Placenta Accreta Spectrum Disorders – The Impact of the Creation of a Multidisciplinary Team on Maternal Outcomes in Portugal

Teixeira, Beatriz; Pinto, Pedro Viana; Realista, Rodrigo; Silva, Manuela; Costa, Antónia; Machado, Ana Paula; Moucho, Marina

doi:10.1055/s-0043-1772482

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Revista Brasileira de Ginecologia e Obstetrícia

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Original Article, High Risk Pregnancy • Rev Bras Ginecol Obstet 45 (12) • 2023 • https://doi.org/10.1055/s-0043-1772482 copy

Placenta Accreta Spectrum Disorders – The Impact of the Creation of a Multidisciplinary Team on Maternal Outcomes in Portugal

Patologia do espectro do acretismo placentário – O impacto da criação de uma equipa multidisciplinar nos desfechos maternos em Portugal

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To describe a cohort of placenta accreta spectrum (PAS) cases from a tertiary care institution and compare the maternal outcomes before and after the creation of a multidisciplinary team (MDT).

Methods

Retrospective study using hospital databases. Identification of PAS cases with pathological confirmation between 2010 and 2021. Division in two groups: standard care (SC) group – 2010–2014; and MDT group – 2015–2021. Descriptive analysis of their characteristics and maternal outcomes.

Results

During the study period, there were 53 cases of PAS (24 - SC group; 29 - MDT group). Standard care group: 1 placenta increta and 3 percreta; 12.5% (3/24) had antenatal suspicion; 4 cases had a peripartum hysterectomy – one planned due to antenatal suspicion of PAS; 3 due to postpartum hemorrhage. Mean estimated blood loss (EBL) was 2,469 mL; transfusion of packed red blood cells (PRBC) in 25% (6/24) - median 7.5 units. Multidisciplinary team group: 4 cases of placenta increta and 3 percreta. The rate of antenatal suspicion was 24.1% (7/29); 9 hysterectomies were performed, 7 planned due to antenatal suspicion of PAS, 1 after intrapartum diagnosis of PAS and 1 after uterine rupture following a second trimester termination of pregnancy. The mean EBL was 1,250 mL, with transfusion of PRBC in 37.9% (11/29) - median 2 units.

Conclusion

After the creation of the MDT, there was a reduction in the mean EBL and in the median number of PRBC units transfused, despite the higher number of invasive PAS disorders.

Keywords
placenta accreta spectrum disorders; multidisciplinary team; maternal morbidity

Characteristics	SC group (n = 24)	MDT group (n = 29)	Total (n = 53)
Maternal age in years, median (range)	33.5 (23–44)	37 (25–43)	36 (23–44)
Pregestational BMI (kg/m²), median (range)	25.4 (18.5–47.5)	23.7 (17.3–30.4)	24.3 (17.3–47.5)
Assisted reproductive techniques – n	3	1	4
Primiparous – n (%)	12 (50)	7 (24.1)	19 (35.8)
Gestational age at delivery, median (range)	38 (32–41)	38 (27–41)	38 (27–41)
Previous cesarean delivery – n (%)	5 (20.8)	15 (51.7)	20 (37.7)
Number of previous cesarean deliveries – n (%)
0	19 (79.2)	14 (48.3)	33 (62.3)
1	4 (16.7)	12 (41.3)	16 (30.2)
2 or more	1 (4.2)	3 (10.3)	4 (6.9)
Other uterine surgical procedures - n	1	1	2
Placenta previa – n (%)	6 (25)	7 (24.1)	13 (24.5)
Placenta previa and previous cesarean deliveries – n (%)	1 (4.2)	6 (20.7)	7 (13.2)
No identifiable risk factors for PAS	14 (58.3)	10 (34.5)	24 (45.3)

	SC group (n = 24)	MDT group (n = 29)	Total (n = 53)
Type of PAS – n (%)
Accreta (FIGO Grade 1)	20 (83.3)	22 (75.9)	42 (79.2)
Increta (FIGO Grade 2)	1 (4.2)	4 (13.8)	5 (9.4)
Percreta (FIGO Grade 3)	3 (12.5)	3 (10.3)	6 (11.3)
Grade 3a	2 (8.4)	1 (3.4)	3 (5.7)
Grade 3b	1 (4.2)	1 (3.4)	2 (3.8)
Grade 3c	0 (0)	1 (3.4)	1 (1.9)
Antenatal suspicion of PAS – n (%)	3 (12.5)	7 (24.1)	10 (18.9)
Intrapartum suspicion of PAS – n (%)	13 (54.2)	15 (51.7)	28 (52.8)
Gestational age at delivery, median (range)	38 (32–41)	38 (27–41)	38 (27–41)
Mode of delivery – n (%)
Cesarean section	13 (54.2)	18 (62.1)	31 (58.5)
Vaginal delivery	11 (45.8)	8 (27.6)	19 (36.5)
Birthweight in grams (mean)	2,926	2,732	2,772
Hysterectomy – n	4	9	13
Planned	1	7	8
Urgent (in the setting of PPH)	3	1^a a Hysterectomy performed after uterine rupture in the context of a second-trimester termination of pregnancy.	4
After intrapartum diagnosis of PAS disorder	0	1	1
Placement of catheters on common iliac arteries – n	1	7	8
Inflated – n	1	3	4

	SC group(n = 24)	MDT group (n = 29)	Total (n = 53)
Estimated blood loss in mL (mean, range)	2,469 (450–8,200)	1,250 (450–4,500)	1,807 (450–8,200)
Early maternal morbidity - n	6	11	17
ICU admission	4	2	6
Need for PRBC transfusion – n (%)	6 (25%)	11 (37.9%)	17 (32.1%)
Number of PRBC units (median, range)	7.5 (2–12)	2 (1–7)	5,5 (1–12)
Coagulopathy	2	0	2
Bladder injury	2	1	3
Ureteral injury	1	0	1
Early re-operation	2	0	2
Late maternal morbidity - n	2	1	3
Hospital re-admission	2	1	3
Delayed re-operation	1	1	2
Neonatal morbidity – n
NICU admission	5	7	12
5 minute Apgar score < 7	2	0	2

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[1] Address for correspondence Beatriz Teixeira, MD Alameda Prof. Hernâni Monteiro, 4200-319, Porto Portugal (e-mail: anabeatrizgteixeira@gmail.com; ana.beatriz.teixeira@chsj.min-saude.pt)