Abstract
BACKGROUND
Management options for placenta accreta spectrum disorder are multiple, without a clear picture of which one is superior. Management guidelines describe the use of a wide range of human and technological resources that are not always available in resource-limited settings.
OBJECTIVE
This consensus seeks agreement on general guidelines that facilitate the management of placenta accreta spectrum in low- and middle-income countries.
STUDY DESIGN
Consensus was developed using the modified Delphi methodology, incorporating 3 successive rounds in which 6 dimensions of placenta accreta spectrum treatment were discussed: pathway for placenta accreta spectrum care, roles at different levels of care, organization of the interdisciplinary teams at the reference hospitals, training interdisciplinary teams, placenta accreta spectrum surgical treatment, and management of placenta accreta spectrum patients without prenatal diagnosis.
RESULTS
Consensus was achieved on all questions on placenta accreta spectrum management. Specific low- and middle-income countries problems were addressed, trying to establish guidelines for the construction of trained placenta accreta spectrum interdisciplinary teams, as well as the rational use of the different therapeutic options available in a limited resources setting. In addition, it is highlighted the need to facilitate contact between patients affected by this disease and the interdisciplinary groups, overcoming administrative barriers typical of some health systems.
CONCLUSION
We present a consensus on the treatment of placenta accreta spectrum in a low- and middle-income countries, based on local experts’ opinions. Construction of high-quality scientific evidence is essential in settings with limited resources.
Key words: consensus development conference, limited resources, low- and middle-income population, placenta accreta spectrum
AJOG Global Reports at a Glance.
Why was this study conducted?
Most placenta accreta spectrum management guidelines do not consider the particularities of resource-limited settings.
Key findings
We point out some difficulties inherent to limited resource scenarios for quality care for women affected by placenta accreta spectrum, and some possible solutions to these difficulties.
What does this add to what is known?
Although it is necessary to establish high-quality standards for the care of placenta accreta spectrum patients, management protocols must consider the particularities of each health system. Between hospitals collaboration and telemedicine are useful strategies to overcome the limitations of limited resources scenarios.
Introduction
Placental accreta spectrum (PAS) is a serious condition associated with massive bleeding and high maternal mortality. Its incidence has increased hand in hand with the higher frequency of cesarean deliveries.1
Although there are multiple surgical treatment options available, there is no clarity as to which one is the best.2,3 Probably, the best alternative is to take into consideration each case, the expertise of the medical team, and hospital resources.
The available management guidelines, issued by international societies, coincide in recommending that surgery should be performed by interdisciplinary groups with experience, and those who have a large number of resources at their disposal.2,3 The application of these guidelines in each country, requires consideration of a set of particular variables found within the local health system, primarily the availability of resources, especially in scenarios where resources are limited.4, 5, 6
In low- and middle-income countries (LMIC), hospitals with high patient flow and experienced interdisciplinary teams, have seldom been described.7,8 Additionally, the recommended training for surgeons in charge of managing PAS cases, is not easy to achieve,9 and often the care of these patients is carried out under inadequate conditions, a fact that contributes to the higher morbidity rates.
The Colombian Federation of Obstetrics and Gynecology Societies (FECOLSOG) recognizes the need to provide recommendations for the management of PAS in the LMIC setting and with this work, it seeks to reach a consensus on general guidelines that facilitate the best quality care for this condition in settings with limited resources.
Materials and Methods
This consensus was developed using a modification of the Delphi method, incorporating 3 successive rounds.10,11 No ethics committee approval was required for this study.
The maternal and perinatal medicine committee of FECOLSOG designed a work plan for the construction of a broad consensus on the diagnosis and management of PAS. Because PAS requires the participation of a large number of specialties, as well as a wide variety of interventions, 3 consensus sessions were proposed (surgical treatment, diagnosis, and presurgical optimization that included anesthetic management).
The first consensus session addressed surgical treatment and its results are discussed in this article.
Based on the available literature and their clinical experience, the consensus development team, formulated initial questions focusing on 6 key dimensions:
-
1.
Pathway for PAS care
-
2.
Roles at different levels of care
-
3.
Organization of interdisciplinary teams at the reference hospitals
-
4.
Training of the interdisciplinary team
-
5.
