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Munoz JL, Blankenship LM, Ireland KE, Ramsey PS, McCann GA. Identification and stratification of placenta percreta with gynecologic oncologist management. Int J Gynecol Cancer 2024:ijgc-2024-005850. [PMID: 39322613 DOI: 10.1136/ijgc-2024-005850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2024] Open
Abstract
OBJECTIVE Gynecologic oncologist involvement in the surgical team of patients with placenta percreta has shown improved patient outcomes. Yet, stratification of cases is dependent on identification of placenta percreta by ultrasonography which has a poor detection rate. To allow patients to receive optimal team management by pre-operative stratification our objective was to identify the pre-operative characteristics of patients with previously underdiagnosed placenta percreta. METHODS A retrospective single institution case-control study was performed from January 2010 to December 2022 of singleton, non-anomalous pregnancies with suspicion for placenta accreta spectrum (PAS). Ultrasonography was used as the primary method of detection. Final inclusion was dependent on histology confirmation of PAS and degree of invasion. We explored the role of concurrent antenatal magnetic resonance imaging (MRI) on patients with previously unrecognized placenta percreta. RESULTS During the 13 year study period, 140 cases of histologically confirmed PAS were managed by our team and met inclusion criteria. A total of 72 (51.4%) cases were for placenta percreta and 27 (37.5%) of these were diagnosed pre-operatively while 45 (62.5%) were only diagnosed post-operatively. Comparison between these two groups revealed patient body mass index (BMI) >30 kg/m2 was independently associated with unrecognized placenta percreta (p=0.006). No findings by MRI were associated with mischaracterization of placenta percreta. Yet, concurrent MRI assessment of patients with BMI >30 kg/m2 (n=18), increased placenta percreta detection by 11 cases (61%). CONCLUSION The ability to determine pre-operatively which patients are more likely to have placenta percreta allows for gynecologic oncologists to be involved in the most complex cases in a planned manner. This study shows that women at risk for placenta accreta spectrum, who are obese (BMI >30 kg/m2), may benefit from further assessment with pre-operative MRI to facilitate appropriate staffing and team availability for cases of placenta percreta.
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Affiliation(s)
- Jessian Louis Munoz
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Houston, Texas, USA
| | | | | | | | - Georgia A McCann
- Obstetrics and Gynecology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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2
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Matsuo K, Huang Y, Matsuzaki S, Vallejo A, Ouzounian JG, Roman LD, Khoury-Collado F, Friedman AM, Wright JD. Cesarean hysterectomy for placenta accreta spectrum: Surgeon specialty-specific assessment. Gynecol Oncol 2024; 186:85-93. [PMID: 38603956 DOI: 10.1016/j.ygyno.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To assess (i) clinical and pregnancy characteristics, (ii) patterns of surgical procedures, and (iii) surgical morbidity associated with cesarean hysterectomy for placenta accreta spectrum based on the specialty of the attending surgeon. METHODS The Premier Healthcare Database was queried retrospectively to study patients with placenta accreta spectrum who underwent cesarean delivery and concurrent hysterectomy from 2016 to 2020. Surgical morbidity was assessed with propensity score inverse probability of treatment weighting based on surgeon specialty for hysterectomy: general obstetrician-gynecologists, maternal-fetal medicine specialists, and gynecologic oncologists. RESULTS A total of 2240 cesarean hysterectomies were studies. The most common surgeon type was general obstetrician-gynecologist (n = 1534, 68.5%), followed by gynecologic oncologist (n = 532, 23.8%) and maternal-fetal medicine specialist (n = 174, 7.8%). Patients in the gynecologic oncologist group had the highest rate of placenta increta or percreta, followed by the maternal-fetal medicine specialist and general obstetrician-gynecologist groups (43.4%, 39.6%, and 30.6%, P < .001). In a propensity score-weighted model, measured surgical morbidity was similar across the three subspecialty groups, including hemorrhage / blood transfusion (59.4-63.7%), bladder injury (18.3-24.0%), ureteral injury (2.2-4.3%), shock (8.6-10.5%), and coagulopathy (3.3-7.4%) (all, P > .05). Among the cesarean hysterectomy performed by gynecologic oncologist, hemorrhage / transfusion rates remained substantial despite additional surgical procedures: tranexamic acid / ureteral stent (60.4%), tranexamic acid / endo-arterial procedure (76.2%), ureteral stent / endo-arterial procedure (51.6%), and all three procedures (55.4%). Tranexamic acid administration with ureteral stent placement was associated with decreased bladder injury (12.8% vs 23.8-32.2%, P < .001). CONCLUSION These data suggest that patient characteristics and surgical procedures related to cesarean hysterectomy for placenta accreta spectrum differ based on surgeon specialty. Gynecologic oncologists appear to manage more severe forms of placenta accreta spectrum. Regardless of surgeon's specialty, surgical morbidity of cesarean hysterectomy for placenta accreta spectrum is significant.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
| | - Yongmei Huang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Shinya Matsuzaki
- Department of Gynecology, Osaka International Cancer Institute, Osaka, Japan
| | - Andrew Vallejo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Fady Khoury-Collado
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Alexander M Friedman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA.
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Muadtongon K, Rattanaburi A, Ajimakul T, Suphasynth Y, Jiamset I, Nantamongkolkul K, Suntharasaj T, Suwanrath C, Pruksanusak N, Petpichetchian C, Suksai M, Chainarong N, Sawaddisan R, Pranpanus S. Successful multidisciplinary team management of placenta accreta spectrum disorder: A referral center model in a middle-income country. Int J Gynaecol Obstet 2024; 165:813-822. [PMID: 38189162 DOI: 10.1002/ijgo.15339] [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: 04/26/2023] [Revised: 08/12/2023] [Accepted: 12/14/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE The aim of the study was to evaluate the outcomes of placenta accreta spectrum (PAS) disorder managed by a multidisciplinary care team (MCT) compared with a conventional care team (CCT) in a PAS referral center in Thailand. METHODS This retrospective single-center cohort study analyzed PAS management outcomes in the PSU PAS Center between January 2010 and December 2022. The incidence of hemorrhage ≥3500 mL and the composite maternal and neonatal outcomes of PAS were compared before and after the introduction of an MCT in 2016. RESULTS Of 227 PAS cases, 219 (96.5%) had pathological confirmation. There were 52 (22.9%) cases of placenta accreta, 119 (52.4%) cases of placenta increta, and 56 (24.7%) cases of placenta percreta. The incidence of estimated blood loss (EBL) ≥3500 mL decreased from 61.8% to 34.3% (P < 0.001) after the establishment of the MCT. The median EBL decreased from 4000 (IQR: 2600,7250) mL to 2250 (1300, 4750) mL (P < 0.001). EBL reduction was statistically significant in the accreta and increta groups (P < 0.001). Red blood cell transfusions decreased from five (3, 9) to two (1, 6) units (P < 0.001) per patient. The length of maternal hospital stays and ICU admissions were statistically shorter when PAS was managed by an MCT (P < 0.001). The length of newborn hospital and ICU stays decreased significantly (P < 0.001). CONCLUSION The incidence of massive postpartum hemorrhage and a composite of maternal and neonatal morbidities in pregnant women with PAS disorder improved significantly after the establishment of an MCT to manage PAS in a middle-income country setting.
