Lived experiences of patients with placenta accreta spectrum in Utah: a qualitative study of semi-structured interviews

Patient Perception of Care, Outcomes, and Consequences from Placenta Accreta Spectrum: A Survey-Based Study

OBJECTIVE

 Placenta accreta spectrum (PAS) is an obstetric diagnosis that carries significant risks. However, little is known about patient perceptions of care. This study was conducted to describe the patient experience, reported outcomes, and assess geographical variation in PAS care in the United States.

STUDY DESIGN

 Partnering with a PAS patient advocacy organization, we conducted an online survey of PAS patients. Perceptions of care and outcomes, and geographic variation were described.

RESULTS

 We received 108 responses (69% response rate); 103 respondents delivered in the United States. Demographic characteristics were similar across each region. Most (67%) reported at least one prior cesarean delivery and 53% reported placenta previa in the PAS pregnancy. Over half (63%) reported an antenatal suspicion of PAS and 66% of those respondents reported changing their delivery hospital as a result of their antenatal diagnosis. Though not statistically significant, both showed variability across regions (both p ≥0.60). Seventy-five percent of respondents with antenatal diagnosis reported their pregnancy was managed by a dedicated PAS care team, which did not differ by region (p = 0.80). A majority of respondents (75%) felt their PAS care team was prepared for their delivery; this too did not vary across regions (p = 0.97). Many respondents reported at least one physical (63%) or mental health (17%) adverse outcome as a result of their PAS pregnancy.

CONCLUSION

 As reported by prior PAS patients, perception of care and outcomes are overall favorable. There are long-term physical and mental adverse consequences reported. Geographical variation is mixed, however, national guidelines are predominately followed.

KEY POINTS

· Patient perceptions of care and outcomes are overall positive and favorable.. · Long lasting physical and mental health consequence from PAS pregnancies are commonly seen.. · Multidisciplinary care is widely adopted for PAS pregnancies..

One-step conservative surgery vs hysterectomy for placenta accreta spectrum: a feasibility randomized controlled trial

BACKGROUND

Placenta accreta spectrum is a serious condition associated with significant maternal morbidity and even mortality. The recommended treatment is hysterectomy. An alternative is 1-step conservative surgery, which involves the en bloc resection of the myometrium affected by placenta accreta spectrum along with the placenta, followed by uterine reconstruction. Currently, there are no studies comparing the 2 techniques in the setting of a randomized controlled trial.

OBJECTIVE

We performed a prospectively registered multicenter randomized controlled trial comparing hysterectomy with 1-step conservative surgery. The aim was to collect feasibility and clinical outcomes of the 2 techniques in women assigned to hysterectomy or 1-step conservative surgery. In addition to assessing participants' willingness to be randomized, we also collected data on intraoperative blood loss, transfusion requirement, serious adverse event, and other clinical outcomes.

STUDY DESIGN

Sixty women with strong antenatal suspicion of placenta accreta spectrum were assigned randomly to either hysterectomy (n=31) or 1-step conservative surgery (n=29).

RESULTS

During a 20-month period, 60 of the 64 eligible patients (93.7%) underwent randomization. Intention-to-treat analysis showed that the clinical outcomes for 1-step conservative surgery were comparable to those of hysterectomy (median intraoperative blood loss, 1740 mL [interquartile range, 1010-2410] vs 1500 mL [interquartile range, 1122-2753]; odds ratio, 1 [1-1]; P=.942; median duration of surgery, 135 minutes [interquartile range, 111-180] vs 155 minutes [interquartile range, 120-185]; odds ratio, 0.99 [0.98-1]; P=.151; transfusion rate, 58.6% vs 61.3%; odds ratio, 0.96 [0.83-1.76]; P=.768; and adverse event rate, 17.2% vs 9.7%; odds ratio, 1.77 [0.43-10.19]; P=.398; respectively). In the subgroup of women with type 1 class on topographic classification, all participants allocated to 1-step surgery had successful outcomes, which were superior to those of hysterectomy. This was evidenced by the shorter surgery duration (median, 125 [interquartile range, 98-128] vs 180 [129-226] minutes; P=.002), lower transfusion rates (46.2% vs 82.4%), and fewer units of red blood cells transfused (median, 1 [interquartile range, 1-1.8] vs 3 [interquartile range, 2-4] units; P=.007).