Surgical treatment of PAS
-
6.
Management of patients with PAS, without prenatal diagnosis
Specialists who worked in reference hospitals that manage complex obstetrical pathologies in different regions of Colombia, were eligible to participate in the consensus. The databases of 2 previously published studies that assessed the availability of hospitals that provided definitive treatment for PAS, were used.8,12 Candidates were invited to participate through email.
A survey was conducted and “consensus” was defined as the agreement of 80% or more of the participants to each of the topics mentioned. There were 3 rounds, the first with a questionnaire sent via email (in a Google form format) with a secure link and individualized for each participant, where in addition to answering the questions anonymously, they were invited to share their comments and propose new questions.
Responses from round 1 were analyzed and the questions that did not reach consensus were included in round 2, which took place in a virtual meeting (through Zoom) in which the results of round 1 were presented and each question was discussed after reviewing the available evidence. Finally, an interactive online questionnaire (build within Zoom) was completed. The questions that did not reach consensus in round 2 would be discussed in a third round. Those questions that did not reach consensus would be accompanied by the development of practical advices. Following the initial meeting, the third round would allow participants to anonymously respond to a new survey including only the questions that needed to be addressed.
The final manuscript was drafted by the consensus development team (A.J.N.C., J.E.S.B., M.B.L., and J.A.B.S.) and then reviewed and approved by all the experts and specialists involved in the consensus.
Results
Twenty-seven national experts were invited to participate, of which, 26 (96.3%) participated in the first round; 37 questions were discussed, and agreement was reached on 29 of them. Seventeen (65.4%) experts participated in the second round where agreement was reached on the remaining 8 questions, and a third round was not needed.
The participants came from 13 different cities of Colombia. The characteristics of the participating experts are described in Table 1.
Table 1.
Characteristics of the experts participating in this consensus
| Variable | Result | |
|---|---|---|
| Years of experience as an obstetriciana | 16 (10.7–26) | |
| Years of experience delivering PAS carea | 11 (8–20.5) | |
| Type of hospital where PAS cases are managed, n (%) | Public | 11 (42.3) |
| Private | 15 (57.7) | |
| University | 13 (50) | |
| Level of complexity of the hospital that manages the PAS cases, n (%) |
1 | 0 |
| 2 | 1 (3.9) | |
| 3 | 9 (34.6) | |
| 4 | 16 (61.5) | |
| Cases per year that are managed in the hospitala | 8 (4–12) | |
PAS, placenta accreta spectrum.
Median (interquartile range).
Nieto-Calvache. Placental accreta spectrum, treatment consensus in a resource-limited setting. Am J Obstet Gynecol Glob Rep 2023.
The questions and the percentages of consensus for each of them are described in Table 2.
Table 2.
Percentage of consensus on each question discussed following the Delphi method
| Key dimensions | Question | Consensus (%) |
|---|---|---|
| Route of attention for PAS | The ideal place for the care of a woman with PAS is the nearest hospital recognized as a reference center for this disease | 88.5 |
| Patients with suspected PAS should be referred to the reference hospital as soon as the suspected diagnosis of PAS becomes a likely possibility. | 84.6 | |
| The severity of the possible complications during the management of PAS justifies a timely referral to the nearest PAS reference center, even if there is no previous referral process initiated from the health insurer. | 92.3 | |
| Surgical management for PAS cases should be carried out by a medical team with specific training in PAS. | 100 | |
| Regulatory entities of healthcare delivery should monitor the referral process for patients with suspected PAS and expedite administrative process in the absence of a previous contract between the insurer and the provider. |
88a | |
| Roles of each player in the different levels of care | Institutions such as hospitals, clinics, and prenatal diagnostic centers that find signs suggestive of PAS on ultrasound should recommend immediate referral of the patient to a hospital recognized as a reference center for PAS. |
100 |
| Primary care institutions (not recognized as reference centers for PAS) should actively search for PAS in patients with risk factors for this disease. | 92.3 | |
| All patients with placenta previa and a history of cesarean delivery in previous pregnancies should be studied to rule out the presence of PAS, ideally there should have at least one ultrasound scan performed to the patient at the reference center. | 92.3 | |
