Keywords
morbidly adherent placenta - cesarean hysterectomy - placenta accreta
Morbidly adherent placentation is associated with increased maternal morbidity and
mortality.[1]
[2] Adverse outcomes are generally related to the associated extensive blood loss and
include disseminated intravascular coagulation, multiorgan failure, prolonged hospitalization,
and death.[1]
[2] Unfortunately, the rates of morbidly adherent placentation continue to rise, in
part due to increased rates of cesarean delivery (CD).[3]
In recent years, there have been mounting evidence supporting the benefits of a standardized
multidisciplinary approach at tertiary teaching hospitals.[4]
[5] Indeed, reports from academic centers in Utah and Texas have reinforced the value
of this approach.[4]
[5] Although ideal in theory, travel to, and delivery at large tertiary teaching institutions
by the parturient facing morbidly adherent placentation if often hampered by numerous
barriers (e.g., socioeconomic, geographic). In hopes of demonstrating the utility
and feasibility of a multidisciplinary program to motived obstetric private practitioners,
our objective was to estimate the impact of the implementation of a similar program
at a high-volume private community hospital.
Materials and Methods
In this retrospective cohort study, we evaluated maternal outcomes in all cases of
histopathologically confirmed morbidly adherent placentation with delivery at St.
David's Women's Center of Texas (Austin, TX) during a 4-year period (2012–2016). Approval
from Institutional Review Board was obtained prior to data collection.
Our multidisciplinary program was implemented in 2012 and includes a standardized
management plan for all cases of known or suspected morbidly adherent placentation.
Patients are routinely admitted at the 33rd week of the pregnancy (unless presenting
earlier with obstetrical complications necessitating admission) to the antepartum
unit under their primary obstetrician's service for planned delivery and cesarean
hysterectomy at the 34th week of the pregnancy. In cases (including transports) where
the primary obstetrician is not a staff at our institution, the patient is admitted
under the obstetrical hospitalist service. All patients are followed by the maternal–fetal
medicine service, who coordinate the overall plan of care. The patient's dedicated
care team included the patient's obstetrician or obstetric hospitalist, dedicated
nursing core with critical care training (readily available given the presence of
dedicated critical care beds and service on our obstetric unit), as well as a consulting
private practitioner team consisting of gynecologic oncology, anesthesiology, urology,
and neonatology. Although consulted on only select cases, interventional radiology
is made aware of every case on admission. Furthermore, all pending morbidly adherent
placentation cases are reviewed at our institutional multidisciplinary perinatal care
conference.
In the majority of cases (when deemed feasible), the patients underwent regional anesthesia
to minimize fetal exposure, and general endotracheal intubation was used after delivery
of the fetus. Large bore intravenous access along with an arterial line was obtained
in all cases. Patients were placed in lithotomy position with legs in stirrups to
allow access for a third surgeon and assessment of vaginal bleeding. The surgical
team included the patient's primary obstetrician (or hospitalist in case of transfer
of care), maternal–fetal medicine specialist, and a gynecologic oncologist. Other
subspecialists (i.e., urology) attended as needed. Abdominal entry was made through
a periumbilical midline incision, and delivery completed via an incision where the
placenta could be avoided. Placental removal was not attempted, and the hysterotomy
was closed to minimize overall blood loss. The technique of the hysterectomy (including
need for use of electrocautery) was left to the discretion of the cosurgeons. Ureteral
stents were placed in the majority of the cases; however, decision to place intravascular
balloons by interventional radiology were individualized and based on multidisciplinary
discuss of each case. Intraoperative fluid resuscitation including blood component
therapy was dictated by maternal–fetal medicine and anesthesiology.
The medical records were reviewed, and data abstracted into Microsoft Access. The
variables of interest included maternal age, gestational age at delivery, gravidity,
parity, number of prior CDs, date of last CD, type of anesthesia, estimated blood
loss, amount of blood products transfused (including packed red blood cells [PRBC],
fresh-frozen plasma, and cryoprecipitate), amount of crystalloids infused, pre- and
postoperative hemoglobin value, anesthesia time, intentional or incidental damage
to bladder, damage to ureter or bowel, neonatal birth weight, postoperative length
of stay, and readmission or reoperation. Our data were compared with the previously
published outcomes of two large cohorts from tertiary teaching hospitals in Utah and
Texas.[4]
[5] With respect to the latter group, our data were compared with their multidisciplinary
group's data. Patient characteristics were compared with the use of descriptive statistics.
Median statistics for variables reported in both Utah and Texas studies[4]
[5] were first converted to mean statistics using the formula demonstrated by Hozo et
al.[6] Once converted, mean statistics for variables in each group were compared using
multiple t-tests. A probability value < 0.05 was considered significant. Analysis was performed
using SPSS (version 20; SPSS Inc., Chicago, IL).
Results
Patient demographics and clinical characteristics are presented in [Table 1]. The comparison groups were similar with respect to maternal age and number of prior
cesareans. Seven patients (25%) did not have a prior CD. Of these, four had a prior
myomectomy, two had prior intrauterine surgery as part of their infertility evaluation
(septal resection and myomectomy), and one reported a dilation and curettage.
