Consenso Colombiano de Tratamiento del Espectro de Acretismo Placentario (EAP) / Colombian Consensus on the Treatment of Placenta Accreta Spectrum (PAS)

RESUMEN Introducción: el espectro de acretismo placentario (EAP) es una condición asociada a sangrado masivo posparto y mortalidad materna. Las guías de manejo publicadas en países de altos ingresos recomiendan la participación de grupos interdisciplinarios en hospitales con recursos suficientes para realizar procedimientos complejos. Sin embargo, algunas de las recomendaciones de estas guías resultan difíciles de aplicar en países de bajos y medianos ingresos. Objetivos: este consenso busca formular recomendaciones generales para el tratamiento del EAP en Colombia. Materiales y métodos: en el consenso participaron 23 panelistas, quienes respondieron 31 preguntas sobre el tratamiento de EAP. Los panelistas fueron seleccionados con base en la participación en dos encuestas realizadas para determinar la capacidad resolutiva de hospitales en el país y la región. Se utilizó la metodología Delphi modificada, incorporando dos rondas sucesivas de discusión. Para emitir las recomendaciones el grupo tomó en cuenta la opinión de los participantes, que lograron un consenso mayor al 80 %, así como las barreras y los facilitadores para su implementación. Resultados: el consenso formuló cinco recomendaciones integrando las respuestas de los panelistas. Recomendación 1. Las instituciones de atención primaria deben realizar búsqueda activa de EAP en pacientes con factores de riesgo: placenta previa e historia de miomectomía o cesárea en embarazo previo. En caso de haber signos sugestivos de EAP por ecografía, las pacientes deben ser remitidas de manera inmediata, sin tener una edad gestacional mínima, a hospitales reconocidos como centros de referencia. Las modalidades virtuales de comunicación y atención en salud pueden facilitar la interacción entre las instituciones de atención primaria y los centros de referencia para EAP. Se debe evaluar el beneficio y riesgo de las modalidades de telemedicina. Recomendación 2. Es necesario que se definan hospitales de referencia para EAP en cada región de Colombia, asegurando el cubrimiento de la totalidad del territorio nacional. Es aconsejable concentrar el flujo de pacientes afectadas por esta condición en unos pocos hospitales, donde haya equipos de cirujanos con entrenamiento específico en EAP, disponibilidad de recursos especializados y un esfuerzo institucional por mejorar la calidad de atención, en busca de tener mejores resultados en la salud de las gestantes con esta condición. Para lograr ese objetivo los participantes recomiendan que los entes reguladores de la prestación de servicios de salud a nivel nacional, regional o local vigilen el proceso de remisión de estas pacientes, facilitando rutas administrativas en caso de que no exista contrato previo entre el asegurador y el hospital o la clínica seleccionada (IPS). Recomendación 3. En los centros de referencia para pacientes con EAP se invita a la creación de equipos que incorporen un grupo fijo de especialistas (obstetras, urólogos, cirujanos generales, radiólogos intervencionistas) encargados de atender todos los casos de EAP. Es recomendable que esos grupos interdisciplinarios utilicen el modelo de "paquete de intervención" como guía para la preparación de los centros de referencia para EAP. Este modelo consta de las siguientes actividades: preparación de los servicios, prevención e identificación de la enfermedad, respuesta ante la presentación de la enfermedad, aprendizaje luego de cada evento. La telemedicina facilita el tratamiento de EAP y debe ser tenida