CONCLUSION

A randomized controlled trial comparing 2 surgical techniques for the treatment of placenta accreta spectrum is feasible. One-step conservative repair is a valid alternative to hysterectomy in the large majority of cases, but this can only be ascertained following intraoperative surgical staging.

Anesthesia and postpartum pain management for placenta accreta spectrum: The healthcare provider perspective

OBJECTIVE

To explore the management and experiences of healthcare providers around anesthetic care in placenta accreta spectrum (PAS).

METHODS

This descriptive survey study was carried out over a 6-week period between January and March 2023. Healthcare providers, both anesthesiologists and those involved in operative care for women with PAS, were invited to participate. Questions invited both quantitative and qualitative responses. Qualitative responses were analyzed using content analysis.

RESULTS

In all, 171 healthcare providers responded to the survey, the majority of whom were working in tertiary PAS referral centers (153; 89%) and 116 (70%) had more than 10 years of clinical experience. There was variation in the preferred primary mode of anesthesia for PAS cases; 69 (42%) used neuraxial only, but 58 (35%) used a combined approach of neuraxial and general anesthesia, with only 12 (8%) preferring general anesthesia. Ninety-nine (61%) were offering a routine antenatal anesthesia consultation. Content analysis of qualitative data identified three main themes, which were "variation in approach to primary mode of anesthesia", "perspectives of patient preferences", and "importance of multidisciplinary team care". These findings led to the development of a decision aid provided as part of this paper, which may assist clinicians in counseling women on their options for care to come to an informed decision.

CONCLUSIONS

Approach to anesthesia for PAS varied between healthcare providers. The final decision for anesthesia should take into consideration the clinical care needs as well as the preferences of the patient.

Anesthesia and postpartum pain management for placenta accreta spectrum: The patient perspective and recommendations for care

OBJECTIVE

Placenta accreta spectrum (PAS) is a high-risk complication of pregnancy, which often requires complex surgical intervention. There is limited literature on the patient experience during the perioperative period and postpartum pain management for PAS. Therefore, this study aims to explore the patient perspective of anesthesia care.

METHODS

Ethical approval was granted by the hospital ethics committee (EC02.2023). This was a descriptive survey study, including women with a history of pregnancy complicated by PAS who were members of two patient advocacy groups. The survey, consisting of both open and closed questions, was performed over a 6-week period between January and March 2023. Content analysis was performed on qualitative data to identify themes, and recommendations for care are suggested.

RESULTS

A total of 347 participants responded to the survey; 76% (n = 252) had a cesarean hysterectomy (n = 252), and general anesthesia was the most common primary mode of anesthesia (39%, n = 130). We identified two overarching themes: experiences of anesthesia and experience of postpartum pain management. Under experiences of anesthesia, three subthemes were identified, namely "communication with the anesthesiologist", "deferring to the expertise of the team", and "consequences of decision around the mode of anesthesia." Under postpartum pain management, two subthemes emerged: "support of specialist PAS team" and "poor pain management following PAS surgery".

CONCLUSIONS

Women want to be involved in decisions around their care, but do not always understand the consequences of their decision-making, such as missing the birth of their child. An antenatal anesthesiology consultation is important to provide women with information, explore preferences, and develop a plan of care for the birth.

