Abstract
Evidence suggests that multidisciplinary teams that perform cesarean hysterectomy for placenta accreta spectrum have better maternal outcomes. The aim of this study was to assess the effects of a multidisciplinary team on outcomes for patients with placenta accreta spectrum at our institution. We examined all planned cesarean hysterectomy procedures performed for placenta accreta syndrome at our hospital between July 1, 2015, and June 30, 2021. Nine and 21 subjects had planned cesarean hysterectomy before and after implementation of the new procedures, respectively. Overall, there was an increase in volume of cases and depth of placental invasion but no change in the demographic characteristics of patients. Additionally, we found decreased blood loss, decreased blood transfusions from a median of 2 units to 0 units, and decreased intensive care unit admission rates from 22.2% to 4.8%, but these results did not reach statistical significance. The main limitation of our study was our small number of subjects. Our findings suggest that multidisciplinary placenta accreta teams improve maternal outcomes for hysterectomy at the time of cesarean delivery.
Keywords: Blood transfusion, hysterectomy, patient care team, placenta accreta
Placenta accreta spectrum (PAS) describes varying degrees of abnormal trophoblast invasion into the myometrium of the uterus and beyond.1 The most common risk factors for PAS include history of cesarean delivery or uterine surgery and placenta previa.2 In recent years the number of cases of PAS has risen drastically in parallel to the overall rate of cesarean deliveries in the United States. PAS is now reported to occur in about 1 out of every 300 pregnancies1 and has significant maternal morbidity and mortality, which is usually related to hemorrhage.3 Despite the significant risks associated with PAS, a recent study indicated that only about a fourth of general obstetricians referred patients with suspected PAS to centers of excellence.4 In July 2018, a multidisciplinary team was created at our hospital to perform hysterectomy at the time of cesarean delivery (C-HYST) for patients with PAS. The primary aim of our study was to compare maternal outcomes for patients with PAS who underwent C-HYST before and after initiation of our multidisciplinary PAS team.
METHODS
The Baylor Scott & White Research Institute institutional review board waived informed consent for our study. We used our electronic medical record system (Epic, Verona, WI) to search for patients who had C-HYST performed from July 1, 2015, through June 30, 2021. Patients who had unplanned C-HYST at the time of cesarean delivery or a C-HYST indication other than PAS were excluded from the study. We performed a manual chart review for each patient and entered demographic and clinical data into Research Electronic Data Capture (REDCap). In July 2018, we created a standardized checklist for C-HYST performed for the indication of PAS (Figure 1).
Figure 1.
Sample checklist for cesarean hysterectomy. CD indicates cesarean delivery; CSE, combined spinal epidural; HYST, hysterectomy; L&D, labor and delivery; NICU, neonatal intensive care unit; OR, operating room; PDS, polydioxanone suture.
We used a chi-square test to evaluate categorical variables in bivariate associations when the expected cell count was ≥5 and used a Fisher’s exact test when expected cell counts were ≤4. We used an unpaired t test to evaluate continuous variables in bivariate associations that had a normal distribution and used a Mann-Whitney U test to evaluate continuous variables in bivariate associations that did not have a normal distribution. We used the Kolmogorov-Smirnoff test to determine if a sample deviated from the normal distribution. Statistical significance was determined a priori to have a P value of 0.05 or less.
RESULTS
Nine and 21 subjects had planned C-HYST before and after implementation of the new procedures, respectively. Checklist use by the multidisciplinary team resulted in decreased blood loss, decreased blood transfusions from a median of 2 units to 0 units, and decreased intensive care unit admission rates from 22.2% to 4.8%, but these results were not statistically significant. Demographic and clinical data for the cohorts are presented in Table 1.
Table 1.