en cuenta por los grupos interdisciplinarios que atienden esta enfermedad. Recomendación 4. Los residentes de Obstetricia deben recibir instrucción en maniobras útiles para la prevención y el tratamiento del sangrado intraoperatorio masivo por placenta previa y EAP, tales como: la compresión manual de la aorta, el torniquete uterino, el empaquetamiento pélvico, el bypass retrovesical y la maniobra de Ward. Los conceptos básicos de diagnóstico y tratamiento de EAP deben incluirse en los programas de especialización en Ginecología y Obstetricia en Colombia. En los centros de referencia del EAP se deben ofrecer programas de entrenamiento a los profesionales interesados en mejorar sus competencias en EAP de manera presencial y virtual. Además, deben ofrecer soporte asistencial remoto (telemedicina) permanente a los demás hospitales en su región, en relación con pacientes con esa enfermedad. Recomendación 5. La finalización de la gestación en pacientes con sospecha de EAP y placenta previa, por imágenes diagnósticas, sin evidencia de sangrado vaginal activo, debe llevarse a cabo entre las semanas 34 y 36 6/7. El tratamiento quirúrgico debe incluir intervenciones secuenciales que pueden variar según las características de la lesión, la situación clínica de la paciente y los recursos disponibles. Las opciones quirúrgicas (histerectomía total y subtotal, manejo quirúrgico conservador en un paso y manejo expectante) deben incluirse en un protocolo conocido por todo el equipo interdisciplinario. En escenarios sin diagnóstico anteparto, es decir, ante un hallazgo intraoperatorio de EAP (evidencia de abultamiento violáceo o neovascularización de la cara anterior del útero), y con participación de personal no entrenado, se plantean tres situaciones: Primera opción: en ausencia de indicación de nacimiento inmediato o sangrado vaginal, se recomienda diferir la cesárea (cerrar la laparotomía antes de incidir el útero) hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura. Segunda opción: ante indicación de nacimiento inmediato (por ejemplo, estado fetal no tranquilizador), pero sin sangrado vaginal o indicación de manejo inmediato de EAP, se sugiere realizar manejo en dos tiempos: se realiza la cesárea evitando incidir la placenta, seguida de histerorrafia y cierre de abdomen, hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura. Tercera opción: en presencia de sangrado vaginal que hace imposible diferir el manejo definitivo de EAP, es necesario extraer el feto por el fondo del útero, realizar la histerorrafia y reevaluar. En ocasiones, el nacimiento del feto disminuye el flujo placentario y el sangrado vaginal se reduce o desaparece, lo que hace posible diferir el manejo definitivo de EAP. Si el sangrado significativo persiste, es necesario continuar con la histerectomía haciendo uso de los recursos disponibles: compresión manual de la aorta, llamado inmediato a los cirujanos con mejor entrenamiento disponible, soporte de grupos expertos de otros hospitales a través de telemedicina. Si una paciente con factores de riesgo para EAP (por ejemplo, miomectomía o cesárea previa) presenta retención de placenta posterior al parto vaginal, es recomendable confirmar la posibilidad de dicho diagnóstico (por ejemplo, realizando una ecografía) antes de intentar la extracción manual de la placenta. Conclusiones: esperamos que este primer consenso colombiano de EAP sirva como base para discusiones adicionales y trabajos colaborativos que mejoren los resultados clínicos de las mujeres afectadas por esta enfermedad. Evaluar la aplicabilidad y efectividad de las recomendaciones emitidas requerirá investigaciones adicionales.