| Hospitals recognized as reference centers for PAS should establish fluid and solid networks with other hospitals that manage low-complex patients, to support the optimal diagnosis and treatment of this disease. |
100 | |
| The use of virtual communication modalities such as telemedicine, tele-expertise and tele-help should be considered as ways to interact between primary care institutions and PAS reference centers. | 100 | |
| The possibility of death from PAS and the proven usefulness of the participation of expert groups in reference hospitals, supports the fact that administrative limitations like absence of previous service agreement between insurer and provider is not a reason for a patient to be denied access to those expert groups. | 92.3 | |
| Structuring of the interdisciplinary teams that manage the PAS cases inside the hospital | It is necessary to favor collaboration between hospitals of different levels of complexity within a region, to identify the hospital or hospitals with the recommended qualifications for optimal PAS care and to thus, expedite immediate access of patients to these hospitals, regardless of their health insurance. Scientific societies and healthcare regulatory agencies should facilitate this. |
96.2 |
| We recommend including the “bundle” model that considers the domains of service readiness, prevention and identification, response, reporting and learning, as a guide for the readiness of hospitals wishing to become reference centers for PAS in limited resources scenarios. | 80a | |
| Telemedicine can facilitate diagnosis, surgical planning and execution, and the process of self-assessment and learning after caring for a patient with PAS. It should be included when planning the diagnosis and treatment of PAS cases. | 80.8 | |
| The designation of a fixed group in charge of assisting to all cases of PAS and the institutional support to facilitate the contact of this group with remote experts to speed up the acquisition of surgical skills, can be a training strategy in the surgical management of this condition. | 92.3 | |
| Training of the players that compose the interdisciplinary team | The basic concepts for diagnosis and treatment of PAS should be included in all obstetrics residence programs in limited resources settings. | 100 |
| All obstetrics and gynecology residents during their academic training, should receive training on useful maneuvers for the prevention and treatment of massive intraoperative bleeding in placenta previa and PAS such as manual aortic compression, uterine tourniquet, pelvic packing, retrovesical bypass and Ward maneuver. | 100 | |
| The flow of patients with suspected PAS forwarded to reference centers within a region, should be favored. Those hospitals with the highest number of cases should offer the opportunity to professionals interested in improving their PAS-management skills to assist in the care of these patients. | 96.1 | |
| PAS reference hospitals must offer permanent educational and care support (face-to-face and remote [telemedicine]) to other hospitals in their region, in relation to the care of this disease. | 96.1 | |
| Scientific societies should encourage the creation of educational programs that focus on the management of PAS. | 100 | |
| E-learning should be included in the educational curriculum to be built around PAS. | 100 | |
| Treatment of PAS | Pregnancy termination in patients with suspected PAS without evidence of active vaginal bleeding should be performed between 34 and 36 weeks 6/7. | 82a |
| A protocol for surgical approach is necessary, with sequential interventions that may vary according to the location of the abnormal placental implantation site. Surgical teams should have several surgical management plans in place, in case they encounter reasons to deviate from their original ones. | 92.3 | |
| Hysterectomy for PAS is a unique procedure that carries out its unique difficulties, which means specific training is indispensable for its correct performance. | 94a | |
| Subtotal hysterectomy can be used in selected cases, such as when vesico-uterine dissection is impossible. It requires special management of the uterine segment and the cervix, and along with it, compressive sutures are usually added. | 88a | |
| “Delayed hysterectomy” (a cesarean delivery that avoids incision of the placenta, followed by the delivery and abdominal closure, with hysterectomy planned a few days later) is useful in selected cases, such as when the initial management is performed by untrained personnel or when optimal resources are not available to perform the hysterectomy at the time of the cesarean delivery. | 100a | |