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Affiliation(s)
- Kan Muadtongon
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Athithan Rattanaburi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thiti Ajimakul
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Yuthasak Suphasynth
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Ingporn Jiamset
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Kulisara Nantamongkolkul
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thitima Suntharasaj
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Chitkasaem Suwanrath
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Ninlapa Pruksanusak
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Chusana Petpichetchian
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Manaphat Suksai
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Natthicha Chainarong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Rapphon Sawaddisan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Savitree Pranpanus
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Munoz JL, Curbelo J, Ramsey PS. An obstetric-specific surgical Apgar score predicts maternal morbidity from cesarean hysterectomy for placenta accreta spectrum. Int J Gynaecol Obstet 2024; 164:912-917. [PMID: 37668180 DOI: 10.1002/ijgo.15069] [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: 01/02/2023] [Accepted: 08/17/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) is a continuum of placental conditions characterized by significant maternal and neonatal morbidity. Tools to accurately predict postoperative morbidity have been lacking due to the hemodynamic changes of pregnancy. The surgical Apgar score (SAS) is a 10-point scale that assesses heart rate, mean arterial pressure, and estimated blood loss. The SAS has been validated to predict morbidity such as blood transfusion and reoperation. METHODS We created an obstetric-specific SAS (ObSAS) scale for physiologic changes of pregnancy (two-fold increase in blood loss, 10% increased heart rate, and 5% decreased mean arterial pressure) and analyzed 110 cases of PAS who underwent cesarean hysterectomy. RESULTS An ObSAS of 0-4 (poorest score) was significantly associated with increased risk of intensive care unit (ICU) admission (odds ratio [OR] 40.6, 95% confidence interval [CI] 7.9-742.9), transfusion >4 units (26/26 patients), and greater surgical morbidity (OR 22.7, 95% CI 4.4-415.0). ObSAS of 9-10 resulted in no ICU admissions (0/12), fewer blood transfusions (OR 0.1, 95% CI 0.1-0.4). and less surgical morbidity (OR 0.09, 95% CI 0.01-0.37). CONCLUSION Given the overall surgical morbidity associated with PAS cesarean hysterectomy, the ObSAS score is a powerful tool with excellent predictive capabilities for ICU admission, blood transfusion, and surgical morbidity, allowing for resource allocation, prophylactic interventions, and optimal patient outcomes.
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Affiliation(s)
- Jessian L Munoz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Jacqueline Curbelo
- University of Texas Health Sciences, San Antonio, Texas, USA
- Department of Obstetrics & Gynecology, University Health System, San Antonio, Texas, USA
| | - Patrick S Ramsey
- University of Texas Health Sciences, San Antonio, Texas, USA
- Department of Anesthesiology, University Health System, San Antonio, Texas, USA
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Neef V, Flinspach AN, Eichler K, Woebbecke TR, Noone S, Kloka JA, Jennewein L, Louwen F, Zacharowski K, Raimann FJ. Management and Outcome of Women with Placenta Accreta Spectrum and Treatment with Uterine Artery Embolization. J Clin Med 2024; 13:1062. [PMID: 38398377 PMCID: PMC10888708 DOI: 10.3390/jcm13041062] [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: 12/31/2023] [Revised: 02/02/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Placenta accreta spectrum (PAS) disorders are a continuum of placental pathologies with increased risk for hemorrhage, blood transfusion and maternal morbidity. Uterine artery embolization (UAE) is a safe approach to the standardization of complex PAS cases. The aim of this study is to analyze anemia and transfusion rate, outcome and anesthesiological management of women who underwent caesarean delivery with subsequent UAE for the management of PAS. MATERIAL AND METHODS This retrospective observational study included all pregnant women admitted to the University Hospital Frankfurt between January 2012 and September 2023, with a diagnosis of PAS who underwent a two-step surgical approach for delivery and placenta removal. Primary procedure included cesarean delivery with subsequent UAE, secondary procedure included placenta removal after a minim of five weeks via curettage or HE. Maternal characteristics, anesthesiological management, complications, anemia rate, blood loss and administration of blood products were analyzed. RESULTS In total, 17 women with PAS were included in this study. Of these, 5.9% had placenta increta and 94.1% had placenta percreta. Median blood loss was 300 (200-600) mL during primary procedure and 3600 (450-5500) mL during secondary procedure. In total, 11.8% and 62.5% of women received red blood cell transfusion during the primary and secondary procedures, respectively. After primary procedure, postpartum anemia rate was 76.5%. The HE rate was 64.7%. Regional anesthesia was used in 88.2% during primary procedure. CONCLUSION The embolization of the uterine artery for women diagnosed with PAS is safe. Anemia management and the implementation of blood conservation strategies are crucial in women undergoing UAE for the management of PAS.
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Affiliation(s)
- Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Armin N. Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Katrin Eichler
- Department of Interventional Radiology, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany;
| | - Tirza R. Woebbecke
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Stephanie Noone
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Jan A. Kloka
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Lukas Jennewein
- Department of Obstetrics and Perinatal Medicine, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (L.J.); (F.L.)
| | - Frank Louwen
- Department of Obstetrics and Perinatal Medicine, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (L.J.); (F.L.)
