Abstract
OBJECTIVE:
Peripartum hysterectomy for placenta accreta spectrum (PAS) requires surgical expertise, multidisciplinary care, and substantial hospital resources (i.e., blood products, critical care services, interventional radiology) to reduce severe maternal morbidity (SMM) and mortality. 1,2 Traditionally, gynecologic oncologists serve as the primary surgeons for PAS within multidisciplinary “Accreta Programs.” However, the rising incidence of PAS poses a public health and surgical challenge demanding increased awareness and clinical acumen of maternal fetal medicine (MFM) specialists.3 To address this, we compared perioperative outcomes before and after implementation of an Accreta Program with MFM as the primary surgeon for peripartum hysterectomy.
STUDY DESIGN:
This is a retrospective cohort study comparing surgical and perioperative outcomes of PAS hysterectomy patients in a Pre-Program cohort (2008–2017) versus a Post-Program cohort (2018–2024). All participants underwent peripartum hysterectomy at delivery based on clinical suspicion of PAS, which was later confirmed by pathology. All specimens were reviewed by a board-certified pathologist. The primary outcome was packed red blood cell (PRBC) transfusion. Secondary outcomes were intraoperative resuscitation, intraoperative and postoperative complications, intraoperative consultation, and indicators of SMM.
The primary surgeon was defined as the surgeon who completed the peripartum hysterectomy, either gynecologic oncology or MFM. If a gynecologic oncologist participated in any portion of the hysterectomy, they were deemed the primary surgeon. Patient characteristics and maternal outcomes were compared in terms of time using Student’s t tests, Wilcoxon rank sum tests, chi-squared tests and Fisher’s exact tests. Univariate and multivariate logistic regression analysis were conducted for each of the binary outcomes. Univariate and multivariate Poisson regression analysis was conducted for the outcomes of estimated blood loss (EBL) and PRBC, due to the skewed distribution of these variables secondary to the nature of the case (scheduled and expected, unscheduled and expected, and emergent/unexpected).
RESULTS:
A total of 145 patients underwent peripartum hysterectomy for PAS: 58 Pre-Program (2008–2017) and 87 Post-Program (2018–2024). The proportion of cases led by MFM as the primary surgeon significantly increased from 17.2% to 93.1%. Table 1 There were notable differences in “Urgency of Case” with higher rates of “Emergent/Unexpected” peripartum hysterectomies in the Pre-Program group along with higher rates of fetal anomalies and oligohydramnios. Table 1
Table 1.
Participant Demographic Characteristics
| Variables | Pre-Program: 2008–2018 | Post-Program : 2018–2024 | P-Value |
|---|---|---|---|
| N=58 | N=87 | ||
| Age (years), Mean (SD) | 34.4 (5.8) | 35.1 (4.6) | 0.45 |
| BMI at delivery (kg/m2), Median (IQR) | 27.8 (25.0,33.3) | 28.6 (25.4,33.4) | 0.46 |
| Gravidity, Median (IQR) | 5.0 (3.0,6.0) | 4.0 (3.0,6.0) | 0.23 |
| Parity, Median (IQR) | 2.0 (2.0,4.0) | 2.0 (1.0,3.0) | 0.11 |
| Race, N(%) | 0.51 | ||
| White | 27 (46.6%) | 37 (42.5%) | |
| Black | 22 (37.9%) | 32 (36.8%) | |
| Hispanic | 3 (5.2%) | 12 (13.8%) | |
| Asian | 3 (5.2%) | 3 (3.4%) | |
