Improved management of placenta accreta spectrum disorders: experience from a single institution

Abstract Objectives To assess the applicability of a standardized multidisciplinary protocol for managing placenta accreta spectrum (PAS) disorders and its impact on the outcomes. Methods We compared patients with PAS manage by a standardized multidisciplinary protocol (T2) to historic controls managed on a case-by-case basis by individual physicians between (T1). The primary outcome is composite maternal morbidity. Secondary outcomes were the rates of surgical complications, estimated blood loss, number of blood products transfused, intensive care unit admissions, ventilator use, and birth weight. Multivariate logistic analysis was used to identify independent predictors of composite maternal morbidity. Results During T1 and T2, we managed 39 and 36 patients with confirmed PAS, respectively. During T2, the protocol could be implemented in 21 cases (58%). Compared to T1, patients managed during T2 had 70% less composite maternal morbidity (95% CI: 0.11–0.82) and lower blood loss (median, 2,000 vs. 1,100 mL, p=0.008). Also, they were 68% less likely to require transfusion of blood products (95% CI: 0.12–0.81; p=0.01), including fewer units of packed red blood cells (median, 2 vs. 0, p=0.02). Management following the protocol was the only independent factor associated with lower composite maternal morbidity (OR: 0.22; 95% CI: 0.05–0.95; p=0.04). Selected maternal and neonatal outcomes were not different among 12 and 15 patients with suspected but unconfirmed PAS disorders managed during T1 and T2, respectively. Conclusions Most patients can be managed under a standardized multidisciplinary protocol for PAS disorders, leading to improved outcomes.

Download Full-text

Clinical outcomes of a false positive antenatal diagnosis of placenta accreta spectrum

American Journal of Perinatology ◽

10.1055/a-1673-5103 ◽

2021 ◽

Author(s):

Bahram Salmanian ◽

Amir A. Shamshirsaz ◽

Karin Fox ◽

nazlisadat meshinchi asl ◽

Hadi Erfani ◽

...

Keyword(s):

Clinical Outcomes ◽

Resource Utilization ◽

False Positive ◽

Maternal Morbidity ◽

Placenta Accreta ◽

Antenatal Diagnosis ◽

Estimated Blood Loss ◽

Management Protocol ◽

Significant Difference ◽

Placenta Accreta Spectrum

Objective: Antenatal diagnosis of placenta accreta spectrum (PAS) is critical to reduce maternal morbidity. While clinical outcomes of women with PAS have been extensively described, little information is available regarding the women who undergo cesarean delivery with a presumptive PAS diagnosis which is not confirmed by histopathologic examination. We sought to examine resource utilization and clinical outcomes of this group of women with a false-positive diagnosis of PAS. Study design: Retrospective analysis of patients with prenatally diagnosed PAS cared for between 2015 and 2020 by our multidisciplinary PAS team. Maternal outcomes were examined. Univariate analysis was performed and a multivariate model was employed to compare outcomes between women with and without histopathologically confirmed PAS. Results: A total of 162 patients delivered with the pre-operative diagnosis of PAS. Of these, 146 (90%) underwent hysterectomy and had histopathologic confirmation of PAS. Thirteen women did not undergo the planned hysterectomy. Three women underwent hysterectomy but pathologic examination did not confirm PAS. In comparing women with and without pathologic confirmation of PAS, the false positive PAS group delivered later in pregnancy (34 vs. 33 weeks of gestation, P=0.015) and had more planned surgery (88% vs. 47%, P = 0.002). There was no difference in skin incision type or hysterotomy placement for delivery. No significant difference in either the estimated blood loss or blood components transfused was noted between groups. Conclusion: Careful intraoperative evaluation of women with pre-operatively presumed PAS resulted in a 3/149 (2%) retrospectively unnecessary hysterectomy. Management of women with PAS in experienced centers benefits patients both in terms of resource utilization and avoidance of unnecessary maternal morbidity, understanding that our results are produced in a center of excellence for PAS. We also propose a management protocol to assist in the avoidance of unnecessary hysterectomy in women with the pre-operative diagnosis of PAS.

