We appreciate Professor_'s comments regarding our paper 11 Nieto-Calvache AJ, Hidalgo A, Maya J, et al. Is there a place for family-centered cesarean delivery during placenta accreta spectrum treatment? Rev Bras Ginecol Obstet. 2022;44(10):925-929. Doi: 10.1055/s-0042-1751060
https://doi.org/10.1055/s-0042-1751060...
on family-centered birth for patients with placenta accreta spectrum (PAS):
• Who should be the companion during a family-centered PAS surgery?
• How to offer continuous support to the patient and her family after the surgery?
• How should risky information be delivered to the patient?
• What type of anesthesia is indicated in each case and how interdisciplinary management affects or is affected by the presence of a companion in the operating room?
Professor _____ points out several questions that go far
beyond the usual questions when facing PAS and we agree with him that experience is required to answer these questions, but above all, having overcome the basic problems that most reference hospitals are concerned with in regard to PAS (reduce bleeding and serious complications, prevent mortality and provide hospitals with the basic resources for optimal care).
Having overcome those "priority" problems, it is easier to think about offering the highest quality during the management of PAS, including key dimensions but generally overshadowed by the risk of dying, such as the psychological impact on the patient and her family, 22 Tol ID, Yousif M, Collins SL. Post traumatic stress disorder (PTSD): The psychological sequelae of abnormally invasive placenta (AIP). Placenta. 2019;81:42-45. Doi: 10.1016/j.placenta.2019.04.004
https://doi.org/10.1016/j.placenta.2019....
the decrease in care costs, fertility preservation, the opinion of the patients about losing her uterus 33 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(11):e052766. Doi: 10.1136/bmjopen-2021-052766
https://doi.org/10.1136/bmjopen-2021-052...
and humanization of birth.
Training in the management of PAS is difficult; multiple factors are required, including personal and group will, a hospital with a high flow of patients that supports the improvement, and the inclusion of quality policies such as self-assessment, research, and inter-institutional collaboration. Additionally, the support of other hospitals in the region is required, that choosing to transfer patients to the reference center instead of admitting with them and trying to solve the problem themselves.
Addressing the concept of "center of excellence" for PAS is almost impossible for hospitals in settings with limited resources. Requirements such as more than 5 years of experience, 100 patients (2-3 per month) treated and availability of many human and technological resources, 44 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(04): 841-850. Doi: 10.1097/GRF.0000000000000393
https://doi.org/10.1097/GRF.000000000000...
,55 Shamshirsaz AA, Fox KA, Erfani H, et al. Multidisciplinary team learning in the management of the morbidly adherent placenta: outcome improvements over time. Am J Obstet Gynecol. 2017; 216(06):612.e1-612.e5. Doi: 10.1016/j.ajog.2017.02.016
https://doi.org/10.1016/j.ajog.2017.02.0...
seem unattainable for most hospitals, 66 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(01):129-136. Doi: 10.1002/ijgo.13960
https://doi.org/10.1002/ijgo.13960...
at least in Latin America. 77 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(25):6104-6111. Doi: 10.1080/14767058.2021.1906858
https://doi.org/10.1080/14767058.2021.19...
In this context, joining efforts between hospitals in the same region is perhaps the only feasible strategy to improve the results of PAS management.
Most interdisciplinary groups choose to go through their " training curve" alone, without sharing their successes and failures with other groups, and even more serious, without being advised (and less supervised) by other groups with more experience. This is shown by the multiplicity of management options published, 88 Sentilhes L, Kayem G, Chandraharan E, Palacios-Jaraquemada J, Jauniaux EFIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Conservative management. Int J Gynaecol Obstet. 2018;140(03):291-298. Doi: 10.1002/ijgo.12410
https://doi.org/10.1002/ijgo.12410...
,99 Allen L, Jauniaux E, Hobson S, Papillon-Smith J, Belfort MAFIGO 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(03):281-290. Doi: 10.1002/ijgo.12409
https://doi.org/10.1002/ijgo.12409...
each one defended by the group that applies it, and the small number of multicenter prospective studies evaluating the same management strategy in different hospitals (which would require that at least one hospital gives in, and applies the surgical technique used in another hospital) or by comparing two different management strategies head-to-head (which implies that several hospitals apply at least two different surgical techniques, which requires training in the technique preferred by another group).
Our group has experienced the difficulties of the traditional individualistic approach. In our city (with 2.2 million inhabitants), there were 10 hospitals that considered themselves reference centers for PAS, operating around 3 cases per year, without sharing any type of information with the other hospitals. Additionally, there was no clear pathway of care for PAS in our country, nor education or research initiatives at the regional level. Considering the economic and cultural limitations of our region, we have invested time in evaluating the usefulness of sharing knowledge, 1010 Nieto-Calvache AJ, Palacios-Jaraquemada JM, Vergara-Galliadi LM, Nieto-Calvache AS, Zambrano MA, Burgos-Luna JM. Training facilitated by interinstitutional collaboration and telemedicine: an alternative for improving results in the placenta accreta spectrum. AJOG Glob Rep. 2021;1(04):100028. Doi: 10.1016/j.xagr.2021.100028
https://doi.org/10.1016/j.xagr.2021.1000...