Demographic and clinical data
| Variable |
Preimplementation
(N = 9) |
Postimplementation
(N = 21) |
P
value |
|---|---|---|---|
| Age (years): median (IQR) | 35 (26–39) | 33 (30–35) | 0.40 |
| Height (cm): mean (SD) | 161.9 (5.8) | 163.0 (8.6) | 0.75 |
| Weight (kg): mean (SD) | 93.5 (19.7) | 90.5 (17.3) | 0.68 |
| Body mass index (kg/m2): mean (SD) | 35.6 (6.9) | 34.2 (6.4) | 0.55 |
| Gravidity: median (IQR) | 5 (4–6) | 5 (4–6) | 0.57 |
| Parity: median (IQR) | 3 (2–4) | 3 (2–4) | 0.94 |
| Gestational weeks at delivery: mean (SD) | 34.2 (2.2) | 33.6 (1.9) | 0.48 |
| Prior cesarean delivery | 8 (88.9%) | 21 (100%) | 0.30 |
| Preoperative hemoglobin (g/dL): mean (SD) | 10.1 (0.6) | 10.5 (1.5) | 0.48 |
| Preoperative diagnosis | 0.30 | ||
| Accreta | 7 (78%) | 15 (71%) | |
| Percreta | 1 (11%) | 6 (29%) | |
| Complete placenta previa | 1 (11%) | 0 | |
| Postoperative diagnosis | |||
| Accreta | 5 (56%) | 9 (43%) | |
| Percreta | 3 (33%) | 8 (38%) | |
| Increta | 1 (11%) | 3 (14%) | |
| No evidence of abnormal placentation | 0 | 1 (5%) | |
| Urgency | 0.67 | ||
| Elective | 6 (67%) | 16 (76%) | |
| Urgent | 3 (33%) | 5 (24%) | |
| Initial anesthetic technique | 1 | ||
| Regional | 9 (100%) | 20 (95%) | |
| General anesthesia | 0 | 1 (5%) | |
| General anesthesia as final anesthetic technique | 8 (89%) | 18 (86%) | 1 |
| Subject remained intubated at end of procedure | 2 (22%) | 1 (5%) | 0.21 |
| Intensive care unit admission | 2 (22%) | 1 (5%) | 0.21 |
| Accreta surgeon present for procedure | 7 (78%) | 21 (100%) | 0.08 |
| Incision to wound closure (min): mean (SD) | 183.4 (88.9) | 184.2 (81.6) | 0.98 |
| Incision to uterine incision (min): mean (SD) | 19.1 (17.3) | 13.2 (8.8) | 0.22 |
| Uterine incision to delivery (min): mean (SD) | 1 (1–3) | 1 (1–2) | 0.44 |
| Delivery to conversion to general anesthesia (min): mean (SD) | 26.7 (27.5)a | 6.4 (2.9)b | <0.01* |
| Delivery to wound closure (min): mean (SD) | 162.2 (81.7) | 169.5 (83.7) | 0.83 |
| Blood loss | N/A | ||
| Estimated blood loss (mL): mean (SD) | 2139 (2364)c | 1580 (401)d | |
| Quantitative blood loss (mL): mean (SD) | N/A | 1777 (1391)e | |
| Total transfused units of PRBC: median (IQR) | 2 (0–5) | 0 (0–2) | 0.15 |
| Units of PRBC transfused intraoperatively: median (IQR) | 0 (0–2) | 0 (0–1) | 0.54 |
| Units of PRBC transfused postoperatively: median (IQR) | 1 (0–2) | 0 (0–1) | 0.11 |
| Total units of FFP transfused: median (IQR) | 0 (0–2) | 0 (0–0) | 0.10 |
| Postoperative hospital days: median (IQR) | 3 (3–4) | 3 (3–4) | 0.86 |
aN = 7; bN = 17, cN = 9; dN = 3; eN = 21.
FFP indicates fresh frozen plasma; IQR, interquartile range; PRBC, packed red blood cells; SD, standard deviation.
DISCUSSION
We found a nonstatistically significant decrease in the number of packed red blood cells transfused in the perioperative period, estimated blood loss, and rate of admission to the intensive care unit in patients who had C-HYST for PAS after we created a multidisciplinary PAS team that used a standardized checklist.
The main limitation of our study was that only 9 and 21 patients had planned C-HYST before and after implementation of our multidisciplinary PAS team, respectively. Even in a tertiary care referral center, C-HYST is a relatively uncommon procedure and statistical significance is difficult to demonstrate in single-center studies. Another limitation of our study was that we transitioned from estimated blood loss to quantitative blood loss for cesarean deliveries in 2018. Quantitative blood loss has been shown to more accurately predict postpartum hemorrhage.5 A final limitation of our study was that we had higher volume and increased complexity of PAS cases after implantation of our multidisciplinary PAS team. Over half of the cases performed before the multidisciplinary team were diagnosed as accreta in the postoperative period, while more than half the cases after implementation were postoperatively diagnosed as increta or percreta.
Several studies have found maternal benefit when multidisciplinary teams care for patients with PAS.6–9 In July 2018, a maternal fetal medicine (MFM) physician at our hospital created a checklist and formed a multidisciplinary team for C-HYST. The checklist was similar to other PAS checklists and included personnel, supplies, medications, and standardized procedures for all C-HYST.10 The multidisciplinary team included members from MFM, anesthesiology, neonatology, urology, and a surgeon experienced in PAS. It also included antenatal management at our institution with follow-up ultrasounds at 28 and 32 weeks, optimization of hemoglobin, and counseling and care coordination through MFM.
Prior to implementation of a multidisciplinary team, patients at our institution had a median hospital stay of 3 days. Yasin and colleagues found a much higher mean postpartum duration of stay of almost 8 days.11 They also demonstrated that hospital stay was related to depth of invasion, with increta and percreta patients staying significantly longer than accreta patients.
