundación Valle del Lili, Cali, Colombia
| | - Luis Alberto Plazas-Córdoba
- Tertiary Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia.,Abnormally Invasive Placenta Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia.,Department Urology, Fundación Valle del Lili, Cali, Colombia
| | - Margarita María Chancy-Castaño
- Tertiary Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia.,Abnormally Invasive Placenta Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia.,Department Urology, Fundación Valle del Lili, Cali, Colombia
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