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Berman ZT, Boone CE, Melber DJ, Ballas J, Parikh R, Ramos G, Kelly T, McHale M, Picel AC, Roberts AC. Intraoperative Multivessel Embolization Reduces Blood Loss and Transfusion Requirements Compared to Internal Iliac Artery Balloon Placement during Cesarean Hysterectomy for Placenta Accreta Spectrum. J Vasc Interv Radiol 2023; 34:1915-1921. [PMID: 37527770 DOI: 10.1016/j.jvir.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/16/2023] [Accepted: 07/23/2023] [Indexed: 08/03/2023] Open
Abstract
PURPOSE To evaluate the effectiveness and safety of prophylactic multivessel selective embolization (MVSE) compared to those of internal iliac artery occlusion balloon (IIABO) placement in patients undergoing cesarean hysterectomy for placenta accreta spectrum (PAS). MATERIALS AND METHODS An institutional review board-approved retrospective series was conducted with consecutive patients with PAS at a single institution between 2010 and 2021. MVSE was performed in a hybrid operating room after cesarean section prior to hysterectomy. IIABO was performed with balloons placed into the bilateral internal iliac arteries, which were inflated during hysterectomy. Median blood loss, transfusion requirements, percentage of cases requiring transfusion, and adverse events were recorded. RESULTS A total of 20 patients treated with embolization and 34 patients with balloon placement were included. Placenta percreta and previa were seen in 60% and 90% of patients, respectively. Median blood loss in the MVSE group was 713 mL (interquartile range [IQR], 475-1,000 mL) compared to 2,000 mL (IQR, 1,500-2,425 mL) in the IIABO group (P < .0001). The median total number of units of packed red blood cell transfusions (0 vs 2.5) and percentage of cases requiring a transfusion (20% vs 65%) were less in the MVSE group (P < .01). A median of 4 vessels (IQR, 3-9) were embolized during MVSE. No major adverse events or nontarget embolization consequences were observed. CONCLUSIONS Prophylactic MVSE is a safe procedure that reduces operative blood loss and transfusion requirements compared to those of IIABO in patients undergoing cesarean hysterectomy for presumed higher-degree PAS.
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Affiliation(s)
- Zachary T Berman
- Department of Radiology, Division of Vascular and Interventional Radiology, University of California San Diego, San Diego, California.
| | - Christine E Boone
- Department of Radiology, Division of Vascular and Interventional Radiology, University of California San Diego, San Diego, California
| | - Dora J Melber
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Jerasimos Ballas
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Rupal Parikh
- Department of Radiology, Division of Vascular and Interventional Radiology, University of California San Diego, San Diego, California
| | - Gladys Ramos
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Thomas Kelly
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Michael McHale
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Andrew C Picel
- Department of Radiology, Division of Interventional Radiology, Stanford University, Stanford, California
| | - Anne C Roberts
- Department of Radiology, Division of Vascular and Interventional Radiology, University of California San Diego, San Diego, California
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Sanders TK, Stewart JK. Placenta Accreta Spectrum: The Role of Interventional Radiology in Multidisciplinary Management. Semin Intervent Radiol 2023; 40:349-356. [PMID: 37575347 PMCID: PMC10415058 DOI: 10.1055/s-0043-1771038] [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: 08/15/2023]
Abstract
Placenta accreta spectrum is increasing in prevalence and poses significant risks to obstetric patients. This article defines characteristics, diagnosis, management, and outcomes of placenta accreta spectrum, highlighting interventional radiology's role in its management as part of a multidisciplinary approach.
