The usefulness of inter-institutional collaboration (teleconsultation, eHealth) in the management of placenta accreta

Telemedicine facilitates surgical training in placenta accreta spectrum

OBJECTIVE

The training of groups responsible for managing patients with placenta accreta spectrum (PAS) is complex because of the lack of hospitals with a high flow of patients and absence of formal educational programs. We report here the results of a virtual training program (VTP) that implemented one-step conservative surgery (OSCS).

METHODS

A prospective observation study of OSCS VTP between three expert groups and PAS reference hospitals without experience in OSCS was performed. Accessible or cost-efficient web meeting platforms were used to implement the VTP components: baseline observation of the participant's prior knowledge; instructions about essential PAS surgery topics; case selection and joint planning of surgery; expert group "telepresence" during surgery and postoperative debriefing.

RESULTS

One-step conservative surgery was performed successfully at six hospitals. All patients had increta/percreta with a median intraoperative bleeding of 1300 ml (IQR 825-2325) and surgical time of 184 min (IQR 113-240). All groups considered the VTP very useful (n = 33, 97%) or useful (n = 1, 3%), they would use it again (definitely: n = 27, 81.8%; or probably: n = 6, 18.2%), and they would recommend it to other colleagues.

CONCLUSION

Tele education and telepresence during PAS surgery facilitates the implementation of OSCS in selected cases.

All maternal deaths related to placenta accreta spectrum are preventable: a difficult-to-tell reality

BACKGROUND

Most maternal deaths related to postpartum hemorrhage are preventable. In most cases, placenta accreta spectrum is the principal cause of severe postpartum hemorrhage; however, there are few studies about maternal deaths, probably because of the legal implications of “problems” in the management of patients who have died.

OBJECTIVE

This study aimed to identify the problems or “delays” in the care of patients who die because of placenta accreta spectrum in Latin America.

STUDY DESIGN

A retrospective, descriptive, observational multicentric study in Latin American hospitals was conducted. The care of patients who died from placenta accreta spectrum was investigated under a “delay” study model that included delays related to patients, institutions, and healthcare providers. Centers of excellence standards of care were taken into account, and 2 analysis moments were included: an initial analysis for each local care group in the place where maternal death occurred and another analysis that included the main researcher. All information were collected through a predesigned survey and discussed by telephone.

RESULTS

Overall, 52 patients in 10 Latin American countries were included, with options for improvement identified in all cases. The most prevalent type of delay was associated with health providers (98% of cases), followed by health institutions (96% of cases) and patients (63% of cases). Each hospital's analysis group defined maternal death as avoidable in all cases and determined that the interventions needed to improve the outcome would present low, moderate, and high difficulties in 28.8%, 48.1%, and 34.8% of cases, respectively.

CONCLUSION

All maternal deaths related to placenta accreta spectrum were potentially preventable, and 76.9% of cases were avoidable by low to moderate complexity interventions.

Lack of experience is a main cause of maternal death in placenta accreta spectrum patients

INTRODUCTION

Placenta accreta spectrum (PAS) is a serious condition with a mortality as high as 7%. However, the factors associated with this type of death have not been adequately described, with an almost total lack of publications analyzing the determining factors of death in this disease. The aim of our work is to describe the causes of death related to PAS and to analyze the associated diagnosis and treatment problems.

MATERIAL AND METHODS

This is an inter-continental, multicenter, descriptive, retrospective study in low- and middle-income countries. Maternal deaths related to PAS between January 2015 and December 2020 were included. Crucial points in the management of PAS, including prenatal diagnosis and details of the surgical treatment and postoperative management, were evaluated.

RESULTS

Eighty-two maternal deaths in 16 low- and middle-income countries, on three continents, were included. Almost all maternal deaths (81 cases, 98.8%) were preventable, with inexperience among surgeons being identified as the most relevant problem in the process that led to death among 87% (67 women) of the cases who had contact with health services. The main cause of death associated with PAS was hemorrhage (69 cases, 84.1%), and failures in the process leading to the diagnosis were detected among 64.6% of cases. Although the majority of cases received medical attention and 50 (60.9%) were treated at referral centers for severe obstetric disease, problems were identified during treatment in all cases.

CONCLUSIONS

Lack of experience and inadequate surgical technique are the most frequent problems associated with maternal deaths in PAS. Continuous training of interdisciplinary teams is critical to modify this tendency.