| One step conservative surgery implies the resection of the abnormal myometrium along with uterine reconstruction, is useful in selected cases and should be well-known by expert groups, as are the other management options | 80.8 | |
| The expectant management of PAS is to leave the placenta in situ for an indefinite period of time. This should be used only by groups with expertise on this technique, and applied only in selected patients where expert personnel are available 24/7. | 92.3 | |
| The interdisciplinary groups found at the PAS reference centers can select patients based on the need for vascular interventions such as ligation of uterine arteries, ligation or occlusion of internal iliac or common iliac arteries, or aortic occlusion; taking into account factors such as the location of the abnormal implantation and the experience of the team. | 94a | |
| There are multiple types of abdominal wall incisions useful in surgery for PAS; however, the managing team should choose the most appropriate one based on their experience and the location of the abnormal implantation. | 80.8 | |
| Intraoperative cell salvage devices are useful, as they help decrease the number of red blood cell bags used. They should be available in reference hospitals for PAS; however, its use is not essential in ALL cases. | 88.5 | |
| When ureteral catheter placement is part of a protocol designed by the managing team, it may be useful in the surgical management of selected cases of PAS. | 88.5 | |
| Managing patients with PAS, without prenatal diagnosis | The optimal approach when a PAS case has been found intraoperatively, varies according to the resources available at the time of surgery and the clinical findings of the patient and the fetus. | 88.5 |
| All hospitals providing obstetrical care, regardless of their level of complexity, should establish a care pathway in the event of an unexpected intraoperative PAS finding, including assessment of the urgency of the procedure and immediate support to the first-response team. There should be an institutional (hospital) response and not only from the professionals (physicians) in charge of the patient. |
88.5 | |
| If a patient with risk factors for PAS (eg, myomectomy or previous cesarean delivery) presents with retained placenta following a vaginal delivery, it is advisable to evaluate the possibility of such a diagnosis (eg, by performing an ultrasound) before attempting manual removal of the placenta. | 80a |
PAS, placenta accreta spectrum.
Item on which consensus was not reached in the first round (in which 26 panelists participated). Now it shows the percentage of agreement obtained in the second round (in which 17 panelists participated).
Nieto-Calvache. Placental accreta spectrum, treatment consensus in a resource-limited setting. Am J Obstet Gynecol Glob Rep 2023.
Last 2 tables show the opinions that the participants have on the need to have different resources available at reference hospitals, for the management of PAS (Table 3) and what a low-complex obstetrical center should have available, to respond to an intraoperative diagnosis of PAS (Table 4).
Table 3.
Experts’ opinion about the need to have resources available for the treatment of placenta accreta spectrum at the reference hospital
| Element | Expert opiniona |
||
|---|---|---|---|
| Indispensable requisite | Availability can be optional | Not necessary | |
| Medical specialties | |||
| Obstetrician with experience in ultrasound diagnosis of PAS | 73.08 | 23.07 | 3.85 |
| Obstetrician with experience in the surgical treatment of PAS | 84.61 | 15.38 | 0 |
| Anesthesiologist with experience in PAS management | 69.23 | 26.92 | 3.85 |
| Urologist with experience in the management of PAS | 50 | 50 | 0 |
| Pathologist with experience in PAS | 23.07 | 50 | 26.92 |
| Radiologist with experience in the diagnosis of PAS | 46.15 | 50 | 3.85 |
| Neonatologist | 69.23 | 30.77 | 0 |
| General surgeon | 73.08 | 26.92 | 0 |
| Vascular surgeon | 42.30 | 57.69 | 0 |
| Specialist in transfusion medicine or hematologist | 34.61 | 50 | 15.38 |
| Hospital services | |||
| Adult intensive care unit | 92.30 | 7.69 | 0 |
| Neonatal intensive care unit | 96.15 | 3.85 | 0 |
| High dependance obstetrical unit | 61.53 | 30.77 | 7.69 |
| Blood bank or transfusion service with the capacity to manage a massive transfusion | 100 | 0 | 0 |
| Interventional radiology service | 69.23 | 30.77 | 0 |
| Intraoperative cell saver | 38.46 | 53.85 | 7.69 |
PAS, placenta accreta spectrum.
Percentage of consensus participants who considered each of the items listed “a must-have,” “an item with optional availability,” or “an item not required.”
Nieto-Calvache. Placental accreta spectrum, treatment consensus in a resource-limited setting. Am J Obstet Gynecol Glob Rep 2023.
Table 4.