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Affiliation(s)
- Troy K. Sanders
- David Geffen School of Medicine at UCLA, Interventional Radiology, Los Angeles, California
| | - Jessica K. Stewart
- David Geffen School of Medicine at UCLA, Interventional Radiology, Los Angeles, California
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Einerson BD, Gilner JB, Zuckerwise LC. Placenta Accreta Spectrum. Obstet Gynecol 2023; 142:31-50. [PMID: 37290094 PMCID: PMC10491415 DOI: 10.1097/aog.0000000000005229] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/08/2023] [Indexed: 06/10/2023]
Abstract
Placenta accreta spectrum (PAS) is one of the most dangerous conditions in pregnancy and is increasing in frequency. The risk of life-threatening bleeding is present throughout pregnancy but is particularly high at the time of delivery. Although the exact cause is unknown, the result is clear: Severe PAS distorts the uterus and surrounding anatomy and transforms the pelvis into an extremely high-flow vascular state. Screening for risk factors and assessing placental location by antenatal ultrasonography are essential for timely diagnosis. Further evaluation and confirmation of PAS are best performed in referral centers with expertise in antenatal imaging and surgical management of PAS. In the United States, cesarean hysterectomy with the placenta left in situ after delivery of the fetus is the most common treatment for PAS, but even in experienced referral centers, this treatment is often morbid, resulting in prolonged surgery, intraoperative injury to the urinary tract, blood transfusion, and admission to the intensive care unit. Postsurgical complications include high rates of posttraumatic stress disorder, pelvic pain, decreased quality of life, and depression. Team-based, patient-centered, evidence-based care from diagnosis to full recovery is needed to optimally manage this potentially deadly disorder. In a field that has relied mainly on expert opinion, more research is needed to explore alternative treatments and adjunctive surgical approaches to reduce blood loss and postoperative complications.
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Affiliation(s)
- Brett D Einerson
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, Utah; Duke University, Durham, North Carolina; and Vanderbilt University Medical Center, Nashville, Tennessee
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Ye Y, Li J, Liu S, Zhao Y, Wang Y, Chu Y, Peng W, Lu C, Liu C, Zhou J. Efficacy of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control in patients with abnormally invasive placenta: a historical cohort study. BMC Pregnancy Childbirth 2023; 23:333. [PMID: 37165316 PMCID: PMC10170700 DOI: 10.1186/s12884-023-05649-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 04/26/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Patients with abnormally invasive placenta (AIP) are at high risk of massive postpartum hemorrhage. Resuscitative endovascular balloon occlusion of the aorta (REBOA), as an adjunct therapeutic strategy for hemostasis, offers the obstetrician an alternative for treating patients with AIP. This study aimed to evaluate the role of REBOA in hemorrhage control in patients with AIP. METHODS This was a historical cohort study with prospectively collected data between January 2014 to July 2021 at a single tertiary center. According to delivery management, 364 singleton pregnant AIP patients desiring uterus preservation were separated into two groups. The study group (balloon group, n = 278) underwent REBOA during cesarean section, whereas the reference group (n = 86) did not undergo REBOA. Surgical details and maternal outcomes were collected. The primary outcome was estimated blood loss and the rate of uterine preservation. RESULTS A total of 278 (76.4%) participants experienced REBOA during cesarean section. The patients in the balloon group had a smaller blood loss during cesarean Sect. (1370.5 [752.0] ml vs. 3536.8 [1383.2] ml; P < .001) and had their uterus salvaged more often (264 [95.0%] vs. 23 [26.7%]; P < .001). These patients were also less likely to be admitted to the intensive care unit after delivery (168 [60.4%] vs. 67 [77.9%]; P = .003) and had a shorter operating time (96.3 [37.6] min vs. 160.6 [45.5] min; P < .001). The rate of neonatal intensive care unit admission (176 [63.3%] vs. 52 [60.4%]; P = .70) and total maternal medical costs ($4925.4 [1740.7] vs. $5083.2 [1705.1]; P = .13) did not differ between the two groups. CONCLUSIONS As a robust hemorrhage-control technique, REBOA can reduce intraoperative hemorrhage in patients with AIP. The next step is identifying associated risk factors and defining REBOA inclusion criteria to identify the subgroups of AIP patients who may benefit more.
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Affiliation(s)
- Yuanhua Ye
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Jing Li
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Shiguo Liu
- Prenatal Diagnosis Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Yang Zhao
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Yanhua Wang
- Interventional Medical Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Yijing Chu
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Wei Peng
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Caixia Lu
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Chong Liu
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Jun Zhou
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China.