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Florian J. Raimann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
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Fitzgerald GD, Newton JM, Atasi L, Buniak CM, Burgos-Luna JM, Burnett BA, Carver AR, Cheng C, Conyers S, Davitt C, Deshmukh U, Donovan BM, Easter SR, Einerson BD, Fox KA, Habib AS, Harrison R, Hecht JL, Licon E, Nino JM, Munoz JL, Nieto-Calvache AJ, Polic A, Ramsey PS, Salmanian B, Shamshirsaz AA, Shamshirsaz AA, Shrivastava VK, Woolworth MB, Yurashevich M, Zuckerwise L, Shainker SA. Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care. Am J Obstet Gynecol MFM 2024; 6:101229. [PMID: 37984691 DOI: 10.1016/j.ajogmf.2023.101229] [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: 09/07/2023] [Revised: 11/02/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.
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Affiliation(s)
- Garrett D Fitzgerald
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI (Dr Fitzgerald).
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Newton)
| | - Lamia Atasi
- Department of Obstetrics and Gynecology, Mercy Hospital, St. Louis, MO (Dr Atasi)
| | - Christina M Buniak
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA (Dr Buniak)
| | | | - Brian A Burnett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Burnett)
| | - Alissa R Carver
- Department of Obstetrics and Gynecology, Wilmington Maternal-Fetal Medicine, Wilmington, NC (Dr Carver)
| | - CeCe Cheng
- Department of Obstetrics and Gynecology, Health Science Center at San Antonio, University of Texas, San Antonio, TX (Dr Cheng)
| | - Steffany Conyers
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Caroline Davitt
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Uma Deshmukh
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Bridget M Donovan
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
| | - Sara Rae Easter
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Easter)
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (Dr Einerson)
| | - Karin A Fox
- Baylor College of Medicine, Houston, TX (Dr Fox)
| | - Ashraf S Habib
- Duke University School of Medicine, Durham, NC (Dr Habib)
| | - Rachel Harrison
- Department of Obstetrics and Gynecology, Advocate Aurora Health, Chicago, IL (Dr Harrison)
| | - Jonathan L Hecht
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Ernesto Licon
- Miller Women's & Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Licon)
| | - Julio Mateus Nino
- Department of Obstetrics and Gynecology, Atrium Health Wake Forest School of Medicine, Winston-Salem, NC (Dr Nino)
| | - Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX (Dr Munoz)
| | | | | | - Patrick S Ramsey
- University of Texas Health/University Health San Antonio, San Antonio, TX (Dr Ramsey)
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, University of Colorado Health Anschutz Medical Campus, Boulder, CO (Dr Salmanian)
| | | | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Vineet K Shrivastava
- Miller Women's and Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Shrivastava)
| | | | - Mary Yurashevich
- Department of Anesthesiology, Duke Health, Durham, NC (Dr Yurashevich)
| | - Lisa Zuckerwise
- and Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Zuckerwise)
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
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7
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Holmes VJ, Skinner S, Silagy M, Rolnik DL, Mol BW, Kroushev A. Changes in practice and management of placenta accreta spectrum disorder: A 20-year retrospective cohort study. Aust N Z J Obstet Gynaecol 2023; 63:786-791. [PMID: 37345840 DOI: 10.1111/ajo.13724] [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: 12/09/2022] [Accepted: 06/05/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Placenta accreta spectrum disorder is an increasingly prevalent cause of maternal morbidity in developed countries. AIMS This study aimed to review the management and outcomes of cases of placenta accreta spectrum, and compare blood loss and blood transfusion rates, over time after an institutional change in planned primary surgeon from gynaecological oncologists to experienced obstetricians. METHODS This retrospective cohort study included all cases of suspected or confirmed placenta accreta spectrum disorder (PASD) between 1999 and 2021 at Monash Health. Data were collected by reviewing medical records to obtain baseline characteristics, details of surgical planning and management and major maternal morbidity outcomes over a 20-year period. The primary surgical lead was recorded as either gynaecological oncologist or experienced obstetricians. The primary outcomes were estimated maternal blood loss and number of units of blood transfused. RESULTS A total of 88 patients were identified: 43 between 1999 and 2015 where gynaecological oncologists were the primary surgeon in 79% of cases and 45 between 2016 and 2021 where experienced obstetricians were the primary surgeon in 73.3% of cases. There was no statistically significant difference in the estimated blood loss between the two time periods (median: 2000 vs 2500 mL, P = 0.669). Hysterectomy rates were significantly reduced in the second time period, from 100 to 73.3%, P < 0.001. CONCLUSION Management of cases of PASDs has improved over time with changes in antenatal diagnosis and perioperative management, and management by experienced obstetricians has similar maternal outcomes compared to those whose management includes the presence of gynaecological oncologists.