ABSTRACT Introduction: Placenta accreta spectrum (PAS) is a condition associated with massive postpartum bleeding and maternal mortality. Management guidelines published in high income countries recommend the participation of interdisciplinary teams in hospitals with sufficient resources for performing complex procedures. However, some of the recommendations contained in those guidelines are difficult to implement in low and medium income countries. Objectives: The aim of this consensus is to draft general recommendations for the treatment of PAS in Colombia Materials and Methods: Twenty-three panelists took part in the consensus with their answers to 31 questions related to the treatment of PAS. The panelists were selected based on participation in two surveys designed to determine the resolution capabilities of national and regional hospitals. The modified Delphi methodology was used, introducing two successive discussion rounds. The opinions of the participants, with a consensus of more than 80 %, as well as implementation barriers and facilitators, were taken into consideration in order to issue the recommendations. Results: The consensus drafted five recommendations, integrating the answers of the panelists. Recommendation 1. Primary care institutions must undertake active search of PAS in patients with risk factors: placenta praevia and history of myomectomy or previous cesarean section. In case of ultrasound signs suggesting PAS, patients must be immediately referred, without a minimum gestational age, to hospitals recognized as referral centers. Online communication and care modalities may facilitate the interaction between primary care institutions and referral centers for PAS. The risks and benefits of telemedicine modalities must be weighed. Recommendation 2. Referral hospitals for PAS need to be defined in each region of Colombia, ensuring coverage throughout the national territory. It is advisable to concentrate the flow of patients affected by this condition in a few hospitals with surgical teams specifically trained in PAS, availability of specialized resources, and institutional efforts at improving quality of care with the aim of achieving better health outcomes in pregnant women with this condition. To achieve this goal, participants recommend that healthcare regulatory agencies at a national and regional level should oversee the process of referral for these patients, expediting administrative pathways in those cases in which there is no prior agreement between the insurer and the selected hospital or clinic. Recommendation 3. Referral centers for patients with PAS are urged to build teams consisting of a fixed group of specialists (obstetricians, urologists, general surgeons, interventional radiologists) entrusted with the care of all PAS cases. It is advisable for these interdisciplinary teams to use the "intervention bundle" model as a guidance for building PAS referral centers. This model comprises the following activities: service preparedness, disease prevention and identification, response to the occurrence of the disease, and debriefing after every event. Telemedicine facilitates PAS treatment and should be taken into consideration by interdisciplinary teams caring for this disease. Recommendation 4. Obstetrics residents must be instructed in the performance of maneuvers that are useful for the prevention and treatment of massive intraoperative bleeding due to placenta praevia and PAS, including manual aortic compression, uterine tourniquet, pelvic packing, retrovesical bypass, and Ward maneuver. Specialization Obstetrics and Gynecology programs in Colombia must include the basic concepts of the diagnosis and treatment of PAS. Referral centers for PAS must offer online and in-person training programs for professionals interested in improving their competencies in PAS. Moreover, they must offer permanent remote support (telemedicine) to other hospitals in their region for patients with this condition. Recommendation 5. Patients suspected of having PAS and placenta praevia based on imaging, with no evidence of active vaginal bleeding, must be delivered between weeks 34 and 36 6/7. Surgical treatment must include sequential interventions that may vary depending on the characteristics of the lesion, the clinical condition of the patient and the availability of resources. The surgical options (total and subtotal hysterectomy, one-stage conservative surgical management and watchful waiting) must be included in a protocol known by the entire interdisciplinary team. In situations in which an antepartum diagnosis is lacking, that is to say, in the face of intraoperative finding of PAS (evidence of purple bulging or neovascularization of the anterior aspect of the uterus), and the participation of untrained personnel, three options are considered: Option 1: In the absence of indication of immediate delivery or of vaginal delivery, the recommendation is to postpone the cesarean section (close the laparotomy before incising the uterus) until the recommended resources for safe surgery are secured. Option 2: If there is an indication for immediate delivery (e.g., non-reassuring fetal status) but there is absence of vaginal bleeding or indication for immediate PAS management, a two-stage management is suggested: cesarean section avoiding placental incision, followed by uterine repair and abdominal closure, until the availability of the recommended resources for safe surgery is ascertained. Option 3: In the event of vaginal bleeding that prevents definitive PAS management, the fetus must be delivered through the uterine fundus, followed by uterine repair and reassessment of the situation. Sometimes, fetal delivery diminishes placental flow and vaginal bleeding is reduced or disappears, enabling the possibility to postpone definitive management of PAS. In case of persistent significant bleeding, hysterectomy should be performed, using all available resources: manual aortic compression, immediate call to the surgeons with the best available training, telemedicine support from expert teams in other hospitals. If a patient with risk factors for PAS (e.g., myomectomy or previous cesarean section) has a retained placenta after vaginal delivery, it is advisable to confirm the possibility of such diagnosis (by means of ultrasound, for example) before proceeding to manual extraction of the placenta. Conclusions: It is our hope that this first Colombian consensus on PAS will serve as a basis for additional discussions and collaborations that can result in improved clinical outcomes for women affected by this condition. Additional research will be required in order to evaluate the applicability and effectiveness of these recommendations.