Management of placenta accreta spectrum in low- and middle-income countries

Placenta accreta spectrum (PAS) can be associated massive intra- and post-operative hemorrhage which when not controlled can lead to maternal death. Important advances have occurred in understanding the pathophysiology and therapeutic options for this condition. The prevalence of PAS at birth is direct association with the cesarean delivery (CD) rate in the corresponding population and is increasing worldwide. Limited health infrastructure in low- and middle-income countries increases the morbidity and mortality of patients with PAS at birth. In many cases, obstetricians working in limited resources settings cannot follow some of the international guideline's recommendations and have to opt for low-cost management procedures. In this review, we describe the particularities of managing PAS care in low- and middle-income countries from of prenatal evaluation of patients at risk of PAS at birth, therapeutic options, and inter-institutional collaboration. We also propose a management protocol based on training of the local obstetric teams rather than on sophisticated technological resources that are almost never available in low-resource scenarios.

Society for Maternal-Fetal Medicine Special Statement: Emergency checklist, planning worksheet, and system preparedness bundle for placenta accreta spectrum

Placenta accreta spectrum is a life-threatening complication of pregnancy that is underdiagnosed and can result in massive hemorrhage, disseminated intravascular coagulation, massive transfusion, surgical injury, multisystem organ failure, and even death. Given the rarity and complexity, most obstetrical hospitals and providers do not have comprehensive expertise in the diagnosis and management of placenta accreta spectrum. Emergency management, antenatal interdisciplinary planning, and system preparedness are key pillars of care for this life-threatening disorder. We present an updated sample checklist for emergent and unplanned cases, an antenatal planning worksheet for known or suspected cases, and a bundle of activities to improve system and team preparedness for placenta accreta spectrum.

Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care

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.

Placenta Accreta Spectrum

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.

Creating a postmortem examination decision aid: Suggestions from bereaved parents of a stillborn

OBJECTIVES

To understand the postmortem decision-making needs and preferences of parents of a stillborn.

METHODS

A qualitative content analysis was conducted. Patients who received stillbirth care at the University of Utah in the last 5 years, were 18 years of age or older, and English speakers, were invited to participate via an email and follow-up phone call. Participants were interviewed about their experiences, values, beliefs, decision-making experience regarding the postmortem examinations of their stillborn, and suggestions for how to assist their decision-making needs.

RESULTS

Nineteen participants who consented to one or more postmortem examination of their stillborn were interviewed. They expressed needing information, altruism, and/or a belief in science as reasons for consenting. The most common reason for declining was already knowing the stillbirth cause. Recommendations for a decision aid included a description of all stillbirth evaluation options, risks and benefits, and a timeline.

CONCLUSION

Participants had a variety of reasons for consenting to or declining postmortem examinations of their stillborn. Recommendations for a decision aid include a full description of each examination, the risks and benefits, and a timeline.

PRACTICAL IMPLICATIONS

An example decision aid was created from recommendations, which presents balanced information to help support couple's decision-making.

Living with a diagnosis of Placenta Accreta Spectrum: Mothers' and Fathers' experience of the antenatal journey and the birth

OBJECTIVE

Much research into Placenta Accreta Spectrum (PAS) has focussed on the associated maternal morbidity and mortality. However, mothers' and fathers' lived experiences of the aftermath of a diagnosis of PAS up to the birth and beyond has received little attention. Therefore, the aim of this study was to increase our understanding of the psychological consequences of PAS on women and their partners during pregnancy, up to and including the birth.

METHODS

In-depth interviews were conducted with 29 participants; 6 couples were interviewed together (n = 12), 6 couples were interviewed separately (n = 12), and 5 women were interviewed without their partner. Data from the antenatal and intrapartum periods are presented. Couples were eligible for inclusion if they had a diagnosis of PAS within the previous 5 years. An Interpretative Phenomenological Analysis approach was used to gather and analyse data. Virtual interviews were conducted over a 3-month period from February to April 2021.

RESULTS

Themes emerged relating to two distinct timepoints, the antenatal period and birth. The antenatal period had two main themes: the first antenatal main theme was "Living with PAS", which had two sub-themes: "Lack of knowledge of PAS" and "Experiences of varied approaches to care". The second antenatal main theme was "Coping with uncertainty", which had two sub-themes of "Getting on with it", and "Emotional toll". Relating to birth, two main themes emerged. The first main theme was "A traumatic experience", with three sub-themes of "Saying goodbye", "Experiencing trauma" and the "Witnessing of trauma" (by fathers). The second main theme which emerged was "Feeling safe in the hands of experts", with two subthemes of "Safety in expert team" and "Relief at surviving".

