Maternal hemodynamics during aortic occlusion with REBOA in patients with placenta accreta spectrum disorder

INTRODUCTION

The effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) in controlling pelvic bleeding has been reported with increasing frequency during surgical management of placenta accreta spectrum (PAS). The deployment of REBOA may lead to significant variations in vital signs requiring special care by anesthesiology during surgery. These modifications of blood pressure by REBOA in PAS patients have not been accurately documented. We report the changes in blood pressure that occur when the aorta is occluded and then released in patients with PAS.

METHODOLOGY

This prospective, observational study includes 10 patients with preoperative PAS suspicion who underwent prophylactic REBOA device insertion between April 2018 and October 2019. REBOA procedural-related data and blood pressure fluctuations under invasive monitoring before and after inflation and deflation were recorded in the operating room.

RESULTS

After prophylactic REBOA deployment in zone 3 of the aorta in PAS patients, we observed a transitory increase in blood pressure (median increase of 22.5 mmHg in SBP and 9.5 mmHg in DBP), which reached severe hypertension (SBP >160 mmHg) in 50% of patients. All patients presented a decrease in blood pressure after the removal of the aortic occlusion (median decrease of 23 mmHg in SBP and 10.5 mmHg in DBP), and 50% (five patients) required the administration of vasopressor drugs.

CONCLUSION

Immediately after aortic occlusion is applied in zone 3 in PAS patients and after the occlusion is removed, significant hemodynamic changes occur, which often lead to therapeutic interventions.

Decreases in resource use after implementing an interdisciplinary management program for patients with placenta accreta spectrum

OBJECTIVE

Placenta accreta spectrum (PAS) often causes severe morbidity and demands the availability of abundant health resources. Research has shown that the participation of experienced interdisciplinary groups in specialized centers improves clinical outcomes. Our objective is to measure resource use variation after implementing an interdisciplinary management program for this condition.

METHODS

Using detailed billing information, hospital care resource use was measured at constant prices for women with PAS who were treated between 2011 and 2019. Cases were classified before (Group 1) and after (Group 2) the implementation of the program. A third group included women with intraoperative MAP findings (Group 3). Comparisons were made using descriptive statistics.

RESULTS

The mean reduction in resource use after the program was 16.5% per patient. The program also reduced variability in resource use as measured by the standard deviation and the coefficient of variation, which decreased by 55.2% and 46.3%, respectively.

CONCLUSION

The interdisciplinary management of patients affected by PAS in experienced hospitals is associated with a reduction in resource use and variability.

Natural Orifice Transluminal Endoscopic Surgery for Correction of Vesicovaginal Fistulas after Hysterectomy Due to Morbidly Adherent Placenta

BACKGROUND

Vesicovaginal fistula (VVF) is a difficult-to-treat complication of obstetric hysterectomy. There are multiple management options, with a preference for surgical repair via abdominal or vaginal approach. We describe a transurethral natural orifice transluminal endoscopic surgery (NOTES) using barbed suture, in 3 cases of VVF after hysterectomy due to morbidly adherent placenta (MAP).

CASES

Three patients with VVFs after hysterectomy due to MAP underwent a transurethral endoscopic suture repair. Two patients had complete resolution of the fistula, and the third required additional repair by laparotomy; however, a decrease was observed in the size of the VVF after the initial endoscopic repair.

CONCLUSION

The transurethral NOTES approach for VVF after MAP hysterectomy is a minimally invasive procedure that is valid as an initial approach for this type of complication.

Trauma team conformation in a war-influenced middle-income country in South America: is it possible?

INTRODUCTION

Trauma teams (TTs) improve outcomes in trauma patients. A multidisciplinary TT was conformed in September 2015 in a tertiary level I trauma university hospital in southwestern Colombia, a middle-income war-influenced country.

OBJECTIVE

To evaluate the impact of a TT in admission-tomography and admission-surgery times as well as mortality in a tertiary center university hospital in a middle-income country war-influenced country.

MATERIAL AND METHODS

Retrospective analytical study. Patients older than 17 years admitted to the emergency room 15 months prior and 15 months after the TT implementation were included. Patients prior to the TT implementation were taken as controls. No exclusion criteria. Four hundred sixty-four patients were included, 220 before the TT implementation (BTT) and 244 after (ATT). Demographic data, trauma characteristics, admission-tomography, and admission-surgery time interval as well as mortality were recorded. Requirement of CT scan or surgery was based on physician decision. The analysis was made on Stata 15.1®. Categorical variables were described as quantities and proportions, and continuous variables as mean and standard deviation or median and interquartile range (IQR). Categorical variables were compared using χ² or Fisher's test and continuous variables using Student's T test or Wilcoxon-Mann-Whitney. A multiple logistic regression model was created to evaluate the impact of being treated in the ATT group on mortality, adjusted by age, trauma severity, and physiological response upon admission.