| Other | 3 (5.2%) | 3 (3.4%) | |
| Tobacco use, N(%) | 6 (10.3%) | 6 (7.0%) | 0.47 |
| HTN, N(%) | 8 (13.8%) | 10 (11.5%) | 0.68 |
| DM, N(%) | 0.23 | ||
| None | 51 (87.9%) | 83 (95.4%) | |
| PGDM | 4 (6.9%) | 3 (3.4%) | |
| GDM | 3 (5.2%) | 1 (1.1%) | |
| MFM as primary surgeon, N(%) | 10 (17.2%) | 81 (93.1%) | <0.001 |
| Fetal anomaly, N(%) | 13 (22.4%) | 8 (9.2%) | 0.027 |
| FGR, N(%) | 5 (8.6%) | 6 (6.9%) | 0.70 |
| Oligohydramnios, N(%) | 9 (15.5%) | 3 (3.4%) | 0.013 |
| GA at delivery (weeks), Median (IQR) | 33.9 (31.6,36.0) | 34.2 (31.5,35.5) | 0.77 |
| Placental pathology, N(%) | 0.038 | ||
| Accreta | 37 (63.8%) | 42 (48.8%) | |
| Increta | 8 (13.8%) | 28 (32.6%) | |
| Percreta | 13 (22.4%) | 16 (18.6%) | |
| Number of prior c-sections, N(%) | 0.24 | ||
| 0 | 3 (5.7%) | 2 (2.6%) | |
| 1 | 15 (28.3%) | 26 (33.8%) | |
| 2 | 16 (30.2%) | 30 (39.0%) | |
| 3 | 10 (18.9%) | 14 (18.2%) | |
| 4 | 7 (13.2%) | 2 (2.6%) | |
| 5 | 2 (3.8%) | 2 (2.6%) | |
| 6 | 0 (0.0%) | 1 (1.3%) | |
| Prior Uterine Surgeries, N(%) | 0.14 | ||
| Dilation and Curettage | 28 (82.4%) | 27 (67.5%) | |
| myomectomy | 3 (8.8%) | 2 (5.0%) | |
| D&C + myomectomy | 1 (2.9%) | 8 (20.0%) | |
| other | 2 (5.9%) | 3 (7.5%) | |
| Urgency of Case, N(%) | 0.002 | ||
| Scheduled and expected | 21 (36.2%) | 57 (65.5%) | |
| Unscheduled and expected | 20 (34.5%) | 17 (19.5%) | |
| Emergent/Unexpected | 17 (29.3%) | 13 (14.9%) | |
| Indication for unscheduled delivery, N(%) | 0.34 | ||
| Bleeding | 21 (55.3%) | 14 (38.9%) | |
| Labor/Rupture of Membranes | 9 (23.7%) | 13 (36.1%) | |
| Non-Reassuring Fetal Heart Tracing | 1 (2.6%) | 0 (0.0%) | |
| Other | 7 (18.4%) | 9 (25.0%) | |
| Antepartum admission, N(%) | 38 (71.7%) | 34 (70.8%) | 0.92 |
| Gestational age at antepartum admission, Median (IQR) | 31.1 (27.7,34.3) | 30.0 (23.2,32.3) | 0.089 |
| Duration of antepartum admission (days), Median (IQR) | 3.0 (1.0,8.0) | 4.0 (2.0,7.0) | 0.83 |
| Reason for antepartum admission, N(%) | 0.027 | ||
| Bleeding | 16 (41.0%) | 15 (44.1%) | |
| PTL/PPROM | 7 (17.9%) | 12 (35.3%) | |
| Planning/distance | 14 (35.9%) | 3 (8.8%) | |
| Other | 2 (5.1%) | 4 (11.8%) | |
HTN is hypertension; DM is diabetes mellitus; GDM is gestational diabetes mellitus; FGR is fetal growth restriction; PTL is preterm labor; PPROM is premature rupture of membranes; MFM is maternal fetal medicine; OR is operating room
In unadjusted analyses, PRBC transfusion did not differ significantly between groups. After adjusting for “Urgency of Case,” the Post-Program group had a significantly lower number of PRBC transfusions when compared to the Pre-Program group, IRR 0.51 [0.45, 0.58] with similar trends in estimated blood loss IRR 0.55 [0.54, 0.55].
When comparing other perioperative measures, the Post-Program group had decreased crystalloid infusion (3000 mL [2350,40000] vs 4250 mL [3000,5250], p<0.001), intensive care unit admission (13 [14.9%] vs 26 [44.8%], p <0.001), Urologic consultations (9 [15.5%] vs 4 [4.7%], p = 0.037), postoperative ileus ( 6 [10.3%] vs 5 [5.7%], p = 0.033), and postoperative length of stay (4 [3,5] vs 5 [4,7], p=0.001). For SMM, both PRBC > 8 units (12 [13.8%] vs 17 [29.3%], p = 0.022) and postoperative infections (7 [8.1%] vs 13 [22.4%], p = 0.015) were lower in the Post-Program group. Table 2
Table 2.