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Affiliation(s)
- Victoria J Holmes
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Sasha Skinner
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Michael Silagy
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Annie Kroushev
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
- Maternal Fetal Medicine Unit, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
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8
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Matsuo K, Sangara RN, Matsuzaki S, Ouzounian JG, Hanks SE, Matsushima K, Amaya R, Roman LD, Wright JD. Placenta previa percreta with surrounding organ involvement: a proposal for management. Int J Gynecol Cancer 2023; 33:1633-1644. [PMID: 37524496 DOI: 10.1136/ijgc-2023-004615] [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] [Indexed: 08/02/2023] Open
Abstract
Placenta accreta spectrum encompasses cases where the placenta is morbidly adherent to the myometrium. Placenta percreta, the most severe form of placenta accreta spectrum (grade 3E), occurs when the placenta invades through the myometrium and possibly into surrounding structures next to the uterine corpus. Maternal morbidity of placenta percreta is high, including severe maternal morbidity in 82.1% and mortality in 1.4% in the recent nationwide U.S. statistics. Although cesarean hysterectomy is commonly performed for patients with placenta accreta spectrum, conservative management is becoming more popular because of reduced morbidity in select cases. Treatment of grade 3E disease involving the urinary bladder, uterine cervix, or parametria is surgically complicated due to the location of the invasive placenta deep in the maternal pelvis. Cesarean hysterectomy in this setting has the potential for catastrophic hemorrhage and significant damage to surrounding organs. We propose a step-by-step schema to evaluate cases of grade 3E disease and determine whether immediate hysterectomy or conservative management, including planned delayed hysterectomy, is the most appropriate treatment option. The approach includes evaluation in the antenatal period with ultrasound and magnetic resonance imaging to determine suspicion for placenta previa percreta with surrounding organ involvement, planned cesarean delivery with a multidisciplinary team including experienced pelvic surgeons such as a gynecologic oncologist, intra-operative assessment including gross surgical field exposure and examination, cystoscopy, and consideration of careful intra-operative transvaginal ultrasound to determine the extent of placental invasion into surrounding organs. This evaluation helps decide the safety of primary cesarean hysterectomy. If safely resectable, additional considerations include intra-operative use of uterine artery embolization combined with tranexamic acid injection in cases at high risk for pelvic hemorrhage and ureteral stent placement. Availability of resuscitative endovascular balloon occlusion of the aorta is ideal. If safe resection is concerned, conservative management including planned delayed hysterectomy at around 4 weeks from cesarean delivery in stable patients is recommended.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Rauvynne N Sangara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Shinya Matsuzaki
- Department of Gynecology, Osaka International Cancer Institute, Osaka, Japan
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Sue E Hanks
- Department of Radiology, University of Southern California, Los Angeles, California, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Rodolfo Amaya
- Department of Anesthesiology, University of Southern California, Los Angeles, California, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
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Horgan R, Hessami K, Hage Diab Y, Scaglione M, D'Antonio F, Kanaan C, Erfani H, Abuhamad A, Shamshirsaz AA. Prophylactic ureteral stent placement for the prevention of genitourinary tract injury during hysterectomy for placenta accreta spectrum: systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:101120. [PMID: 37549736 DOI: 10.1016/j.ajogmf.2023.101120] [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: 07/16/2023] [Accepted: 08/01/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE This study aimed to assess the effectiveness of prophylactic ureteral stent placement for the prevention of genitourinary tract injury at the time of cesarean hysterectomy for placenta accreta spectrum. The secondary objectives were to assess mean blood loss, operative time, number of packed red blood cells transfused, and rates of urinary tract infection among patients undergoing cesarean hysterectomy for placenta accreta spectrum with and without prophylactic ureteral stent placement. DATA SOURCES The search was performed using PubMed, Cochrane Library, and ClinicalTrials.gov from inception to February 2022 to December 2022. The protocol for this review was registered with the International Prospective Register of Systematic Reviews before data collection (registration number: CRD42022372817). STUDY ELIGIBILITY CRITERIA All studies that examined differences in the rate of genitourinary tract injury among women undergoing cesarean hysterectomy for prenatally suspected placenta accreta spectrum with and without placement of prophylactic ureteral stents were included. Genitourinary injury was defined as cystotomy, ureteral injury, and/or bladder fistula. Cases of both intentional and unintentional genitourinary injuries were included in the analysis. METHODS For all studies meeting the inclusion criteria, the following data were extracted: number of included patients, maternal demographic information, obstetrical history, type of invasive placentation, placement of stents (yes or no), type of stent placed, blood loss, operative time, genitourinary tract injury, and urinary tract infection. Pooled data analysis was completed using the Review Manager (version 5.3; Nordic Cochrane Centre, Copenhagen, Denmark; Cochrane Collaboration, 2014). The summary measures were reported as summary relative risk or as summary mean difference. The quality and risk of biases of the included studies were assessed according to the Newcastle-Ottawa Scale. RESULTS Overall, 9 studies, including 848 patients, fulfilled our inclusion criteria and were included in our analysis. Moreover, 523 patients (61.7%) had prophylactic ureteral stents placed, and 325 patients (38.3%) did not. Genitourinary injury occurred in 138 of 523 patients (26.4%) in the ureteral stent group vs 83 of 325 patients (25.5%) in the no ureteral stent group (relative risk, 0.94; 95% confidence interval, 0.74-1.20). The mean number of packed red blood cells transfused did not differ between the 2 groups. The pooled analysis demonstrated decreased blood loss among patients who received prophylactic ureteral stents, with a mean difference of 392 mL (95% confidence interval, 52.74-738.13). CONCLUSION Our systematic review and meta-analysis demonstrated no difference in the rates of genitourinary tract injury with the use of prophylactic ureteral stent placement among cases of prenatally suspected placenta accreta spectrum undergoing cesarean hysterectomy.
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Affiliation(s)
- Rebecca Horgan
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Drs Horgan, Diab, Kanaan, and Abuhamad).
| | - Kamran Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Hessami and Erfani); Maternal-Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA (Drs Hessami and Shamshirsaz)
| | - Yara Hage Diab
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Drs Horgan, Diab, Kanaan, and Abuhamad)
| | - Morgan Scaglione
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT (Dr Scaglione)
| | - Francesco D'Antonio
- Department of Obstetrics and Gynecology, Centre for High-Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy (Dr D'Antonio)
| | - Camille Kanaan
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Drs Horgan, Diab, Kanaan, and Abuhamad)
| | - Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Hessami and Erfani)
| | - Alfred Abuhamad
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Drs Horgan, Diab, Kanaan, and Abuhamad)
| | - Alireza A Shamshirsaz
- Maternal-Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA (Drs Hessami and Shamshirsaz)
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10
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Einerson BD, Sandlin AT, Afshar Y, Sharawi N, Fox KA, Newton JM, Shainker SA, Pezeshkmehr A, Carusi DA, Moroz L. General Management Considerations for Placenta Accreta Spectrum. Am J Perinatol 2023; 40:1026-1032. [PMID: 37336221 DOI: 10.1055/s-0043-1761915] [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
The ideal management of a patient with placenta accreta spectrum (PAS) includes close antepartum management culminating in a planned and coordinated delivery by an experienced multidisciplinary PAS team. Coordinated team management has been shown to optimize outcomes for mother and infant. This section provides a consensus overview from the Pan-American Society for the Placenta Accreta Spectrum regarding general management of PAS.