The increased volume of PAS cases at our institution may in part be due to the increasing rates of PAS.12 Our institution also implemented a maternal fetal transport system in 2021 during the last 2 months of the study period. This significantly increased the volume and acuity of MFM transfers that our institution received. The maternal fetal transport team has already allowed us to capture more patients with PAS in our surrounding area.
In 2021, the Texas state legislature passed a bill signed by the governor that requires hospitals with a level IV maternal designation to have a multidisciplinary PAS team that participates in continuous education and quality improvement.13 Our hospital carries a level IV maternal designation, and our multidisciplinary PAS team was designed to meet those requirements.
We found that the implementation of a multidisciplinary team and standardized checklist to perform C-HYST procedures in patients with PAS was associated with improved maternal outcomes, although they did not reach statistical significance. Future large-scale studies are needed to examine the effect of multidisciplinary care teams and checklists on patients who undergo C-HYST for PAS. The results of this study are generalizable to institutions that perform planned C-HYST procedures on patients with PAS.
References
- 1.Silver RM. Abnormal placentation: placenta previa, vasa previa, and placenta accreta. Obstet Gynecol. 2015;126(3):654–668. doi: 10.1097/AOG.0000000000001005. [DOI] [PubMed] [Google Scholar]
- 2.Society of Gynecologic Oncology American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine, Cahill AG, et al. Placenta accreta spectrum. Am J Obstet Gynecol. 2018;219(6):B2–B16. doi: 10.1016/j.ajog.2018.09.042. [DOI] [PubMed] [Google Scholar]
- 3.Nieto-Calvache AJ, Palacios-Jaraquemada JM, Osanan G, et al; Latin American Group for the Study of Placenta Accreta Spectrum.. Lack of experience is a main cause of maternal death in placenta accreta spectrum patients. Acta Obstet Gynecol Scand. 2021;100(8):1445–1453. doi: 10.1111/aogs.14163. [DOI] [PubMed] [Google Scholar]
- 4.Silver RM, Fox KA, Barton JR, et al. Center of excellence for placenta accreta. Am J Obstet Gynecol. 2015;212(5):561–568. doi: 10.1016/j.ajog.2014.11.018. [DOI] [PubMed] [Google Scholar]
- 5.Blosser C, Smith A, Poole AT.. Quantification of blood loss improves detection of postpartum hemorrhage and accuracy of postpartum hemorrhage rates: a retrospective cohort study. Cureus. 2021;13(2):e13591. doi: 10.7759/cureus.13591. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.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(4):841–850. doi: 10.1097/GRF.0000000000000393. [DOI] [PubMed] [Google Scholar]
- 7.Al-Khan A, Gupta V, Illsley NP, et al. Maternal and fetal outcomes in placenta accreta after institution of team-managed care. Reprod Sci. 2014;21(6):761–771. doi: 10.1177/1933719113512528. [DOI] [PubMed] [Google Scholar]
- 8.Sylvester-Armstrong K, Reeder C, Patrick K, et al. Improved management of placenta accreta spectrum disorders: experience from a single institution. J Perinat Med. 2021;50:286–293. doi: 10.1515/jpm-2021-0263. [DOI] [PubMed] [Google Scholar]
- 9.Gillespie C, Sangi-Haghpeykar H, Munnur U, Suresh MS, Miller H, Hawkins SM.. The effectiveness of a multidisciplinary, team-based approach to cesarean hysterectomy in modern obstetric practice. Int J Gynaecol Obstet. 2017;137(1):57–62. doi: 10.1002/ijgo.12093. [DOI] [PubMed] [Google Scholar]
- 10.Tussey C, Olson C.. Creating a multidisciplinary placenta accreta program. Nurs Womens Health. 2018;22(5):372–386. doi: 10.1016/j.nwh.2018.08.002. [DOI] [PubMed] [Google Scholar]
- 11.Yasin N, Slade L, Atkinson E, Kennedy-Andrews S, Scroggs S, Grivell R.. The multidisciplinary management of placenta accreta spectrum (PAS) within a single tertiary centre: A ten-year experience. Aust N Z J Obstet Gynaecol. 2019;59(4):550–554. doi: 10.1111/ajo.12932. [DOI] [PubMed] [Google Scholar]
- 12.Liu X, Wang Y, Wu Y, et al. What we know about placenta accreta spectrum (PAS). Eur J Obstet Gynecol Reprod Biol. 2021;259:81–89. doi: 10.1016/j.ejogrb.2021.02.001. [DOI] [PubMed] [Google Scholar]
- 13.An act relating to the designation of centers of excellence for the management and treatment of placenta accreta spectrum disorder [Texas H.B.A . No. A1164]. 2021. https://capitol.texas.gov/tlodocs/87R/billtext/pdf/HB01164F.pdf#navpanes=0.