Experts' opinion on the requirements of a basic obstetrics service to respond when an intraoperative finding of placenta accreta spectrum arises
| Element | Experts’ opiniona |
||
|---|---|---|---|
| Indispensable requisite | Availability can be optional | Not necessary | |
| Protocol for obstetrical hemorrhage care | 100 | 0 | 0 |
| Availability for emergency blood transfusion | 100 | 0 | 0 |
| Additional assistance or second-call physicians to provide support in the event of a serious case | 96.15 | 3.85 | 0 |
| Emergency referral pathway to hospitals that manage more complex cases | 100 | 0 | 0 |
| Immediate contact with PAS reference centers (telemedicine?) | 100 | 0 | 0 |
| Training in manual occlusion of the aorta | 88.46 | 11.54 | 0 |
| Training in pelvic packing | 100 | 0 | 0 |
| Tranexamic acid | 100 | 0 | 0 |
| Oxytocic medication | 92.30 | 3.85 | 3.85 |
| Hydrostatic balloons for uterine tamponade | 92.30 | 3.85 | 3.85 |
| Nonpneumatic antishock garment | 84.61 | 15.38 | 0 |
| Resources for the prevention of hypothermia | 100 | 0 | 0 |
| Devices for crystalloid heating | 96.15 | 3.85 | 0 |
PAS, placenta accreta spectrum.
Percentage of consensus participants who considered each of the items listed “a must-have,” “an item with optional availability,” or “an item not required.”
Nieto-Calvache. Placental accreta spectrum, treatment consensus in a resource-limited setting. Am J Obstet Gynecol Glob Rep 2023.
Comment
Principal findings
This consensus on PAS management addresses specific LMIC problems and seeks to establish guidelines for the assemble of interdisciplinary teams trained in PAS care, as well as the rational use of the different therapeutic options available in a setting with limited resources. In addition, the need to facilitate contact between patients affected by this disease and the interdisciplinary groups was addressed, overcoming the administrative barriers inherent to some healthcare systems.
Results
There was consensus among the participants that the different ways in which the disease manifests, calls for an individualized management.
There are multiple treatment options for PAS and a considerable amount of time is required to train and be adept in each of them.9 Thus, many hospitals choose a particular management strategy and apply it to all their patients, regardless of the particularities of each case. It is worrying that the only management strategy available in many hospitals is hysterectomy, even when some of the patients taken to surgery for suspected PAS do not actually have PAS (false positive diagnosis by prenatal ultrasound)13 or when some of them have a desire for future fertility.14 The fluid and continuous interaction between different interdisciplinary teams may facilitate the dissemination of expertise of some experts, as well as their training in different management options.
The panelists agree that hysterectomy is not the only treatment option and that the characteristics of each case may indicate either hysterectomy (immediate or delayed), one step conservative surgery, modified subtotal hysterectomy, or expectant management (leaving the placenta in situ).2,3 Reference hospitals for PAS should have the sufficient training to apply each of these techniques as needed, as well as to support other hospitals in their region when they are faced with a case that cannot be referred under ideal circumstances.
It has been reported that almost half of PAS cases are diagnosed during a cesarean delivery performed because of another obstetrical condition (false negative diagnosis in prenatal ultrasound).15 Thus, it is a reality that any hospital where cesarean deliveries are performed, may face the situation in which surgeons with no experience in the management of PAS, must define how to proceed when faced with an intraoperative diagnosis of this condition. The participants in the consensus, agree on the need to foresee this situation and consider that the “bundle” model described for postpartum hemorrhage16 and other obstetrical emergencies, can guide the activities to be carried out at the different levels of care in relation to PAS.
Emphasis is placed on the preparation of interdisciplinary teams in reference hospitals for PAS (Table 3), but also in all obstetrical departments of lower-complexity hospitals (Table 4). The latter, without any previous preparation, will not respond optimally to the incidental finding of PAS and thus lead to poor clinical outcomes.
Clinical implications
The panelists agreed on the incorporation of new concepts in the management of PAS such as topographic classification of PAS and telemedicine during the care of women affected by this condition.
It has been described that evaluating the location of the uterine abnormality in PAS, allows the differentiation between complex cases,17 selecting candidates for more invasive interventions,18 and it is possible that a topographic classification strengthens the histologic classification proposed by FIGO (The International Federation of Gynecology and Obstetrics),19 but further studies are needed to validate these considerations.
Similarly, telemedicine has been described as useful at strengthening interdisciplinary PAS teams, prenatal diagnosis,20 surgical planning,21 surgical performance,22 and postoperative learning activities.23 However, the usefulness of telemedicine in overcoming the geographic, economic, and administrative barriers inherent to LMICs, needs to be evaluated further.