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Affiliation(s)
| | - Adam T Sandlin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arizona
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Nadir Sharawi
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arizona
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetric and Gynecology, Baylor College of Medicine (Texas Children's Hospital Pavilion for Women), Houston, Texas
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center Nashville, Tennessee
| | - Scott A Shainker
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amir Pezeshkmehr
- Department of Radiology Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Daniela A Carusi
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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11
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Munoz JL, Blankenship LM, Ramsey PS, McCann GA. Implementation and outcomes of a uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Am J Obstet Gynecol 2023; 229:61.e1-61.e7. [PMID: 36965865 DOI: 10.1016/j.ajog.2023.03.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall degree of placental adherence, and thus patients with placenta increta or percreta represent a high-risk category of patients. Hemorrhage and transfusion of blood products represent 90% of placenta accreta spectrum morbidity. Both tranexamic acid and uterine artery embolization independently decrease obstetrical hemorrhage. OBJECTIVE This study aimed to provide an evidence-based intraoperative protocol for placenta accreta spectrum management. STUDY DESIGN This study was a pre- and postimplementation analysis of concomitant uterine artery embolization and tranexamic acid in cases of patients with antenatally suspected placenta increta and percreta over a 5-year period (2018-2022). For comparison, a 5-year (2013-2017) preimplementation group was used to assess the impact of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Patient demographics and clinically relevant outcomes were obtained from electronic medical records. RESULTS A total of 126 cases were managed by the placenta accreta spectrum team, of which 66 had suspected placenta increta/percreta over the 10-year time period. Two patients were excluded from the postimplementation cohort because they did not undergo both interventions. Thus, 30 (30/64; 47%) were treated after implementation of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum, and 34 (34/64; 53%) preimplementation patients did not undergo uterine artery embolization or tranexamic acid infusion. With the uterine artery embolization and tranexamic acid protocol, operative times were longer (416 vs 187 minutes; P<.01), and patients were more likely to receive general anesthesia (80% vs 47%; P<.01). However, blood loss was reduced by 33% (2000 vs 3000 cc; P=.03), overall blood transfusion rates decreased by 51% (odds ratio, 0.05 [95% confidence interval, 0.001-0.20]; P<.01), and massive blood transfusion (>10 units transfused) was reduced 5-fold (odds ratio, 0.17 [95% confidence interval, 0.02-0.17]; P=.02). Postoperative complication rates remained unchanged (4 vs 10 events; P=.14). Neonatal outcomes were equivalent. CONCLUSION The uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum is an effective approach to the standardization of complex placenta accreta spectrum cases that results in optimal perioperative outcomes and reduced maternal morbidity.
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Affiliation(s)
- Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Logan M Blankenship
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Patrick S Ramsey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Georgia A McCann
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
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12
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Golbasi H, Bayraktar B, Golbasi C, Omeroglu I, Sever B, Adiyaman D, Kayhan Omeroglu S, Ekin A, Özeren M. Expected Versus Unexpected Delivery for Placenta Accreta Spectrum (PAS) Disorders with Same Team in Single Tertiary Center. Z Geburtshilfe Neonatol 2022; 226:391-398. [PMID: 36100249 DOI: 10.1055/a-1915-5832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To evaluate the maternal and neonatal outcomes of expected and unexpected pathologically proven placenta accreta spectrum (PAS) cases in a single multidisciplinary center. MATERIAL AND METHODS This was a retrospective cohort study of 92 PAS cases from January 2011 until September 2021. Only cases with histopathologically invasive placentation were included in the study. The cases diagnosed at the time of delivery were defined as unexpected PAS (uPAS) and those diagnosed antenatally as expected PAS (ePAS). Maternal and neonatal outcomes of both groups were compared. RESULTS Thirty-five (38%) of 92 cases were in the uPAS group. Placenta previa and high-grade PAS (percreata) were significantly higher in the ePAS group (p=0.028, p<0.001; respectively). The mean packed red blood cell transfusion was significantly higher in the uPAS group (p=0.030) but transfusions of other blood products were similar in the two groups. There was no significant difference in intraoperative complication rates between the two groups. Preterm delivery (<37 weeks) was significantly higher in the ePAS group (p<0.001), but there was no significant difference between the two groups in terms of adverse neonatal outcomes. CONCLUSIONS Our single center data show that although ePAS cases include more highly invasive PAS cases, maternal hemorrhagic morbidity is lower than uPAS cases. Reducing maternal morbidity in PAS cases can be achieved by increasing antenatal diagnosis.
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Affiliation(s)
- Hakan Golbasi
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Burak Bayraktar
- University of Health Sciences Tepecik Training and Research Hospital, Department of Obstetrics and Gynecology, Izmir, Turkey
| | - Ceren Golbasi
- Tinaztepe University Faculty of Health Sciences, Department of Obstetrics and Gynecology, Izmir, Turkey
| | - Ibrahim Omeroglu
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Baris Sever
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Duygu Adiyaman
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Seyda Kayhan Omeroglu
- University of Health Sciences Suat Seren Chest Diseases and Surgery Training and Research Hospital, Department of Anesthesia and Reanimation, Izmir, Turkey
| | - Atalay Ekin
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Mehmet Özeren
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
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13
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Munoz JL, Hernandez B, Curbelo J, Ramsey PS, Ireland KE. Effect of anesthesia selection on neonatal outcomes in cesarean hysterectomies for placenta accreta spectrum (PAS). J Perinat Med 2022; 50:1210-1214. [PMID: 35607729 DOI: 10.1515/jpm-2022-0062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/02/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Optimal treatment for placenta accreta spectrum (PAS) is late-preterm cesarean hysterectomy to minimize maternal morbidity. This study aims to assess the impact of surgical planning during this gestational age on neonates as a key part of the pregnancy dyad. METHODS A retrospective cohort analysis was performed of 115 singleton, non-anomalous pregnancies complicated by PAS at the University of Texas Health San Antonio Placenta Accreta program from 2005 to 2020. Univariate and multivariate analyses were performed to identify the individual impact of variables such as anesthesia selection, advancing gestational age and operative characteristics. RESULTS With regards to neonatal intubation, on multivariate analysis, neuraxial anesthesia (OR=0.09, [95% CI 0.02, 0.37]) and advancing gestational age (OR=0.49 [95% CI 0.34, 0.71]) were independent protective factors. In addition, NICU length of stay was directly impacted by neuraxial anesthesia (IRR=0.73, [95% CI 0.55, 0.97]) and advancing gestational age (IRR=0.80 [95% CI 0.76, 0.84]), resulting in shorter NICU admissions. CONCLUSIONS As gestational age at delivery may not be modifiable in cases of PAS, the utilization of neuraxial anesthesia (as oppose to general anesthesia) presents a modifiable intervention which may optimize neonatal outcomes from cesarean hysterectomy.
