Abstract

BACKGROUND: Multidisciplinary care for placenta accreta spectrum (PAS) improves pregnancy outcomes, but the specific components of such multidisciplinary collaboration varies between institutions. As experience with PAS increases, assessing new surgical techniques and protocols is crucial to help improve maternal outcomes and to advocate for hospital resources.OBJECTIVE: To assess a novel multidisciplinary protocol for the treatment of PAS that involves cesarean delivery, multivessel uterine embolization (MVE), and hysterectomy as a single procedure within a hybrid operative suite.STUDY DESIGN: This was a matched pre-post study of PAS cases managed before (2010-2017) and after implementation of the PASTIME protocol (2018-2021) at a tertiary medical center. Historical cases were previously managed with internal iliac artery balloon placement in select cases, with the decision to inflate the balloons intraoperatively at the discretion of the primary surgeon. PASTIME cases were compared to historical cases in a 1:2 ratio matched on PAS severity and surgical urgency. The primary outcome was transfusion requirement of packed red blood cells (PRBC). Secondary outcomes included: surgical estimated blood loss (EBL), operative and postoperative complications, procedural time, length of stay (LOS), and neonatal outcomes.RESULTS: Fifteen PASTIME cases and 30 matched historical cases were included for analysis. No significant demographic differences were noted between groups. A median [interquartile range] of 0 [0-2] units PRBC were transfused in the PASTIME group compared to 2 [0-4.5] units in the historical group (p = 0.045) with 5 of 15 (33.3%) PASTIME cases requiring blood transfusion as compared to 19/30 (63.3%) in the historical group (p = 0.11). EBL was significantly lower in the PASTIME group with a median [interquartile range] of 750 mL [450-1,050] compared to 1,750 mL [1,050-2,500] in the historical group (p = 0.003). There were no cases of massive transfusion (> 10 red blood cell units in 24 hours) in the PASTIME group, compared to 5/30 (16.7%) in the historical group (p=0.15). There were no intra-operative deaths from hemorrhagic shock using the PASTIME protocol, while this occurred in 2 historical cases. Mean duration of interventional radiology (IR) procedure time was longer in the PASTIME group (67.8 vs 34.1 minutes, p=0.002). Intensive care unit (ICU) and postpartum length of stay were similar, and surgical and post-operative complications were not significantly different between groups. Gestational age and neonatal birth weights were similar, however neonatal length of stay was longer in the PASTIME group (median duration 32 days vs 15 days, p = 0.02) with a trend towards low APGAR scores. Arterial cord blood pH < 7.2, respiratory distress syndrome, and intubation rates were not statistically different.CONCLUSIONS: A multidisciplinary pathway including a single-surgery protocol with multivessel uterine embolization is associated with a decrease in blood transfusion requirements and EBL with no increase in operative complications. The PASTIME protocol provides a definitive surgical method that warrants consideration by other centers specializing in PAS treatment.

View details for DOI 10.1016/j.ajog.2021.07.001

View details for PubMedID 34245679