A multidisciplinary approach and implementation of a specialized hemorrhage control team improves outcomes for placenta accreta spectrum

Abstract

The main complication of placenta accreta spectrum (PAS) is massive bleeding. Endoarterial occlusion techniques have been incorporated into the management of this pathology. Our aim was to examine the endovascular practice patterns among PAS patients treated during a 9-year period in a low-middle income country in which an interdisciplinary group's technical skills were improved with the creation of a PAS team. METHODOLOGY:A retrospective cohort study including all PAS patients treated from December 2011 to November 2020 was performed. We compared the clinical results obtained according to the type of endovascular device used (group 1, internal iliac artery occlusion balloons; group 2, resuscitative endovascular balloons of the aorta; group 3, no arterial balloons due to low risk of bleeding) and according to the year in which they were attended (reflects the PAS team level of experience). A fourth group of comparisons included the woman diagnosed during a cesarean delivery and treated in a nonprotocolized way. RESULTS:A total of 113 patients were included. The amount of blood loss decreased annually, with a median of 2,500 mL in 2014 (when endovascular occlusion balloons were used in all patients) and 1,394 mL in 2020 (when only 38.5% of the patients required arterial balloons). Group 3 patients (n = 16) had the lowest bleeding volume (1,245 mL) and operative time (173 minutes) of the entire population studied. Group 2 patients (n = 46) had a bleeding volume (mean, 1,700 mL) and transfusions frequency (34.8%) slightly lower than group 1 patients (n = 30) (mean of 2,000 mL and 50%, respectively). They also had lower hysterectomy frequency (63% vs. 76.7% in group 1) and surgical time (205 minutes vs. 275 in group 1) despite a similar frequency of confirmed PAS and S2 compromise. CONCLUSION:Endovascular techniques used for bleeding control in PAS patients are less necessary as interdisciplinary groups improve their surgical and teamwork skills.

The Clinical Evaluation of IIA Balloon Occlusion for Pernicious Placenta Previa Patients with Placenta Accreta: A Retrospective Study

“…In our study, the transfusion rate was 91.3% in the balloon group and 100% in the control group, which was much higher than the 50% or so reported in the literature [23] . In our hospital, autologous blood transfusion is one of the necessary means to reduce the bleeding during the operation of pregnant women with placenta accreta spectrum.…”

Factors to consider when seeking better results in placenta accreta spectrum

“…Exposing oneself to one's peers demands both internal improvement and self-criticism processes that are the basis of the four domains of the postpartum hemorrhage bundles applied to PAS. 3 We agree with the need for multicenter studies that evaluate not only the relation between volume and results but also the impact of…”

“…Nevertheless, it is necessary to consider other activities (Figure 1) that are well summarized in the care models, called "bundles". 3 Although it is easy to focus on the execution (response to the surgical challenge), there are three additional components of quality care: some precede treatment, such as readiness, recognition, and prevention, and the other follows it, reporting and systems learning.…”

The clinical evaluation of IIA balloon occlusion in caesarean delivery for patients with PAS: a retrospective study

“…In our study, the transfusion rate was 91.3% in the balloon group and 100% in the control group, which was much higher than the 50% or so reported in the literature [ 22 ]. In our hospital, autologous blood transfusion is one of the necessary means to reduce the bleeding during the operation of pregnant women with placenta accreta spectrum.…”