Safer outcomes for placenta accreta spectrum disorders: A decade of quality improvement

Abstract

Objective To describe the evolution and evaluation of protocol‐based multidisciplinary quality improvement (QI) in women undergoing cesarean hysterectomy for radiologically suspected and pathologically confirmed placenta accreta spectrum (PAS) disorders. Methods A single‐center, retrospective cohort study was conducted of all patients undergoing cesarean hysterectomy for PAS disorders between March 2009 and June 2018. Two distinct periods were defined to compare outcomes: 2009–2011 (initial period) and 2017–2018 (current period). Primary outcomes included blood loss and administration of blood products. Secondary outcomes included perioperative levels of hemoglobin, adverse events and complications, time to mobilization, and length of hospitalization. Results Among the 105 consecutive patients identified, there were 26 in the initial period and 32 in the current period. With the implementation of all QI care bundles, median estimated surgical blood loss halved from 2000 ml in the initial period to 1000 ml in the current period, and fewer patients required allogenic blood transfusion (61.5% vs 25%). Patients in the current period demonstrated improved postoperative levels of hemoglobin compared to those in the initial period (101 g/L vs 89 g/L) and had a shorter median postoperative hospital stay (3 days vs 5 days). Conclusion These results support the implementation of a multifaceted QI and patient care initiative for women with PAS disorders.

Placenta accreta spectrum: a non-oncologic challenge for gynecologic oncologists

“…The ideal composition of these multidisciplinary teams may consider consultation by the following core specialties: obstetrics, maternal-fetal medicine, surgical gynecology or gynecologic oncology, anesthesia, neonatology, and perinatal mental health services 22. Additional teams which may also require consultation include hematology, urology, general surgery, vascular surgery, and intensive care.…”

“…Hematology consultation may be required in such cases where indicated. Our group, and others, also advocate the use of intra-operative cell salvage where available, to reduce the need for allogenic blood transfusion 22…”

Planned cesarean hysterectomy for placenta accreta spectrum: safe with the right team

“…1 More recently, our group has reported on quality improvement initiatives that translated to improved patient outcomes. 3 These initiatives include standardization of antenatal care, patient blood management with the use of prophylactic tranexamic acid, elective use of cell salvage, and internal iliac artery ligation. The initiatives also include a monthly retrospective self-audit to discuss areas for improvement in patient care.…”

“…The Table summarizes the reported blood loss during CH from recognized PAS centers in North America. 1,3,4 We encourage French PAS centers to introspect on these differing surgical outcomes. Letters to the Editors ajog.org…”

“…Interestingly, in a small retrospective singlecenter study conducted from 2000 to 2009 in the Toronto center where Murji et al are affiliated, the mean estimated blood loss was significantly reduced (900AE754 mL vs 3625AE2154; P<.05), and the coagulopathy rate tended to be lower (10% [1/10] vs 43% [7/16]) in the conservative management group than the cesarean hysterectomy group. 3 Moreover, a strength of our large prospective multicenter study is that our results were not collected only from very specialized centers but from a larger spectrum of specialized and general centers, with the inclusion of women with or without prenatal diagnosis of placenta accreta spectrum (PAS). This may better reflect the real-world organization of care and incidences of blood-loss-related outcomes in women with PAS managed either by conservative management or cesarean hysterectomy.…”