Table 1
Patient demographics and clinical characteristics
|
Group 1
(Austin, n = 28)
|
Group 2
(Utah, n = 79)
|
Group 3
(Texas, n = 57)
|
p-Value
(1 vs. 2)
|
p-Value
(1 vs. 3)
|
|
Age (y)
|
35 (22–46)
|
32 (20–44)
|
33 (24–45)
|
0.42
|
0.82
|
|
Gestational age at delivery (wk)
|
34 (26–39)
|
34 (17–41)
|
34 (16–39)
|
0.05
|
0.01
|
|
Gravidity
|
4 (2–9)
|
5 (2–13)
|
4 (1–14)
|
0.02
|
0.17
|
|
Parity
|
2 (1–5)
|
3 (0–11)
|
3 (0–12)
|
0.01
|
0.07
|
|
Prior cesarean delivery
|
21 (75%)
|
72 (91%)
|
51 (93%)
|
0.96
|
0.97
|
|
Number of prior cesarean deliveries
|
|
0
|
4 (14%)
|
7 (9%)
|
4 (7%)
|
0.47
|
0.43
|
|
1
|
6 (21%)
|
26 (33%)
|
12 (21%)
|
0.34
|
0.16
|
|
2
|
7 (25%)
|
19 (24%)
|
24 (42%)
|
0.99
|
0.15
|
|
3 or more
|
8 (29%)
|
27 (34%)
|
17 (30%)
|
0.65
|
0.99
|
Note: Group 1, index study group from our center; Group 2, published data of multidisciplinary
group in Utah; and Group 3, published data of multidisciplinary group in Texas. Data
presented as median (range), n (%) unless otherwise specified.
Operative characteristics and patient outcomes are presented in [Table 2]. In the 28 cases included for evaluation, our group's median estimated blood loss
(2.1 L), median PRBC transfused (4 units), cases requiring > 4 units of PRBC (60%),
median anesthesia time (240 minutes), median length of stay (5 days), or rates of
maternal morbidity (including bladder or bowel injury) or reoperation did not statistically
differ from the published Utah or Texas data. There were no maternal deaths in our
cohort.
Table 2
Operative characteristics and patient outcomes
|
Group 1
(Austin, n = 28)
|
Group 2
(Utah, n = 79)
|
Group 3
(Texas, n = 57)
|
p-Value
(1 vs. 2)
|
p-Value
(1 vs. 3)
|
|
Estimated blood loss (L)
|
3 (0.75–21)
|
2 (0.15–10)
|
2.1 (0.5–18)
|
0.08
|
0.27
|
|
PRBC units transfused
|
4 (0–23)
|
Not reported
|
4 (0–23)
|
–
|
0.17
|
|
More than 4 PRBC units transfused
|
17 (61%)
|
34 (43%)
|
37 (65%)
|
0.05
|
0.65
|
|
Crystalloids infused (L)
|
6 (2–10)
|
Not reported
|
4 (1–16)
|
–
|
0.98
|
|
Hemoglobin decrease (mg/dL)
|
1.1 (−4.6 to 5.5)
|
Not reported
|
0.15 (−2.5 to 5.2)
|
–
|
0.90
|
|
Anesthesia time (min)
|
243 (63–450)
|
Not reported
|
287 (74–608)
|
–
|
0.06
|
|
Bowel injury
|
1 (3%)
|
Not reported
|
1 (2%)
|
–
|
0.35
|
|
Ureteral injury
|
5 (17%)
|
5 (6%)
|
1 (2%)
|
0.69
|
0.02
|
|
Birth weight (g)
|
2,665 (2,020–3,543)
|
Not reported
|
2,400 (800–3,900)
|
–
|
0.17
|
|
Length of stay (d)
|
5 (3–12)
|
5 (3–13)
|
4 (2–12)
|
0.17
|
0.80
|
|
Reoperation rate
|
2 (7%)
|
2 (3%)
|
3 (5%)
|
0.21
|
0.35
|
Abbreviation: PRBC, packed red blood cells.
Note: Group 1, index study group from our center; Group 2, published data of multidisciplinary
group in Utah; and Group 3, published data of multidisciplinary group in Texas. Data
presented as median (range), n (%) unless otherwise specified.
Discussion
Morbidly adherent placentation is associated with increased morbidity and requires
an increased level of attention from obstetric providers. Recent reports from Utah
and Texas by Eller et al and Shamshirsaz et al, respectively, have demonstrated the
value of a standardized multidisciplinary approach to improve outcomes when dealing
with this vexing obstetrical problem.[4]
[5] However, as mentioned earlier, there are numerous barriers which may preclude a
patient from being cared for at a large tertiary academic/teaching center; therefore,
focus must be placed on implementing such models of care in the community setting.
Our data demonstrate that implementation of a multidisciplinary morbidly adherent
placentation program in the private practice–community hospital setting is feasible
with outcomes similar to those at tertiary teaching hospitals.
In designing this study, we purposely chose to compare our outcomes to two different
studies, as each held a different value to us. In the report by Eller et al, the comparison
group was rather heterogeneous considering it included several community hospitals,
and left some to conclude that the variables may have biased the results toward a
more favorable one for the multidisciplinary group.[5] Our outcomes (from a community program) indeed supports their conclusion that such
an approach is effective, and that their results were not biased. In the report by
Shamshirsaz et al, the authors employed an aggressive and contemporary approach to
morbidly adherent placentation in a resource rich, large academic center, which should
serve a benchmark for other programs to use when implementing such a program.[4] Indeed, we utilize many of their approaches (except for the described modified radical
hysterectomy), and reassuringly, our data demonstrated similar outcomes in our cohort.
Our higher rate of ureteral injury may be due to the standard absence of their reported
radical hysterectomy approach, and accordingly, we have now implemented this into
our program.
Our study has some limits, which merit discussion. Our sample size was relatively
small compared with the larger published series by Eller et al and Shamshirsaz et
al; therefore, drawing any meaningful conclusion about the less frequent complications
or variables was precluded. Furthermore, the retrospective nature of the study precluded
our ability to capture some other variables of interest including body mass index,
which invariably impacts operative outcomes.
Despite these limitations, our data support the value and utility of a multidisciplinary
morbidly adherent placentation program in the private practice/community hospital.
Implementation of such program may prove beneficial in remote centers, where various
factors may prohibit patient travel to a larger center.