with an emphasis on mistakes made, improvement opportunities 1111 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 (08):1445-1453. Doi: 10.1111/aogs.14163
https://doi.org/10.1111/aogs.14163...
and collaborative research. To our surprise, very inexpensive strategies such as informal telemedicine, 1212 Nieto-Calvache AJ, Palacios-Jaraquemada JM, Aguilera LR, et al. Telemedicine facilitates surgical training in placenta accreta spectrum. Int J Gynaecol Obstet. 2022;158(01):137-144. Doi: 10.1002/ijgo.14000
https://doi.org/10.1002/ijgo.14000...
virtual education and communication facilitated by free or low-cost platforms 1313 Nieto-Calvache AJ, Maya J, Vergara Galliadi LM, Nieto Calvache AS. Low-cost or free access virtual platforms utility in placenta accreta spectrum. AJOG Glob Rep. 2022;2(01):100048. Doi: 10.1016/j.xagr.2021.100048
https://doi.org/10.1016/j.xagr.2021.1000...
have had a positive impact on the diagnostic and therapeutic performance of various PAS teams.
Of course, our appreciations must be confirmed with additional studies, but we cannot stop emphasizing the importance of collaborative work to travel faster on the path to excellence and address elements such as patient preferences (choosing who accompanies her in elective surgery, deciding whether to preserve her uterus or her fertility in selected cases, etc.) and the family psychological impact of this serious diagnosis; without neglecting strategies to make the management of PAS increasingly safer.
References
-
1Nieto-Calvache AJ, Hidalgo A, Maya J, et al. Is there a place for family-centered cesarean delivery during placenta accreta spectrum treatment? Rev Bras Ginecol Obstet. 2022;44(10):925-929. Doi: 10.1055/s-0042-1751060
» https://doi.org/10.1055/s-0042-1751060 -
2Tol ID, Yousif M, Collins SL. Post traumatic stress disorder (PTSD): The psychological sequelae of abnormally invasive placenta (AIP). Placenta. 2019;81:42-45. Doi: 10.1016/j.placenta.2019.04.004
» https://doi.org/10.1016/j.placenta.2019.04.004 -
3Einerson 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(11):e052766. Doi: 10.1136/bmjopen-2021-052766
» https://doi.org/10.1136/bmjopen-2021-052766 -
4Shamshirsaz 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(04): 841-850. Doi: 10.1097/GRF.0000000000000393
» https://doi.org/10.1097/GRF.0000000000000393 -
5Shamshirsaz AA, Fox KA, Erfani H, et al. Multidisciplinary team learning in the management of the morbidly adherent placenta: outcome improvements over time. Am J Obstet Gynecol. 2017; 216(06):612.e1-612.e5. Doi: 10.1016/j.ajog.2017.02.016
» https://doi.org/10.1016/j.ajog.2017.02.016 -
6Brown 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(01):129-136. Doi: 10.1002/ijgo.13960
» https://doi.org/10.1002/ijgo.13960 -
7Nieto-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(25):6104-6111. Doi: 10.1080/14767058.2021.1906858
» https://doi.org/10.1080/14767058.2021.1906858 -
8Sentilhes L, Kayem G, Chandraharan E, Palacios-Jaraquemada J, Jauniaux EFIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Conservative management. Int J Gynaecol Obstet. 2018;140(03):291-298. Doi: 10.1002/ijgo.12410
» https://doi.org/10.1002/ijgo.12410 -
9Allen L, Jauniaux E, Hobson S, Papillon-Smith J, Belfort MAFIGO 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(03):281-290. Doi: 10.1002/ijgo.12409
» https://doi.org/10.1002/ijgo.12409 -
10Nieto-Calvache AJ, Palacios-Jaraquemada JM, Vergara-Galliadi LM, Nieto-Calvache AS, Zambrano MA, Burgos-Luna JM. Training facilitated by interinstitutional collaboration and telemedicine: an alternative for improving results in the placenta accreta spectrum. AJOG Glob Rep. 2021;1(04):100028. Doi: 10.1016/j.xagr.2021.100028
» https://doi.org/10.1016/j.xagr.2021.100028 -
11Nieto-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 (08):1445-1453. Doi: 10.1111/aogs.14163
» https://doi.org/10.1111/aogs.14163 -
12Nieto-Calvache AJ, Palacios-Jaraquemada JM, Aguilera LR, et al. Telemedicine facilitates surgical training in placenta accreta spectrum. Int J Gynaecol Obstet. 2022;158(01):137-144. Doi: 10.1002/ijgo.14000
» https://doi.org/10.1002/ijgo.14000 -
13Nieto-Calvache AJ, Maya J, Vergara Galliadi LM, Nieto Calvache AS. Low-cost or free access virtual platforms utility in placenta accreta spectrum. AJOG Glob Rep. 2022;2(01):100048. Doi: 10.1016/j.xagr.2021.100048
» https://doi.org/10.1016/j.xagr.2021.100048
Publication Dates
-
Publication in this collection
07 Aug 2023 -
Date of issue
May 2023