Download Full-text

Surgery for Uterine Preservation in Placenta Accreta Spectrum: A Retrospective Cohort Study

10.21203/rs.3.rs-827630/v1 ◽

2021 ◽

Author(s):

Yi-Lei Li ◽

Tao Li ◽

Wen Peng ◽

Xiang-Bin Liu ◽

Hong-Mei Wang

Keyword(s):

Blood Loss ◽

Placenta Accreta ◽

Psychological Trauma ◽

Uterine Preservation ◽

Cesarean Scar ◽

Estimated Blood Loss ◽

Placenta Accreta Spectrum ◽

Placental Invasion ◽

Cervical Involvement ◽

Surgery Duration

Abstract Background: Owing to high risks of maternal morbidity, surgical complications, and loss of fertility, including psychological trauma caused by cesarean hysterectomy, innovative approaches for uterine preservation have been investigated. This study aimed to determine the efficacy of a novel eight-step surgical protocol for uterine preservation in placenta accreta spectrum (PAS) overlying the previous cesarean scar.Methods: We retrospectively studied consecutive patients with PAS overlying the cesarean scar, who were treated between December 2015 and October 2019 using the protocol. The depth and extension of placental invasion and severity of pelvic adhesion were assessed intraoperatively. Information regarding the gestational week at surgery, surgery duration, estimated blood loss (EBL), bladder injury, and post-procedural recovery was retrieved from the hospital database. Multiple linear regression was used to analyze factors influencing surgical blood loss. EBL was compared between the perioperative aortic balloon and non-balloon groups in severe cases using t-tests.Results: Overall, 115 patients with PAS were included. The mean EBL and surgery duration were 1666.1±1379.0 mL and 2.2±0.8 h, respectively. The uterus was successfully preserved in all patients with one surgery. Incidences of placenta accreta, increta, and percreta were 40 (35.8%), 46 (40.0%), and 29 (25.2%) cases, respectively. Extensive placental invasion and cervical involvement were observed in 41.7% and 28.7% of patients, respectively. EBL was significantly correlated with the extent of placental invasion, cervical involvement, and pelvic adhesion. No difference was seen in EBL between the balloon and non-balloon groups among the 44 patients with severe PAS.Conclusion: The eight-step protocol is effective for uterine preservation in PAS overlying the cesarean scar. EBL is affected by the extent of placental invasion, cervical involvement, and severity of pelvic adhesion. Perioperative aortic balloon should be used conservatively.

Download Full-text

Multidisciplinary Approach for the Management of Complex Hepatic Injuries AAST-OIS Grades IV—V: A Prospective Study

Scandinavian Journal of Surgery ◽

10.1177/145749690709600306 ◽

2007 ◽

Vol 96 (3) ◽

pp. 214-220 ◽

Cited By ~ 31

Author(s):

J. A. Asensio ◽

P. Petrone ◽

L. Garcí-Núñez ◽

B. Kimbrell ◽

E. Kuncir

Keyword(s):

Emergency Department ◽

Logistic Regression ◽

Blood Loss ◽

Blood Cells ◽

Multidisciplinary Approach ◽

Stepwise Logistic Regression ◽

Packed Red Blood Cells ◽

Emergency Department Thoracotomy ◽

Estimated Blood Loss ◽

Hepatic Injuries

Background: Complex hepatic injuries grades IV—V are highly lethal. The objective of this study is to assess the multidisciplinary approach for their management and to evaluate if survival could be improved with this approach. Study Design: Prospective 54-month study of all patients sustaining hepatic injuries grades IV—V managed operatively at a Level I Trauma Center. Main outcome measure: survival. Statistical analysis: univariate and stepwise logistic regression. Results: Seventy-five patients sustained penetrating (47/63%) and blunt (28/37%) injuries. Seven (9%) patients underwent emergency department thoracotomy with a mortality of 100%. Out of the 75 patients, 52 (69%) sustained grade IV, and 23 (31%) grade V. The estimated blood loss was 3,539±-3,040 ml. The overall survival was 69%, adjusted survival excluding patients requiring emergency department thoracotomy was 76%. Survival stratified to injury grade: grade IV 42/52–81%, grade V 10/23–43%. Mortality grade IV versus V injuries (p <0.002; RR 2.94; 95% CI 1.52–5.70). Risk factors for mortality: packed red blood cells transfused in operating room (p=0.024), estimated blood loss (p<0.001), dysryhthmia (p<0.0001), acidosis (p=0.051), hypothermia (p=0.04). The benefit of angiography and angioembolization indicated: 12% mortality (2/17) among those that received it versus a 36% mortality (21/58) among those that did not (p=0.074; RR 0.32; 95% CI 0.08–1.25). Stepwise logistic regression identified as significant independent predictors of outcome: estimated blood loss (p=0.0017; RR 1.24; 95% CI 1.08–1.41) and number of packed red blood cells transfused in the operating room (p=0.0358; RR 1.16; 95% CI 1.01–1.34). Conclusions: The multidisciplinary approach to the management of these severe grades of injuries appears to improve survival in these highly lethal injuries. A prospective multi-institutional study is needed to validate this approach.