It is usual that physicians who diagnose PAS choose not to refer patients to other hospitals and decide to treat them themselves,24 even if they do not have all the necessary resources. In addition, there are several conditions that limit the immediate referral of these patients, to hospitals with more expertise in the treatment of the condition. The participants in this consensus agree on the need to facilitate contact between patients with PAS and expert interdisciplinary teams in hospitals recognized as reference centers, hopefully, from the moment the disease is suspected. To facilitate this process, it is necessary to overcome administrative roadblocks for the regulatory bodies that provide healthcare services in a region.
Primary care institutions have an important role in the active search for PAS, especially in patients with risk factors.25 Timely referral of women with suspected PAS to reference hospitals should be accompanied by feedback and monitorization of the ground-level hospitals, which can then evaluate their performance and improve it over time. Activities such as telehealth or teleultrasound can be effective in facilitating contact between patients and expert groups.20
Research implications
Local knowledge production and collaboration with international research initiatives are needed, to address specific LMIC problems that have not been addressed in international management guidelines. The adaptation of the recommendations disclosed in the different PAS management guidelines to the particular context of each LMIC, is indispensable. The technological and human resources available in each hospital are different, the administrative and legislative dynamics of healthcare with each country are variable, and the expectations of patients in each culture are diverse. Likewise, the response that healthcare teams provide to PAS should be considered by hospitals long before a patient affected by the disease consults that center.
Scientific societies have an important responsibility to unite professionals interested in PAS and generate spaces for the construction and dissemination of scientific knowledge.
They also have a role in generating educational options on PAS, providing an environment where hospitals and professionals can improve their skills in the management of this condition. The participants in this consensus consider that basic concepts of diagnosis and management of PAS should be explicitly included in the curriculum of universities that offer an obstetrics and gynecology residency program. The large concentration of PAS patients in some reference hospitals, facilitates the design of PAS–related educational experiences for visiting obstetricians.
Strengths and limitations
Treatment of PAS requires the consideration of multiple factors, and their implementation in each hospital implies a large number of adjustments to the already functional management guidelines, as well as local processes, as diverse as the medical centers. The present consensus is insufficient, considering the diversity of the therapeutic options and difficulties inherent to the management of PAS; however, it seeks to draw attention to some particularly fragile dimensions in resource-limited settings, such as the preparation of medical teams, early recognition of the disease, appropriate response, and joint learning activities in the region.
Conclusion
We present a consensus on the treatment of PAS in a LMIC, based on local expert opinions. Although it is necessary to build high-quality scientific evidence in settings with limited resources, the use of training based on available resources will allow a more rational management and surely a decrease in morbidity.
Acknowledgments
Grupo Desarrollador del Consenso, Comité Medicina Materna y Perinatal de la Federación Colombiana de Obstetricia y Ginecología (FECOLSOG):
• Adda Rozo: Hospital San José́, Fundación Universitaria de Ciencias de la Salud, Bogotá́, Colombia.
• Adriana Messa Bryon: Clínica de Espectro de Acretismo Placentario, Fundación Valle de Lili, Cali, Colombia.
• Alejandro Colonia: Hospital General de Medellín, Medellín, Colombia.
• Armando Gómez: Clínica la Misericordia, Barranquilla, Colombia.
• Arturo Cardona: Clínica del Prado, Grupo Quirón Salud, Medellín, Colombia.
• Carlos Caicedo: Subred integrada de Servicios de Salud Centro Oriente E.S.E., Universidad Antonio Nariño, Bogotá́, Colombia.
• Fabian Dorado: Hospital Federico Lleras Acosta, Ibagué, Colombia.
• Jaime Silva: Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia.
• Javier Carvajal: Clínica de Espectro de Acretismo Placentario, Fundación Valle de Lili, Cali, Colombia.
• Jesús Velásquez: Hospital Universitario San Vicente Fundación, Universidad de Antioquia, Medellín, Colombia.
• Jorge Niño: Hospital Universitario Clínica San Rafael, Bogotá, Colombia.
• Juan Manuel Burgos: Clínica de Espectro de Acretismo Placentario, Fundación Valle de Lili, Cali, Colombia.