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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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Lumbreras-Marquez MI, Villela-Franyutti D, Reale SC, Farber MK. Coagulation Management in Obstetric Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00517-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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The effect of prophylactic balloon occlusion in patients with placenta accreta spectrum: a Bayesian network meta-analysis. Eur Radiol 2021; 32:3297-3308. [PMID: 34846565 DOI: 10.1007/s00330-021-08423-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 10/04/2021] [Accepted: 10/18/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Placenta accreta spectrum (PAS) can induce severe life-threatening obstetric hemorrhage. Herein, we conducted a Bayesian network meta-analysis of previous studies to evaluate the relative benefits of different prophylactic balloon occlusion (PBO) procedures. METHODS PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to July 2021. Blood loss volume, blood transfusion volume, and hysterectomy rate were regarded as the primary endpoints. The data were pooled using a Bayesian network and traditional pairwise meta-analysis. RESULTS Fifty-nine articles with a total sample size of 5150 patients were included. Compared with no PBO (non-PBO) intervention, PBO of the abdominal aorta (PBOAA, mean difference(MD) - 1.02, 95% credible interval (CrI) - 1.4 to - 0.67), common iliac artery (PBOCIA, MD - 0.84; 95%CrI - 1.36 to - 0.06) and internal iliac artery (PBOIIA, MD - 0.42; 95%CrI - 0.72 to - 0.13) significantly lowered blood loss volume, with PBOAA being more effective than PBOIIA (MD - 0.60; 95%CrI - 1.05 to - 0.17). PBOAA and PBOIIA also significantly decreased blood loss volume (MD - 2.33; 95%CrI - 3.74 to - 0.94, MD - 1.57; 95%CrI - 2.77 to - 0.47 respectively) and hysterectomy rate (OR 0.31; 95%CrI 0.16 to 0.54, OR 0.53; 95%CrI 0.29 to 0.92 respectively). PBOAA has the highest probability of being more effective in reducing the blood loss volume, blood transfusion volume, and hysterectomy rate. CONCLUSIONS Performing PBOAA, PBOCIA, or PBOIIA in PAS patients is an effective way to minimize blood loss volume, while PBOAA and PBOIIA also reduce blood transfusion volume and hysterectomy rate. PBOAA is a notably more effective strategy to reduce blood loss volume than PBOIIA. KEY POINTS • PBOAA, PBOCIA, and PBOIIA procedures can significantly reduce the blood loss volume compared to non-PBO intervention in PAS patients, of which PBOAA was more effective than the PBOIIA procedure. • PBOAA and PBOIIA could significantly reduce the blood transfusion volume and hysterectomy rate in contrast to the non-PBO intervention in patients with PAS. • According to our statistical treatment ranking, PBOAA was statistically superior in reducing blood transfusion volume, blood transfusion volume, and hysterectomy rate than other PBO procedures.
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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Aryananda RA, Rodriguez F, Ordoñez CA, Messa Bryon A, Calvache JPB, Lopez J, Campos CI, Mejia M, Rengifo M, Galliadi LMV, Maya J, Zambrano MA, Aguayo IP, Carabalí IG, Burgos JM. How to identify patients who require aortic vascular control in placenta accreta spectrum disorders? Am J Obstet Gynecol MFM 2021; 4:100498. [PMID: 34610485 DOI: 10.1016/j.ajogmf.2021.100498] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The placenta accreta spectrum disorder may lead to severe complications. Helpful interventions to prevent placenta accreta spectrum bleeding include vascular control procedures in the aorta or pelvic vessels. Although these procedures are related to lower intraoperative bleeding, they are associated with complications, so the possibility of selecting patients at highest risk of bleeding while avoiding vascular procedures for all cases is attractive. OBJECTIVE We describe an intraoperative staging protocol whose objective is to identify the need to use vascular control procedures in patients with placenta accreta spectrum. We also describe the results of its application in a placenta accreta spectrum referral hospital. STUDY DESIGN This descriptive, retrospective study included patients with suspected prenatal placenta accreta spectrum treated at a referral center for placenta accreta spectrum between April 2016 and June 2020. The use of the resuscitative endovascular balloon occlusion of the aorta allowed the prevention and treatment of excessive bleeding; its application was performed according to 3 approaches: (1) presurgical use in all placenta accreta spectrum patients (Group 1), (2) according to the prenatal placenta accreta spectrum topography (Group 2), and (3) according to the "intraoperative staging" (Group 3). In addition, the frequency of use of resuscitative endovascular balloon occlusion of the aorta and the clinical results in the management of placenta accreta spectrum were described in the 3 groups. RESULTS Seventy patients underwent surgery for a prenatal suspicion of placenta accreta spectrum. Of these, 16 underwent intraoperative staging (Group 3); in 20 cases, resuscitative endovascular balloon occlusion of the aorta was used based on the prenatal imaging topographic classification (Group 2), and in the remaining 34 patients (Group 1), it was always used before the laparotomy. The frequency of use of resuscitative endovascular balloon occlusion of the aorta was progressively lower in Groups 1 (32 patients, 94.1% of cases), 2 (11 patients, 75% of cases), and 3 (4 patients, 25% of cases). Similarly, resuscitative endovascular balloon occlusion of the aorta went from being applied predominantly before the laparotomy (all cases in Group 1) to being applied after intraoperative staging (all cases in Group 3). The percentage of endovascular devices applied but not used, decreased from 23.5% in Group 1 to 0% in Group 3. Complications related to the resuscitative endovascular balloon occlusion of the aorta were seen in 4 patients (2 women in Group 1, and 1 woman each in Groups 2 and 3). CONCLUSION The "intraoperative staging" of placenta accreta spectrum allows the optimization of the use of resuscitative endovascular balloon occlusion of the aorta, which decreases the frequency of its use without increasing the volume of blood loss.