Download Full-text

Placenta accreta spectrum disorders—experience of management in a German tertiary perinatal centre

Archives of Gynecology and Obstetrics ◽

10.1007/s00404-020-05875-x ◽

2020 ◽

Author(s):

Anja Bluth ◽

Axel Schindelhauer ◽

Katharina Nitzsche ◽

Pauline Wimberger ◽

Cahit Birdir

Keyword(s):

Caesarean Section ◽

Blood Loss ◽

Placenta Accreta ◽

Caesarean Section Rate ◽

Management Strategies ◽

Management Approach ◽

Optimal Setting ◽

Placenta Accreta Spectrum ◽

Management Approaches

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.

Download Full-text

The Choice of Anesthesia During Organ-Saving Operations Concerning Patients With Placenta Accreta Spectrum Disorders

Russian Sklifosovsky Journal Emergency Medical Care ◽

10.23934/2223-9022-2020-9-2-221-230 ◽

2020 ◽

Vol 9 (2) ◽

pp. 221-230

Author(s):

E. N. Plakhotina ◽

T. N. Belousova ◽

I. A. Kulikov ◽

R. V. Latyshev ◽

K. M. Pavlyutina

Keyword(s):

Blood Loss ◽

General Anesthesia ◽

Epidural Anesthesia ◽

Placenta Accreta ◽

Pain Syndrome ◽

Tissue Perfusion ◽

Optimal Method ◽

Clear Trend ◽

Placenta Accreta Spectrum ◽

Spectrum Disorders

Abstract Placenta accreta (PAS-disorders) is one of the most serious complications of pregnancy, associated with the risk of massive uterine bleeding, massive hemotransfusion and maternal mortality. Peripartum hysterectomy is a common treatment strategy for patients with placenta accreta. Currently, there is a clear trend of changing surgical tactics in favor of organ-saving operations, but there are no studies devoted to anesthesiological support of such operations.The aim of the study is to substantiate an effective and safe method of anaesthesia in organ-saving operations for placenta accreta spectrum disorders.Materia l and methods The study involved 80 patients with a diagnosis of placenta accreta spectrum disorders, confirmed intraoperatively, who underwent organ-saving operations. The patients were randomized depending on the method of anesthesia into 3 groups: general anesthesia, spinal anesthesia with planned conversion to general after fetal extraction and epidural anesthesia with planned conversion to general also after fetal extraction. The comparison of intraoperative hemodynamics, efficiency of tissue perfusion, efficiency of antinociceptive protection at the stages of surgery was performed. A comparative analysis of the volume of blood loss and blood transfusion, time of patients activation in the postoperative period, severity of pain on the first day after surgery, duration of hospital stay before discharge and comparison of the assessment of the newborn according to Apgar score at first and fifth minute after extraction.Conclusion The study shows that the optimal method of anesthesia in organ-saving operations for placenta accreta spectrum disorders is epidural anesthesia with its planned conversion to general anesthesia with an artificial lung ventilation after fetal extraction. Such an approach to anesthesia allows to maintain stable hemodynamic profile with minimal vasopressor support, sufficient heart performance, providing effective tissue perfusion and a high level of antinociceptive protection at the intraoperative stage and reduce the volume of intraoperative blood loss and hemotransfusion. In the current study there were no differences in neonatal outcomes and duration of hospitalization depending on the method of anesthesia. The advantage of epidural anesthesia with its conversion to general anesthesia was earlier activation after surgery and lower intensity of postoperative pain syndrome.

Download Full-text

Surgical advances in the management of placenta accreta spectrum: establishing new expectations for operative blood loss

The Journal of Maternal-Fetal & Neonatal Medicine ◽

10.1080/14767058.2020.1852213 ◽

2020 ◽

pp. 1-10

Author(s):

Liviu Cojocaru ◽

Allison Lankford ◽

Jessica Galey ◽

Shobana Bharadwaj ◽

Bhavani S. Kodali ◽

...