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Affiliation(s)
- Jessian L Munoz
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, University Health System, San Antonio, TX, USA
| | - Brian Hernandez
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, University Health System, San Antonio, TX, USA
| | - Jacqueline Curbelo
- Department of Anesthesiology, University of Texas Health Sciences Center at San Antonio, University Health System, San Antonio, TX, USA
| | - Patrick S Ramsey
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, University Health System, San Antonio, TX, USA
| | - Kayla E Ireland
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, University Health System, San Antonio, TX, USA
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14
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Enste R, Cricchio P, Dewandre PY, Braun T, Leonards CO, Niggemann P, Spies C, Henrich W, Kaufner L. Placenta Accreta Spectrum Part II: hemostatic considerations based on an extended review of the literature. J Perinat Med 2022; 51:455-467. [PMID: 36181735 DOI: 10.1515/jpm-2022-0233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022]
Abstract
"Placenta accreta spectrum" (PAS) is a rare but serious pregnancy condition where the placenta abnormally adheres to the uterine wall and fails to spontaneously release after delivery. When it occurs, PAS is associated with high maternal morbidity and mortality-as PAS management can be particularly challenging. This two-part review summarizes current evidence in PAS management, identifies its most challenging aspects, and offers evidence-based recommendations to improve management strategies and PAS outcomes. The first part of this two-part review highlighted the general anesthetic approach, surgical and interventional management strategies, specialized "centers of excellence," and multidisciplinary PAS treatment teams. The high rates of PAS morbidity and mortality are often provoked by PAS-associated coagulopathies and peripartal hemorrhage (PPH). Anesthesiologists need to be prepared for massive blood loss, transfusion, and to manage potential coagulopathies. In this second part of this two-part review, we specifically reviewed the current literature pertaining to hemostatic changes, blood loss, transfusion management, and postpartum venous thromboembolism prophylaxis in PAS patients. Taken together, the two parts of this review provide a comprehensive survey of challenging aspects in PAS management for anesthesiologists.
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Affiliation(s)
- Rick Enste
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Patrick Cricchio
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Pierre-Yves Dewandre
- Department of Anesthesia and Intensive Care Medicine, Université de Liège, Liege, Belgium
| | - Thorsten Braun
- Department of Obstetrics and 'Exp. Obstetrics', Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christopher O Leonards
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Phil Niggemann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics and 'Exp. Obstetrics', Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lutz Kaufner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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15
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Enste R, Cricchio P, Dewandre PY, Braun T, Leonards CO, Niggemann P, Spies C, Henrich W, Kaufner L. Placenta accreta spectrum part I: anesthesia considerations based on an extended review of the literature. J Perinat Med 2022; 51:439-454. [PMID: 36181730 DOI: 10.1515/jpm-2022-0232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022]
Abstract
"Placenta accreta spectrum" (PAS) describes abnormal placental adherence to the uterine wall without spontaneous separation at delivery. Though relatively rare, PAS presents a particular challenge to anesthesiologists, as it is associated with massive peripartum hemorrhage and high maternal morbidity and mortality. Standardized evidence-based PAS management strategies are currently evolving and emphasize: "PAS centers of excellence", multidisciplinary teams, novel diagnostics/pharmaceuticals (especially regarding hemostasis, hemostatic agents, point-of-care diagnostics), and novel operative/interventional approaches (expectant management, balloon occlusion, embolization). Though available data are heterogeneous, these developments affect anesthetic management and must be considered in planed anesthetic approaches. This two-part review provides a critical overview of the current evidence and offers structured evidence-based recommendations to help anesthesiologists improve outcomes for women with PAS. This first part discusses PAS management in centers of excellence, multidisciplinary care team, anesthetic approach and monitoring, surgical approaches, patient safety checklists, temperature management, interventional radiology, postoperative care and pain therapy. The diagnosis and treatment of hemostatic disturbances and preoperative prepartum anemia, blood loss, transfusion management and postpartum venous thromboembolism will be addressed in the second part of this series.
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Affiliation(s)
- Rick Enste
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Patrick Cricchio
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Pierre-Yves Dewandre
- Department of Anesthesia and Intensive Care Medicine, Université de Liège, Liege, Belgium
| | - Thorsten Braun
- Department of Obstetrics and 'Exp. Obstetrics', Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christopher O Leonards
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Phil Niggemann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics and 'Exp. Obstetrics', Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lutz Kaufner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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16
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Matsuo K, Vestal NL, Rau AR, Sangara RN, Youssefzadeh AC, Bainvoll L, Matsuzaki S, Roman LD, Ouzounian JG, Wright JD. Gynecologic oncologists in surgery for placenta accreta spectrum: a survey for practice, experience, and interest. Int J Gynecol Cancer 2022; 32:1433-1442. [PMID: 36167437 DOI: 10.1136/ijgc-2022-003830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Surgery for placenta accreta spectrum is associated with significant maternal morbidity and mortality. The role of gynecologic oncologists in the surgical management of placenta accreta spectrum is currently under investigation. This study examined the practices, experiences, and interests of gynecologic oncologists in placenta accreta spectrum surgeries. METHODS The intervention was an anonymous, cross-sectional, 20-question survey sent to 1084 members of the Society of Gynecologic Oncology in the USA. RESULTS A total of 184 gynecologic oncologists responded to the survey (response rate 17.0%). Most participating gynecologic oncologists have been practicing for >10 years after fellowship (53.2%), practice in urban-teaching hospitals (84.8%) with delivery volumes ≥3000/year (54.3%), and have a multidisciplinary approach (82.5%). Three-quarters (78.7%) feel that the rate of placenta accreta spectrum is increasing over time. One-third (35.5%) perform ≥6 hysterectomies for placenta accreta spectrum yearly. Less than half (45.5%) practice conservative management. Approximately half are involved from the beginning of the case (49.7%) and perform the surgery in the main operating room (59.4%). Almost three-quarters (71.6%) have experienced surgical blood loss >5 L and one-third (36.6%) have experienced cases with blood loss >10 L. About half (50.3%) of participants are interested in placenta accreta spectrum surgery for future practice. Gynecologic oncologists engaging in a multidisciplinary approach are more likely to practice in an urban-teaching hospital, have higher surgical volume, be involved from the beginning of the case, and be interested in placenta accreta spectrum surgery. Those >10 years post-training and in the Southern US region are more likely to practice conservative management or delayed hysterectomy. CONCLUSION This society-based cross-sectional survey suggests that gynecologic oncologists are actively involved in the surgical management of placenta accreta spectrum in the USA. Nearly half of gynecologic oncologists who responded to the survey expressed interest in surgery for placenta accreta spectrum.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA .,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Nicole L Vestal