• Juan Carlos Rincón: Hospital Universitario San Rafael, Clínica Medilaser, Tunja, Colombia.
• Lía Matera Torres: Centro Hospitalario Serena del Mar, Universidad de Cartagena, Cartagena, Colombia.
• Orlando Villamizar: Clínica Santa Ana, Cúcuta, Colombia.
• Sandra Olaya: Hospital Universitario SES de Caldas, Manizales, Colombia.
• Virna Medina: Clínica Imbanaco Grupo Quirón Salud, Cali, Colombia.
• Jimmy Castañeda: Director de Educación, FECOLSOG.
Footnotes
The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript.
Patient consent was not required because no personal information or details are included.
Cite this article as: Nieto-Calvache AJ, Sanín-Blair JE, Buitrago M, et al. Placenta accreta spectrum: treatment consensus in a resource-limited setting. Am J Obstet Gynecol Glob Rep 2023;XX:x.ex–x.ex.
References
- 1.Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. J Matern Fetal Neonatal Med. 2011;24:1341–1346. doi: 10.3109/14767058.2011.553695. [DOI] [PubMed] [Google Scholar]
- 2.Sentilhes L, Kayem G, Chandraharan E, Palacios-Jaraquemada J, Jauniaux E, FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel FIGO consensus guidelines on placenta accreta spectrum disorders: conservative management. Int J Gynaecol Obstet. 2018;140:291–298. doi: 10.1002/ijgo.12410. [DOI] [PubMed] [Google Scholar]
- 3.Allen L, Jauniaux E, Hobson S, Papillon-Smith J, Belfort MA, FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel FIGO consensus guidelines on placenta accreta spectrum disorders: nonconservative surgical management. Int J Gynaecol Obstet. 2018;140:281–290. doi: 10.1002/ijgo.12409. [DOI] [PubMed] [Google Scholar]
- 4.Maaløe N, Ørtved AMR, Sørensen JB, et al. The injustice of unfit clinical practice guidelines in low-resource realities. Lancet Glob Health. 2021;9:e875–e879. doi: 10.1016/S2214-109X(21)00059-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Olayemi E, Asare EV, Benneh-Akwasi Kuma AA. Guidelines in lower-middle income countries. Br J Haematol. 2017;177:846–854. doi: 10.1111/bjh.14583. [DOI] [PubMed] [Google Scholar]
- 6.Stokes T, Shaw EJ, Camosso-Stefinovic J, Imamura M, Kanguru L, Hussein J. Barriers and enablers to guideline implementation strategies to improve obstetric care practice in low- and middle-income countries: a systematic review of qualitative evidence. Implement Sci. 2016;11:144. doi: 10.1186/s13012-016-0508-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Brown AD, Hart JM, Modest AM, et al. Geographic variation in management of patients with placenta accreta spectrum: an International Survey of Experts (GPASS) Int J Gynaecol Obstet. 2022;158:129–136. doi: 10.1002/ijgo.13960. [DOI] [PubMed] [Google Scholar]
- 8.Nieto-Calvache AJ, Palacios-Jaraquemada JM, Hidalgo A, et al. Management practices for placenta accreta spectrum patients: a Latin American hospital survey. J Matern Fetal Neonatal Med. 2022;35:6104–6111. doi: 10.1080/14767058.2021.1906858. [DOI] [PubMed] [Google Scholar]
- 9.Shamshirsaz AA, Fox KA, Erfani H, Belfort MA. The role of centers of excellence with multidisciplinary teams in the management of abnormal invasive placenta. Clin Obstet Gynecol. 2018;61:841–850. doi: 10.1097/GRF.0000000000000393. [DOI] [PubMed] [Google Scholar]
- 10.Jones J, Hunter D. Consensus methods for medical and health services research. BMJ. 1995;311:376–380. doi: 10.1136/bmj.311.7001.376. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32:1008–1015. [PubMed] [Google Scholar]