RESULTS

The admission-tomography time interval was 56 min (IQR 39-100) in the BTT group and 40 min (IQR 24-76) in the ATT group, p < 0.001. The admission-surgery time interval was 116 min (IQR 63-214) in the BTT group and 52 min (IQR 24-76) in the ATT group, p < 0.001. Mortality in the BTT group was 18.1% and 13.1% in the ATT group. Adjusted OR was 0.406 (0.215-0.789) p = 0.006 CONCLUSIONS: A trauma team conformation in a war-influenced middle-income country is feasible and reduces mortality as well as admission-surgery and admission-tomography time intervals in trauma patients.

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

Introduction: The availability of interdisciplinary groups trained in morbidly adherent placenta (MAP) is limited. Telemedicine can be a useful strategy to bring patients affected by MAP to institutions specialized in its management. We sought to assess how useful an informal teleconsultation is for MAP cases among users who contacted a reference center for this pathology in a low middle-income country.Methodology: Likert-type surveys were conducted among specialist physicians who carried out teleconsultation with a MAP experienced institution, for assessing how useful the remote assistance was.Results: In 15-month period, 21 teleconsultations associated with MAP were recorded. Teleconsultation was considered "very useful" by 100% of obstetricians. Among the physicians, 90.5% said they would "definitely use the service again" if they had a new case of MAP and 85.7% said that they would "always recommend" the service to other groups of specialists.Conclusion: Teleconsultation in MAP cases is perceived by service users as a useful tool in the management of affected patients. In a context with few specialized centers in the management of this condition, telemedicine must be taken into account when designing comprehensive care strategies for this rare and highly morbid disease.

Cesarean scar pregnancy, the importance of immediate treatment

Introduction: Cesarean scar pregnancy (CSP) is an uncommon entity, with high morbidity. Its diagnosis is difficult and delays in management are frequent. We report a series of cases of CSP and analysis of the differences in the outcomes depending on the moment of pregnancy in which they are treated.Case report: Twelve patients with a diagnosis of CSP. Seven of them were diagnosed and treated in the first trimester, often required more than one type of management, but were not transfused or presented complications. The five patients diagnosed lately in the pregnancy, always required cesarean section and emergency hysterectomy, with massive bleeding, transfusions, urinary or vascular complications.Discussion: CSP can be complicated by abnormal placental invasion when pregnancy continuity is allowed. The ideal management is the termination of pregnancy shortly after the diagnosis is made. Our series highlights the diagnostic difficulties that lead to late treatment with frequent complications.Conclusion: It is essential to perform routine analysis of the site of implantation of the gestational sac in the first-trimester ultrasonography and the CSP suspected cases should be handled by interdisciplinary teams in experienced centers.

A systematic multidisciplinary initiative may reduce the need for blood products in patients with abnormally invasive placenta

Introduction: The main complication of the abnormally invasive placenta is massive bleeding, with transfusions required frequently. We aim to evaluate the impact of interdisciplinary management on transfusion practices in women with abnormally invasive placenta.Methodology: Clinical outcomes of women with abnormally invasive placenta treated between 2011 and 2019 were reviewed, including transfusion frequency. Patients divided into three groups: group A (women treated before the introduction of interdisciplinary management), group B (women attended to by a fixed interdisciplinary group), and group C (women with no accreta prenatal diagnosis).Results: Patients with prenatal diagnosis and attended by a fixed interdisciplinary group (group B) required fewer units of red blood cells to be prepared and transfused (median number of units, 0 versus 2 in group A and 3 in group C).Conclusion: The participation of an interdisciplinary group, with strict standards for transfusion, reduces the frequency of use of blood substitutes during the care of women with abnormally invasive placenta.

Urinary tract injuries during treatment of patients with morbidly adherent placenta

INTRODUCTION

Urinary tract injuries (UTI) are a frequent complication of morbidly adherent placenta (MAP) management. In this study, we aim to characterize the type of UTI that occurs and to define if their incidence varies after establishing a fixed interdisciplinary group for the protocolized management of patients with MAP.

METHODOLOGY

All patients with confirmed MAP attended between 2011 and 2019 in our institution, were included. We analyzed the effect of a change in the surgical protocol including rigid ureteral catheters, vesicouterine dissection before hysterotomy and interdisciplinary planning, in the bladder or ureteral injuries incidence.

RESULTS

The study included 65 women. UTI was identified in 27.7% of patients and was associated with a greater volume of blood loss, transfusion requirement, hospital stay, and the need for additional surgeries. There was a high frequency of UTI in patients without protocolized management. The use of rigid ureteral catheters and retrovesical dissection before hysterotomy were associated with a less ureteral injury.

CONCLUSIONS

Developing expertise among the members of the surgical team is essential to improve results. Using rigid ureteral catheters, performing retrovesical dissection before hysterotomy, and performing less extensive surgeries in selected patients are associated with a low frequency of ureteral injuries.