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alesandra R Rau
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rauvynne N Sangara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Ariane C Youssefzadeh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Liat Bainvoll
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and gynecology, Columbia University College of Physicians and Surgeons, New York City, New York, USA
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17
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Munoz JL, Blankenship LM, Ramsey PS, McCann GA. Importance of the gynecologic oncologist in management of cesarean hysterectomy for Placenta Accreta Spectrum (PAS). Gynecol Oncol 2022; 166:460-464. [PMID: 35781164 DOI: 10.1016/j.ygyno.2022.06.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Placenta Accreta Spectrum (PAS) is an invasive placental disorder characterized by significant maternal and fetal morbidity. Utilization of multidisciplinary teams has been shown to optimize patient outcomes. Our objective was to assess the impact of cesarean hysterectomy performed by gynecologic oncologists versus Ob/Gyn specialists in maternal morbidity. METHODS A retrospective cohort study was performed of singleton, non-anomalous pregnancies complicated by PAS University of Texas Health San Antonio Placenta Accreta program from 2010 to 2021. Our primary outcome was a maternal morbidity composite of any of the following: estimated blood loss >2 L, ICU admission, intraoperative acidosis and post-operative length of stay >4 days. In addition, demographic and pregnancy data were obtained. Univariate and multivariate analyses were performed to identify the individual impact of variables such as general anesthesia, episodes of vaginal bleeding, uterine artery embolization, emergent delivery and placenta percreta pathology. RESULTS 122 pregnancies complicated by PAS who underwent cesarean hysterectomy were identified from 2010 to 2021. Gynecologic oncologists were the primary surgeons for 62 (50.8%) of these cases. The involvement of gynecologic oncologists increased over the time period from 16% to 80%. Gynecologic oncologists were more like to be involved in cases with an antenatal diagnosis of placenta percreta (11.7 vs 37.1%, p = 0.001) and these cases were characterized by increased composite maternal morbidity (65 vs 83.9%, p = 0.02). These cases were also significantly longer (151 vs 271 min, p < 0.0001), involved greater usage of urinary stents (36.7 vs 66.1%, p = 0.002) and had longer post-operative lengths of stay (3 vs 4 days, p < 0.0001). PAS cesarean hysterectomies by gynecologic oncologists were less likely to be supracervical (25 vs 3.2%, p = 0.0005). Multivariate analysis controlling for placenta percreta, uterine artery embolization, vaginal bleeding and emergent delivery showed no difference in composite maternal morbidity (aOR = 0.95, 95%CI [0.35-2.52]) and lower rates of intraoperative acidosis (aOR = 0.36, 95%CI [0.14-0.93]) or post-operative length of stay >4 days (aOR = 0.37, 95%CI [0.15-0.91]). CONCLUSIONS Gynecologic oncologists play a critical role in the surgical management of PAS cesarean hysterectomies. When compared to Ob/Gyn specialists, gynecologic oncologists are more likely to act as primary surgeons in complex cases similar morbidity and greater post-operative outcomes.
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Affiliation(s)
- Jessian L Munoz
- University of Texas Health Sciences Center at San Antonio, Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University Health System, San Antonio, TX, United States of America.
| | - Logan M Blankenship
- University of Texas Health Sciences Center at San Antonio, Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, University Health System, San Antonio, TX, United States of America
| | - Patrick S Ramsey
- University of Texas Health Sciences Center at San Antonio, Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University Health System, San Antonio, TX, United States of America
| | - Georgia A McCann
- University of Texas Health Sciences Center at San Antonio, Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, University Health System, San Antonio, TX, United States of America
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18
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Touhami O, Allen L, Flores Mendoza H, Murphy MA, Hobson SR. Placenta accreta spectrum: a non-oncologic challenge for gynecologic oncologists. Int J Gynecol Cancer 2022; 32:ijgc-2021-003325. [PMID: 35478092 DOI: 10.1136/ijgc-2021-003325] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Placenta accreta spectrum disorders are a major risk factor for severe postpartum hemorrhage and maternal death worldwide, with a rapidly growing incidence in recent decades due to increasing rates of cesarean section. Placenta accreta spectrum disorders represent a complex surgical challenge, with the primary concern of massive obstetrical hemorrhagic sequelae and organ damage, occurring in the context of potentially significant anatomical and physiological changes of pregnancy. Most international obstetrical organizations have published guidelines on placenta accreta spectrum, embracing the creation of regionalized 'Centers of Excellence' in the diagnosis and management of placenta accreta spectrum, which includes a dedicated multidisciplinary surgical team. One mandatory criterion for these Centers of Excellence is the presence of a surgeon experienced in complex pelvic surgeries. Indeed, many institutions in the United States and worldwide rely on gynecologic oncologists in the surgical management of placenta accreta spectrum due to their experience and skills in complex pelvic surgery. Surgical management of placenta accreta spectrum frequently includes challenging pelvic dissection in regions with distortion of anatomy alongside large aberrant neovascularization. With a goal of definitive management through cesarean hysterectomy, surgeons require a systematic and thoughtful approach to promote prevention of urologic injuries, embrace measures to secure challenging hemostasis and, in selected cases, employ conservative management where indicated or desired. In this review recommendations are made for gynecologic oncologists regarding the management and important considerations in the successful care of placenta accreta spectrum disorders. Where required, gynecologic oncologists are encouraged to be proactively involved in the management of placenta accreta spectrum, not only intra-operatively, but also in the development of clinical protocols, guidelines, and pre-operative counseling of patients, as a 'call if needed' approach is suboptimal for this potentially major and life-threatening condition.