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Affiliation(s)
- Albaro José Nieto-Calvache
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos).
| | | | - Rozi Aditya Aryananda
- Dr Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia (Dr Aryananda)
| | - Fernando Rodriguez
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); División de Trauma y Emergencias, Departamento de Cirugía General, Fundación Valle del Lili, Cali, Colombia (Drs Rodriguez and Ordoñez)
| | - Carlos A Ordoñez
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); División de Trauma y Emergencias, Departamento de Cirugía General, Fundación Valle del Lili, Cali, Colombia (Drs Rodriguez and Ordoñez)
| | - Adriana Messa Bryon
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
| | - Juan Pablo Benavides Calvache
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
| | - Jaime Lopez
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
| | - Clara Ivette Campos
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Patología y Laboratorio Clínico, Fundación Valle del Lili, Cali, Colombia (Dr Campos)
| | - Mauricio Mejia
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Radiología e Imágenes Diagnósticas, Fundación Valle del Lili, Cali, Colombia (Drs Mejia and Rengifo)
| | - Martin Rengifo
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Radiología e Imágenes Diagnósticas, Fundación Valle del Lili, Cali, Colombia (Drs Mejia and Rengifo)
| | | | - Juliana Maya
- Programa de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Drs Maya, Aguayo, and Carabalí)
| | - Maria Andrea Zambrano
- Programa de Ginecología y Obstetricia, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Dr Zambrano)
| | - Isabella Prado Aguayo
- Programa de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Drs Maya, Aguayo, and Carabalí)
| | - Isabella Gutierrez Carabalí
- Programa de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Drs Maya, Aguayo, and Carabalí)
| | - Juan Manuel Burgos
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
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Melber DJ, Berman ZT, Jacobs MB, Picel AC, Conturie CL, Zhang-Rutledge K, Binder PS, Eskander RN, Roberts AC, McHale MT, Ramos GA, Ballas J, Kelly TF. Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization: the PASTIME protocol. Am J Obstet Gynecol 2021; 225:442.e1-442.e10. [PMID: 34245679 DOI: 10.1016/j.ajog.2021.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/27/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Multidisciplinary care of placenta accreta spectrum cases improves pregnancy outcomes, but the specific components of such a multidisciplinary collaboration varies between institutions. As experience with placenta accreta spectrum increases, it is crucial to assess new surgical techniques and protocols to help improve maternal outcomes and to advocate for hospital resources. OBJECTIVE This study aimed to assess a novel multidisciplinary protocol for the treatment of placenta accreta spectrum that comprises cesarean delivery, multivessel uterine embolization, and hysterectomy in a single procedure within a hybrid operative suite. STUDY DESIGN This was a matched prepost study of placenta accreta spectrum cases managed before (2010-2017) and after implementation of the Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol (2018-2021) at a tertiary medical center. Historical cases were managed with internal iliac artery balloon placement in selected cases with the decision to inflate the balloons intraoperatively at the discretion of the primary surgeon. Intraoperative Embolization cases were compared with historical cases in a 1:2 ratio matched on the basis of placenta accreta spectrum severity and surgical urgency. The primary outcome was a requirement for transfusion with packed red blood cells. Secondary outcomes included estimated surgical blood loss, operative and postoperative complications, procedural time, length of stay, and neonatal outcomes. RESULTS A total of 15 Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization cases and 30 matched historical cases were included in the analysis. There were no demographic differences noted between the groups. A median (interquartile range) of 0 units (0-2 units) of packed red blood cells were transfused in the Intraoperative Embolization group compared with 2 units (0-4.5 units) in the historical group (P=.045); 5 of 15 (33.3%) Intraoperative Embolization cases required blood transfusions compared with 19 of 30 (63.3%) cases in the historical group (P=.11). The estimated blood loss was significantly less in the Intraoperative Embolization group with a median (interquartile range) of 750 mL (450-1050 mL) compared with 1750 mL (1050-2500 mL) in the historical group (P=.003). There were no cases requiring massive transfusion (≥10 red blood cell units in 24 hours) in the Intraoperative Embolization group compared with 5 of 30 (16.7%) cases in the historical group (P=.15). There were no intraoperative deaths from hemorrhagic shock using the Intraoperative Embolization protocol, whereas this occurred in 2 of the historical cases. The mean