- 12.Nieto-Calvache AJ, López-Girón MC, Nieto-Calvache A, Messa-Bryon A, Benavides-Calvache JP, Burgos-Luna JM. A nationwide survey of centers with multidisciplinary teams for placenta accreta patient care in Colombia, observational study. J Matern Fetal Neonatal Med. 2022;35:2331–2337. doi: 10.1080/14767058.2020.1786052. [DOI] [PubMed] [Google Scholar]
- 13.Salmanian B, Shamshirsaz AA, Fox KA, et al. Clinical outcomes of a false-positive antenatal diagnosis of placenta accreta spectrum. Am J Perinatol. 2021 doi: 10.1055/a-1673-5103. [Epub ahead of print] [DOI] [PubMed] [Google Scholar]
- 14.Einerson BD, Watt MH, Sartori B, Silver R, Rothwell E. Lived experiences of patients with placenta accreta spectrum in Utah: a qualitative study of semi-structured interviews. BMJ Open. 2021;11 doi: 10.1136/bmjopen-2021-052766. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Silveira C, Kirby A, Melov SJ, Nayyar R. Placenta accreta spectrum: we can do better. Aust N Z J Obstet Gynaecol. 2022;62:376–382. doi: 10.1111/ajo.13471. [DOI] [PubMed] [Google Scholar]
- 16.Main EK, Goffman D, Scavone BM, et al. National partnership for maternal safety: consensus bundle on obstetric hemorrhage. Anesth Analg. 2015;121:142–148. doi: 10.1097/AOG.0000000000000869. [DOI] [PubMed] [Google Scholar]
- 17.Kingdom JC, Hobson SR, Murji A, et al. Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020. Am J Obstet Gynecol. 2020;223:322–329. doi: 10.1016/j.ajog.2020.01.044. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Nieto-Calvache AJ, Palacios-Jaraquemada JM, Aryananda RA, et al. How to identify patients who require aortic vascular control in placenta accreta spectrum disorders? Am J Obstet Gynecol MFM. 2022;4 doi: 10.1016/j.ajogmf.2021.100498. [DOI] [PubMed] [Google Scholar]
- 19.Jauniaux E, Ayres-de-Campos D, Langhoff-Roos J, Fox KA, Collins S, FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel FIGO classification for the clinical diagnosis of placenta accreta spectrum disorders. Int J Gynaecol Obstet. 2019;146:20–24. doi: 10.1002/ijgo.12761. [DOI] [PubMed] [Google Scholar]
- 20.Sandlin AT, Magann EF, Whittington JR, et al. Management of pregnancies complicated by placenta accreta spectrum utilizing a multidisciplinary care team in a rural state. J Matern Fetal Neonatal Med. 2022;35:5964–5969. doi: 10.1080/14767058.2021.1903425. [DOI] [PubMed] [Google Scholar]
- 21.Nieto-Calvache AJ, Zambrano MA, Herrera NA, et al. Resective-reconstructive treatment of abnormally invasive placenta: Inter Institutional Collaboration by Telemedicine (ehealth) J Matern Fetal Neonatal Med. 2021;34:765–773. doi: 10.1080/14767058.2019.1615877. [DOI] [PubMed] [Google Scholar]
- 22.Aitken K, Cram J, Raymond E, Okun N, Allen L, Windrim R. “Mobile” medicine: a surprise encounter with placenta percreta. J Obstet Gynaecol Can. 2014;36:377. doi: 10.1016/S1701-2163(15)30579-X. [DOI] [PubMed] [Google Scholar]
- 23.Nieto-Calvache AJ, Palacios-Jaraquemada JM, Aguilera LR, et al. Telemedicine facilitates surgical training in placenta accreta spectrum. Int J Gynaecol Obstet. 2022;158:137–144. doi: 10.1002/ijgo.14000. [DOI] [PubMed] [Google Scholar]
- 24.Wright JD, Silver RM, Bonanno C, et al. Practice patterns and knowledge of obstetricians and gynecologists regarding placenta accreta. J Matern Fetal Neonatal Med. 2013;26:1602–1609. doi: 10.3109/14767058.2013.793662. [DOI] [PubMed] [Google Scholar]
- 25.Coutinho CM, Giorgione V, Noel L, et al. Effectiveness of contingent screening for placenta accreta spectrum disorders based on persistent low-lying placenta and previous uterine surgery. Ultrasound Obstet Gynecol. 2021;57:91–96. doi: 10.1002/uog.23100. [DOI] [PubMed] [Google Scholar]