CONCLUSIONS

This study highlights the significant psychological consequences a diagnosis of PAS has on mothers and fathers, how they try to come to terms with the diagnosis and the experience of a traumatic birth, and how management within a specialist team can alleviate some of these fears.

"Living in a vacuum": Lived experiences of maternal near-miss among women with placenta accreta spectrum

BACKGROUND

Placenta accreta spectrum (PAS) is one of the life-threatening complications of pregnancy, the prevalence of which has increased in parallel with the caesarean section rate.

OBJECTIVE

The purpose of this study was to investigate the experiences of mothers with PAS who have also experienced maternal near miss.

METHODS

The participants of this study included 8 mothers who had experienced near miss due to placenta accreta during the past year, as well as two husbands and two health care professionals. Data collection was done using face-to-face, in-depth virtual and in-person interviews. In this qualitative study, the interpretive phenomenological analysis approach was used to analyse the data.

RESULTS

The superordinate theme that emerged from the lived experiences of the studied mothers is 'Living in a vacuum', which was derived from 3 main themes. The theme of 'distorted identity' is related to the mothers' experience of losing the uterus as a symbol of femininity and nostalgia for the former self. The theme of 'exacerbated exhaustion' indicates the burnout and fatigue perceived by these mothers and has dimensions far beyond the exhaustion caused by performing parenting duties. The third theme, 'a threatened future', reflects these mothers' vague image of the future in terms of health, preservation of life, and the continuation of living together with the husband.

CONCLUSIONS

It seems that mothers with PAS need to be covered by integrated and well-organised psycho-social support from the time they are diagnosed with the complication until long after delivery due to the high potentiality of maternal near miss.

Is conservative management of placenta accreta spectrum disorders practical in the United States?

This commentary discusses the issues related to conservative management (also called leaving the placenta in situ or intentional retention of the placenta) of placenta accreta spectrum disorders. Considerations related to placenta accreta spectrum disorder management in the United States are compared with France, where conservative management is a well-accepted management option. The history of placenta accreta spectrum disorder treatment is reviewed, finding that since 1937, the most common treatment in the United States been cesarean-hysterectomy without placental removal. Although definitive studies have yet to be conducted, a growing body of evidence suggests that conservative management is able to reduce maternal morbidity, compared with cesarean-hysterectomy. International and national guidelines from several countries are examined. Comparisons between the United States and France that are addressed in the commentary include population and geography, structure of the healthcare system, physician training and acceptability, and patient acceptability. Considering the differences between the countries, conservative management is feasible in the United States. Different options for placenta accreta spectrum disorder management should be rigorously researched in multicenter international collaborations. Conservative management should be considered as an option for women with placenta accreta spectrum disorders in the United States, especially for those desiring fertility preservation.

A review of placenta accreta spectrum and its outcomes for perinatal mental health

OBJECTIVES

Placenta accreta spectrum conditions are rare, life-threatening disorders of placentation encountered in the perinatal period, with lasting impacts on maternal quality of life and psychological wellbeing. Although the obstetric outcomes are well-known, further review is warranted to explore the psychological sequelae that may accompany these conditions.

CONCLUSIONS

The occurrence of placenta accreta spectrum during pregnancy is a major life stressor that can contribute to the development of psychiatric co-morbidity including posttraumatic stress disorder, depression and anxiety disorders. Early recognition of psychological distress and symptomatic profile is recommended at all stages of perinatal care complicated by this rare spectrum of conditions.