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Affiliation(s)
- Omar Touhami
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Centre Intégré Universitaire de Santé et Services Sociaux CIUSSS du Saguenay-Lac-Saint-Jean, Sherbrooke University, Sherbrooke, Quebec, Canada
| | - Lisa Allen
- Department of Obstetrics and Gynecology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Homero Flores Mendoza
- Department of Obstetrics and Gynecology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - M Alix Murphy
- Department of Obstetrics and Gynecology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Sebastian Rupert Hobson
- Department of Obstetrics and Gynecology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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19
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Placental thickness correlates with placenta accreta spectrum (PAS) disorder in women with placenta previa. Abdom Radiol (NY) 2021; 46:2722-2728. [PMID: 33388802 DOI: 10.1007/s00261-020-02894-9] [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: 09/20/2020] [Revised: 11/29/2020] [Accepted: 12/04/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To evaluate the association of placental thickness with placenta accreta spectrum disorder in placenta previa. METHODS In this IRB-approved, retrospective study, ultrasound (US) reports were retrospectively queried for keyword previa. US performed closest to mid-gestation were included. Three measurements were performed at the thickest portion of the placenta on longitudinal transabdominal images. Operative reports and surgical pathology were used as the reference standard. Statistical analysis was performed using unpaired T-tests and receiver operating curve (ROC) analysis. RESULTS Sixty-five patients with placenta previa were included: 38 with PAS disorder and 27 without PAS disorder, clinically or pathologically. 38/38 (100%) patients of PAS group and 16/27 (59.3%) patients of non-PAS group had history of prior cesarean section. The average placental thickness was 4.3 cm (range 1.8 cm to 7.8 cm) for PAS group and 3.0 cm (range 0.6 cm to 5.3 cm) for non-PAS group (p < 0.001). Placental thickness in patients without PAS disorder and history of prior cesarean section was 3.1 (± 1.1) cm. This was statistically different from patients who had history of prior cesarean section with PAS diagnosis (4.3 cm, P<0.01). Using ROC analysis, a threshold measurement of 4.5 cm leads to sensitivity of 50% and specificity of 96%. CONCLUSION Our results demonstrate that among women with placenta previa, increased placental thickness at lower uterine segment correlates with placenta accreta spectrum disorder. A threshold of 4.5 cm can be useful for screening patients with placenta previa and risks factors for PAS.
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20
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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Hidalgo A, Vergara-Galliadi LM, Cortés Charry R, Aguilera Daga LR, Verástegui Goyzueta R, Osanan G, Fernandez J, Corrales F, Mereci W, Yuen-Chon V, Guevara E, Zúñiga LA, Girón, Turcios FE, Muñoz H, Perez AM, Meade P, Basanta N, Pineda JP. Management practices for placenta accreta spectrum patients: a Latin American hospital survey. J Matern Fetal Neonatal Med 2021; 35:6104-6111. [PMID: 33843408 DOI: 10.1080/14767058.2021.1906858] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Placenta accreta spectrum (PAS) causes severe morbidity and can result in maternal death. It must be managed in specialized centers with interdisciplinary groups, but few publications have described the usual management within a specific geographic region. We intend to describe the usual approach for PAS in reference centers in Latin America. METHODOLOGY This was an observational, multicenter, cross-sectional study conducted in Latin American PAS reference centers. A standardized survey was implemented and applied to obstetric service coordinators and leaders of interdisciplinary groups with experience in PAS between September and November 2020. RESULTS One hundred fifty-four hospitals were included. Most of them (64.3%) handle approximately one case of PAS every two months, and almost all centers (89.6%) believe that their performance could be improved. CONCLUSIONS Most of the reference centers for PAS in Latin America attend to a small number of cases each year, and almost all of these hospitals identify opportunities to improve the management or approach for PAS in women.
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Affiliation(s)
| | | | - Alejandra Hidalgo
- Facultad de Ciencias de la Salud, Programa de Medicina, Universidad Icesi, Cali, Colombia
| | | | | | | | | | - Gabriel Osanan
- Department of Obstetrics and Gynaecology, Faculty of medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | | | | | | | | | | | - Girón
- Hospital Mario Catarino Rivas, San Pedro Sula, Honduras
| | | | | | | | - Paulo Meade
- Hospital Lomas de San Luis, Cuidad de México, México
| | - Nicolas Basanta
- Hospital General de agudos Juan A Fernández, Buenos Aires, Argentina
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21
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Bluth A, Schindelhauer A, Nitzsche K, Wimberger P, Birdir C. Placenta accreta spectrum disorders-experience of management in a German tertiary perinatal centre. Arch Gynecol Obstet 2020; 303:1451-1460. [PMID: 33284419 PMCID: PMC8087589 DOI: 10.1007/s00404-020-05875-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 11/03/2020] [Indexed: 10/26/2022]
Abstract
PURPOSE Placenta accreta spectrum (PAS) disorders can cause major intrapartum haemorrhage. The optimal management approach is not yet defined. We analysed available cases from a tertiary perinatal centre to compare the outcome of different individual management strategies. METHODS A monocentric retrospective analysis was performed in patients with clinically confirmed diagnosis of PAS between 07/2012 and 12/2019. Electronic patient and ultrasound databases were examined for perinatal findings, peripartum morbidity including blood loss and management approaches such as (1) vaginal delivery and curettage, (2) caesarean section with placental removal versus left in situ and (3) planned, immediate or delayed hysterectomy. RESULTS 46 cases were identified with an incidence of 2.49 per 1000 births. Median diagnosis of placenta accreta (56%), increta (39%) or percreta (4%) was made in 35 weeks of gestation. Prenatal detection rate was 33% for all cases and 78% for placenta increta. 33% showed an association with placenta praevia, 41% with previous caesarean section and 52% with previous curettage. Caesarean section rate was 65% and hysterectomy rate 39%. In 9% of the cases, the placenta primarily remained in situ. 54% of patients required blood transfusion. Blood loss did not differ between cases with versus without prenatal diagnosis (p = 0.327). In known cases, an attempt to remove the placenta did not show impact on blood loss (p = 0.417). CONCLUSION PAS should be managed in an optimal setting and with a well-coordinated team. Experience with different approaches should be proven in prospective multicentre studies to prepare recommendations for expected and unexpected need for management.
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Affiliation(s)
- Anja Bluth
- Department of Gynecology and Obstetrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
| | - Axel Schindelhauer
- Department of Gynecology and Obstetrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Katharina Nitzsche
- Department of Gynecology and Obstetrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Pauline Wimberger
- Department of Gynecology and Obstetrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Cahit Birdir
- Department of Gynecology and Obstetrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
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