duration of the interventional radiology procedure was longer in the Intraoperative Embolization group (67.8 vs 34.1 minutes; P=.002). Intensive care unit admission and postpartum length of stay were similar, and surgical and postoperative complications were not significantly different between the groups. The gestational age and neonatal birthweights were similar; however, the neonatal length of stay was longer in the Intraoperative Embolization group (median duration, 32 days vs 15 days; P=.02) with a trend toward low Apgar scores. Incidence of arterial umbilical cord blood pH <7.2 and respiratory distress syndrome and intubation rates were not statistically different between the groups. CONCLUSION A multidisciplinary pathway including a single-surgery protocol with multivessel uterine embolization is associated with a decrease in blood transfusion requirements and estimated blood loss with no increase in operative complications. The Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol provides a definitive surgical method that warrants consideration by other centers specializing in placenta accreta spectrum treatment.
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10
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Advances in anesthetic and obstetric management of patients with placenta accreta spectrum. Curr Opin Anaesthesiol 2021; 34:260-268. [PMID: 33935172 DOI: 10.1097/aco.0000000000000985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The incidence of placenta accreta spectrum is increasing and it is a leading cause of peripartum hysterectomy and massive postpartum hemorrhage. The purpose of the present article is to provide a contemporary overview of placenta accreta spectrum pertinent to the obstetric anesthesiologist. RECENT FINDINGS Recent changes in the terminology used to report invasive placentation were proposed to clarify diagnostic criteria and guidelines for use in clinical practice. Reduced morbidity is associated with scheduled preterm delivery in a center of excellence using a multidisciplinary team approach. Neuraxial anesthesia as a primary technique is increasingly being used despite the known risk of major bleeding. The use of viscoelastic testing and endovascular interventions may aid hemostatic resuscitation and improve outcomes. SUMMARY Accurate diagnosis and early antenatal planning among team members are essential. Obstetric anesthesiologists should be prepared to manage a massive hemorrhage, transfusion, and associated coagulopathy. Increasingly, viscoelastic tests are being used to assess coagulation status and the ability to interpret these results is required to guide the transfusion regimen. Balloon occlusion of the abdominal aorta has been proposed as an intervention that could improve outcomes in women with placenta accreta spectrum, but high-quality safety and efficacy data are lacking.
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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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Do all patients with placenta accreta spectrum require endovascular balloons? Am J Obstet Gynecol MFM 2021; 3:100364. [PMID: 33785464 DOI: 10.1016/j.ajogmf.2021.100364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/07/2021] [Indexed: 12/21/2022]
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Hawthorn BR, Ratnam LA. Role of interventional radiology in placenta accreta spectrum (PAS) disorders. Best Pract Res Clin Obstet Gynaecol 2021; 72:25-37. [PMID: 33640296 DOI: 10.1016/j.bpobgyn.2021.01.007] [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: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 10/22/2022]
Abstract
Placenta accreta spectrum (PAS) disorders are rare but potentially life-threatening obstetric conditions, which can result in severe post-partum haemorrhage (PPH). Traditional management necessitates peripartum hysterectomy, but this carries high rates of morbidity and mortality. More recently, interventional radiology techniques have been developed in order to reduce morbidity and preserve fertility. This article summarises and compares the various reported interventional radiology techniques. Arterial embolisation performed to treat PPH is the therapeutic option which is supported by the highest degree of evidence. The role of preventative procedures, such as temporary balloon occlusion of the internal iliac arteries or distal aorta, continues to be debated due to conflicting outcome data and concerns regarding associated morbidity. The choice of which, if any, interventional radiological technique is utilised is determined by local expertise, available resources and the planned obstetric approach. The most complex patients are likely to benefit from multidisciplinary management in high-volume centres.
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Affiliation(s)
- Benjamin R Hawthorn
- St George's Hospital University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom.
| | - Lakshmi A Ratnam
- St George's Hospital University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom.
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