Quality of surgical management of placenta accreta spectrum in a tertiary center in Sri Lanka: baseline study for quality improvement project: problems and solutions

Introduction

Placenta accreta spectrum (PAS) is associated with a multitude of maternal and fetal complications. Events related to its management have resulted in significant psychological morbidity, with lifelong consequences which warrant continuous support to cope with their lives. The objective of the study is to highlight the importance of multidisciplinary holistic care and explore room for improvement in the provision of care for women with PAS.

Methods

Our study was conducted on deliveries complicated with PAS from January 2019 to June 2021. 27 women were diagnosed with PAS during this period and received treatment. Impact of life event scale- revised (IES-R) and short form health survey-36(SF-36) questionnaires were administered to assess the impact of PAS on their lives. In depth interviews were conducted with the women. A multidisciplinary team meeting was later conducted to formulate a comprehensive care plan for women with PAS.

Results

The response rate was 96.2%. Mean age of the sample is 34.1 years (SD 4.3). Interval to current pregnancy varies from 0.6 years to 10 years with mean of 4.6 years. Mean gestational age of diagnosis of PAS was 25.4(SD 6.7) weeks. The care bundle provided for women with PAS was evaluated in all cases.

Surgery was conducted electively in 82% of patients. Blood transfusions were noted in 85%. Mean pre-operative stay was 9.5 days (SD 8.3) and mean post-operative stay was 8.8 days (SD 8). Total hospital stay ranged from 6 to 48 days (mean 19.5 days, SD 11.4).

IES-R scores were significant in 4/26 patients. There was no correlation with the interval from the surgery with any of the subscales or with the total scores. The lapsed time after the surgery had a significant correlation with physical functioning and pain domains of the SF-36 questionnaire.

Description of the experience, loss of femininity with loss of the uterus, concerns and fears about the future and measures to improve the quality of care were the themes identified and described.

A multidisciplinary team meeting, consisting of consultant obstetricians performing surgery for PAS, anesthetists, hematologist, transfusion medicine specialist, urologist, physiotherapist, nutritionist and nursing officers from ICU and wards, was held and their contributions helped to map out a definitive care plan.

Conclusions

PAS is associated with long term physical and psychological morbidity. Continuous support through quarterly clinic visits and telephone conversations may alleviate the psychological trauma. However, some physical disabilities may be lifelong and life changing. Importance of reducing primary caesarean section and promoting trial of labour after caesarean delivery should be promoted among patients and caregivers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04840-7.

Living beyond placenta accreta spectrum: parent's experience of the postnatal journey and recommendations for an integrated care pathway

BACKGROUND

Placenta Accreta Spectrum is associated with significant clinical maternal morbidity and mortality, which has been extensively described in the literature. However, there is a dearth of research on the lived experiences of pregnant people and their support partners. The aim of this study is to describe living beyond a pregnancy and birth complicated by PAS for up to four years postpartum. Participants experiences inform the development of an integrated care pathway of family centered support interventions.

METHODS

An Interpretative Phenomenological Analysis approach was applied to collect data through virtual interviews over a 3-month period from February to April 2021. Twenty-nine participants shared their stories; six people with a history of PAS and their support partners were interviewed together (n = 12 participants), six were interviewed separately (n = 12 participants), and five were interviewed without their partner. Pregnant people were eligible for inclusion if they had a diagnosis of PAS within the previous 5 years. This paper focuses on the postnatal period, with data from the antenatal and intrapartum periods described separately.

RESULTS

One superordinate theme "Living beyond PAS" emerged from interviews, with 6 subordinate themes as follows; "Living with a different body", "The impact on relationships", "Coping strategies", "Post-traumatic growth", "Challenges with normal care" and recommendations for "What needs to change". These themes informed the development of an integrated care pathway for pregnant people and their support partners to support them from diagnosis up to one year following the birth.

CONCLUSION

Parents described the challenges of the postnatal period in terms of the physical and emotional impact, and how some were able to make positive life changes in the aftermath of a traumatic event. An integrated care pathway of simple supportive interventions, based on participant recommendations, delivered as part of specialist multidisciplinary team care may assist pregnant people and their support partners in alleviating some of these challenges.