Keyword(s):

Blood Loss ◽

Placenta Accreta ◽

Operative Blood Loss ◽

Placenta Accreta Spectrum

Download Full-text

A novel approach to reduce blood loss in patients with placenta accreta spectrum disorder

The Journal of Maternal-Fetal & Neonatal Medicine ◽

10.1080/14767058.2019.1656194 ◽

2019 ◽

pp. 1-10 ◽

Cited By ~ 1

Author(s):

Ozhan M. Turan ◽

Allison Shannon ◽

Mehmet R. Asoglu ◽

Katherine R. Goetzinger

Keyword(s):

Blood Loss ◽

Placenta Accreta ◽

Spectrum Disorder ◽

Reduce Blood Loss ◽

Novel Approach ◽

Placenta Accreta Spectrum

Download Full-text

Efficacy of tranexamic acid in reducing blood loss, blood and blood products requirements in Cesarian sections for patients with placenta accreta

Ain-Shams Journal of Anesthesiology ◽

10.1186/s42077-019-0051-9 ◽

2019 ◽

Vol 11 (1) ◽

Author(s):

Tamer Hamed Ibrahim

Keyword(s):

Platelet Count ◽

Placebo Group ◽

Blood Loss ◽

Tranexamic Acid ◽

Placenta Accreta ◽

Controlled Study ◽

Intraoperative Blood Loss ◽

Blood Products ◽

Coagulation Profile ◽

Significant Difference

Abstract Background Placenta accreta is an obstetric emergency and the main cause of maternal morbidity and mortality due to the associated bleeding and coagulopathy. Tranexamic acid has been widely used to decrease blood loss in trauma patients and patients with postpartum hemorrhage. We aimed at studying the effect of tranexamic acid in reducing blood loss and blood transfusion in patients with placenta accreta. Methods In a double-blinded randomized controlled study, 46 patients were recruited and divided into two groups, Group A is the tranexamic group where patients received 10 mg/kg tranexamic acid after cord clamping and continued on tranexamic infusion 10 mg/kg/h till the end of the surgery. Group B is the placebo where patients received normal saline instead. Primary outcome was the amount of intraoperative blood loss, and other outcomes included the number of blood and blood products transfused intraoperative and in the first 24 h postoperative, the immediate postoperative Hb level, platelet count, and coagulation profile. Data were collected, coded, tabulated, and then analyzed using Minitab® 16.1.0 statistics software package. Variables were presented as mean and standard deviation and analyzed using unpaired t test. Any difference with p value < 0.05 was considered statistically significant. Results Amount of intraoperative blood loss was significantly less in the tranexamic group 2232 ± 1204 ml compared to the placebo group 3405 ± 1193 ml (p value 0.002), and patients in the tranexamic group received less units of packed red blood cells, fresh frozen plasma, and platelets compared to those in the placebo group (4.2 ± 1.9 vs 6.1 ± 2.2 with p value 0.003, 3.4 ± 1.3 vs 4.2 ± 1.2 with P value 0.036 and 4.8 ± 2.1 vs 6.2 ± 2.4 with p value 0.041, respectively). There was no statistically significant difference in the first postoperative Hb level, platelet count, and coagulation profile between the two groups; however, the amount of blood and products transfused in the first 24 h postoperative were significantly less in the tranexamic group Conclusion Tranexamic acid infusion was effective in reducing intraoperative blood loss and intraoperative and postoperative blood and blood products’ transfusion.

Download Full-text

When is the ideal time to remove cerclage in cases requiring cesarean hysterectomy for placenta accreta spectrum?

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20190972 ◽

2019 ◽

Vol 8 (4) ◽

pp. 1668

Author(s):

Futa Ito ◽

Shinya Matsuzaki ◽

Masayuki Endo ◽

Tadashi Kimura

Keyword(s):

Preterm Birth ◽

Maternal Morbidity ◽

Birth Rate ◽

Placenta Accreta ◽

Cervical Insufficiency ◽

Short Cervix ◽

Cesarean Hysterectomy ◽

Preterm Birth Rate ◽

Placenta Accreta Spectrum ◽

The Ideal

Placenta accreta spectrum (PAS) presents one of the highest risks to pregnancy and often requires a cesarean hysterectomy for management, but the challenges associated with this surgery often cause severe obstetric haemorrhaging and high rates of maternal morbidity. Shirodkar cerclage is usually performed in cases with cervical insufficiency, a short cervix with previous preterm birth, etc., to decrease the preterm birth rate. It is recommended that Shirodkar cerclage is removed when the patient approaches term, but the ideal timing of removal for patient for whom cesarean hysterectomy is planned is not clear. Here, authors present a case of PAS in whom Shirodkar cerclage that was difficult to remove at the timing of cesarean hysterectomy. After cesarean hysterectomy, the patient had a vaginal abscess and required antibiotic therapy for approximately two weeks. In the light of our case, authors discuss the timing of removal of cerclage in the cases of PAS.

Download Full-text