Maternal Outcomes
| Variables | Pre-Program: 2008–2017 | Post-Program: 2018–2024 | P-Value |
|---|---|---|---|
| N=58 | N=87 | ||
| INTRAOPERATIVE RESUSCITATION NEEDS | |||
| PRBC, Median (IQR) | 3.5 (1.0,11.0) | 2.0 (1.0,5.0) | 0.13 |
| FFP, Median (IQR) | 1.0 (0.0,6.0) | 2.0 (0.0,4.0) | 0.68 |
| Cryoprecipitate, Median (IQR) | 0.0 (0.0,0.0) | 0.0 (0.0,1.0) | 0.74 |
| Platelets, Median (IQR) | 0.0 (0.0,1.0) | 0.0 (0.0,1.0) | 0.066 |
| Total Transfusion (units), Median (IQR) | 6.0 (1.0,17.0) | 4.0 (1.0,11.0) | 0.26 |
| EBL (mL), Median (IQR) | 2550.0 (1700.0,6000.0) | 2640.0 (2000.0,4464.0) | 0.76 |
| Crystalloid (mL), Median (IQR) | 4250.0 (3000.0,5250.0) | 3000.0 (2350.0,4000.0) | <0.001 |
| TXA administration, N(%) | 4 (6.9%) | 75 (88.2%) | <0.001 |
| Hemoglobin decrease (g/dL), Median (IQR) | 1.8 (0.5,3.0) | 1.2 (0.3,2.1) | 0.086 |
| INTRAOPERATIVE AND POSTOPERATIVE RESOURCES | |||
| Intra-operative complication, N(%) | 12 (20.7%) | 23 (26.4%) | 0.43 |
| GI, N(%) | 2 (3.4%) | 5 (5.7%) | 0.70 |
| Urologic, N(%) | 0.43 | ||
| none | 45 (77.6%) | 68 (78.2%) | |
| stitch in bladder | 1 (1.7%) | 0 (0.0%) | |
| cystotomy | 8 (13.8%) | 16 (18.4%) | |
| ureteral injury | 3 (5.2%) | 3 (3.4%) | |
| cystotomy + ureteral injury | 1 (1.7%) | 0 (0.0%) | |
| ICU admission, N(%) | 26 (44.8%) | 13 (14.9%) | <0.001 |
| ICU Duration (days), N(%) | 0.025 | ||
| 0 | 0 (0.0%) | 5 (29.4%) | |
| 1 | 14 (66.7%) | 8 (47.1%) | |
| 2 | 2 (9.5%) | 3 (17.6%) | |
| 3 | 2 (9.5%) | 1 (5.9%) | |
| 4 | 3 (14.3%) | 0 (0.0%) | |
| Postoperative LOS, Median Day (IQR) | 5.0 (4.0,7.0) | 4.0 (3.0,5.0) | 0.001 |
| INTRAOPERATIVE CONSULTATION | |||
| IR, N (%) | 12 (20.7%) | 28 (32.6%) | 0.12 |
| Urology/stents, N(%) | 9 (15.5%) | 4 (4.7%) | 0.037 |
| General Surgery, N(%) | 7 (12.1%) | 6 (7.0%) | 0.30 |
| OPERATIVE DESCRIPTION | |||
| GETA, N(%) | 47 (81.0%) | 43 (79.6%) | 0.85 |
| Vertical skin incision, N(%) | 47 (81.0%) | 75 (86.2%) | 0.40 |
| Cystoscopy, N(%) | 29 (50.0%) | 80 (92.0%) | <0.001 |
| POSTOPERATIVE COMPLICATIONS | |||
| Gastrointestinal, N(%) | 0.033 | ||
| none | 48 (82.8%) | 82 (94.3%) | |
| ileus | 6 (10.3%) | 5 (5.7%) | |
| obstruction | 3 (5.2%) | 0 (0.0%) | |
| other | 1 (1.7%) | 0 (0.0%) | |
| Urologic, N(%) | 4 (6.9%) | 3 (3.5%) | 0.44 |
| Postoperative Transfusion, N(%) | 1 (1.7%) | 8 (9.2%) | 0.086 |
| SEVERE MATERNAL MORBIDITY | |||
| PRBC transfusion >8 units, N(%) | 17 (29.3%) | 12 (13.8%) | 0.022 |
| Readmission, N(%) | 8 (13.8%) | 8 (9.2%) | 0.39 |
| Postoperative DVT or VTE, N(%) | 6 (10.3%) | 6 (6.9%) | 0.46 |
| Postoperative infection, N(%) | 13 (22.4%) | 7 (8.1%) | 0.015 |
| Reoperation, N(%) | 8 (13.8%) | 6 (6.9%) | 0.17 |
EBL is estimated blood loss; PRBC is packed red blood cells; FFP is fresh frozen plasma; TXA is tranexamic acid; ICU is intensive care unit; LOS is length of stay; IR is interventional radiology; GETA is general endotracheal anesthesia; DVT is deep vein thrombosis; VTE is venous thromboembolism
DISCUSSION
This study highlights the MFM specialist as a non-inferior and viable option to serve as primary surgeon for PAS related peripartum hysterectomies. Program implementation was associated with reduced transfusion requirements and improved perioperative outcomes, similar to results from other published multidisciplinary cohorts.4,5 The importance of complex surgical expertise in MFM is becoming increasingly apparent as 1) PAS cases continue to rise 2) risk factors for surgical morbidity (i.e., BMI, prior surgery, etc.) increase and 3) the increased prevalence of maternity care centers that are physically separated from traditional adult hospitals and their resources.
Favorable outcomes are not explained by surgical specialty alone in this cohort. The creation of an Accreta Program inclusive of nursing, blood bank, interventional radiology, critical care services, and anesthesiology is paramount to maternal survival and decreased morbidity. Although hospital resources and support were similar between the groups in this cohort, program creation and organization championed providers within each medical discipline to support accreta perioperative services and care coordination. Additionally, there was a significant decrease in “Unexpected/Emergent” PAS hysterectomies in the Post-Program group secondary to early and timely diagnosis of PAS. These measures led to increased operative preparedness and multidisciplinary care, thereby improving maternal outcomes.
Future research in PAS surgical outcomes could focus on comparing MFMs and gynecologic oncologists within the same contemporaneous multidisciplinary framework as primary surgeons. Additionally, data on surgeon experience may help clarify which program components most directly drive optimal maternal outcomes.
Footnotes
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