Evaluation of protocol of management of morbidly adherent placenta in maternity Zagazig university hospital

Background: Morbidly adherent placenta (MAP) defines the abnormal adherence of the placenta to the underlying uterine wall. It has a rising incidence world-wide. The risk of placental abnormalities increases in the presence of uterine scars due to cesarean delivery or gynecologic procedures. It may lead to massive obstetric hemorrhage resulting in serious complications such as DIC, transfusion related complications. Aim: Evaluation of protocol of management of patients with morbidly adherent placenta at Maternity Zagazig University Hospital and its effect on pregnancy outcome to find the best method of management to decrease associated morbidity and mortality.Patients and methods: This cohort study conducted on 120 patients diagnosed as having morbidly adherent placenta and were admitted to Zagazig University Hospitals.Results: In our study there were 48 cases (40%) managed by CS only and 72 cases (60%) managed by hysterectomy.Conclusion: well-planned caesarean hysterectomy with placenta left in situ adopting multidisciplinary approach is the recommended management option for MAP

Percretismo placentario: manejo con oclusión de arterias ilíacas internas, embolización de arterias uterinas y oclusión de arterias ilíacas comunes / Placenta previa percreta: handling with occlusion of internal iliac artery, uterine artery embolization and occlusion of common iliac arteries

Presentamos el caso de una embarazada con placenta ístmica, percreta, previa central, con extensas anastomosis vasculares y flujo de alta velocidad. En la resolución mediante cesárea-histerectomía, para prevenir la hemorragia intraoperatoria, se utilizó una intervención radiológica en secuencia de oclusión temporal de las ilíacas internas, embolización de las arterias uterinas, reposicionamiento e insuflación de balones en ilíacas comunes. Se logró mantener estabilidad hemodinámica y el control del sangrado; estando ocluida la circulación uterina hubo pérdidas moderadas en la parte final de la operación. Se discuten la característica poco común de la implantación y percretismo ístmico, y el beneficio del uso combinado de la oclusión vascular con la cirugía expedita para minimizar el riesgo materno.

We present a patient with placenta previa percreta and oclusive. It had extensive vascular anastomosis with high velocity flow, in which resolution by cesarean-hysterectomy was done for bleeding control and followed by temporal occlusion of iliac arteries, embolization of uterine arteries, reposition and insuflation of balloons in common iliac arteries. The patient was stable and moderated bleeding happened to the end of intervention when the uterine arterial circulation was occluded. We discuss the uncommon of isthmic implantation and percretism and the benefits of both vascular occlusion and expedite surgery for to minimize maternal compromise or damage.

Fertility sparing surgery on placenta invasion anomalies and placenta previa

Abnormal placental invasion has increased parallel with persistent rise in Caesarean delivery. Management relies on accurate diagnosis and delivery should be planned at an institution with appropriate expertise and resources for managing this condition. We present a case of a placenta invasion anomaly which is the major risk factors of peripartum deaths. In this case we try to explain our approach which reduces unnecessary hysterectomy rates. In order to avoid postpartum hemorrhage and hysterectomy protocols, our approach which consists bilateral hypogastric arterial ligation, Bakri balloon tamponade and if necessary methotrexate therapy can be applied successfully

Impact of antenatal diagnosis and management strategies in morbidity adherent placenta

To study the pattern, demography and management options in placenta accreta in a tertiary care centre. 1st January 2004 to 15 August 2008 at Military Hospital, Rawalpindi and between 1[st] Sep 2008 to 30[th] Oct 2009 at Combined Military Hospital, Multan. All cases of placenta accreta seen during the study period were included in the study. Placenta accreta was defined as placenta being adherent to uterine wall without easy separation. Patient's demography, presence or absence of prenatal diagnosis and the management strategy i.e. conservative or otherwise was documented on a proforma. Success or failure of surgical approach used was noted. Assessment of maternal morbidity in the form of amount of blood/blood product transfused and early and late complications was made and compared with other cases that were antenatally diagnosed or were undiagnosed. A total of 28 cases were analyzed during study period. The incidence of placenta accreta was 6.3/10000. Mean maternal age was 30.7 years. Placenta praevia obstetrical hysterectomy was performed in 17 [61%] cases and had to be backed up by internal iliac artery ligation in 7[25%] Requirement for blood transfusion in antenatally diagnosed cases was almost 50% less than those of undiagnosed cases and the same was true for fresh frozen plasma [3.75 +/- 4.18 versus 6.75 +/- 5.41], platelet transfusion [P=0.04], stay in intensive care unit [1.56 +/- 1.82 versus 3.41 +/- 3.28] and use of mechanical ventilation [7% versus 11%]. There was no mortality in this series. Intra-operative internal iliac artery ligation reduces blood loss before and after hysterectomy and should be done in cases with placents accreta to reduce morbidity and mortality

Placenta acreta / Placenta accreta

A implantação anormal da placenta na parede uterina configura a placenta acreta e é causa importante de morbimortalidade materna, devido ao grande risco de hemorragias.O diagnóstico pré-natal, sobretudo com ultrassonografia, é ideal porque permiteplanejar individualmente a conduta. Na maioria das vezes, entretanto, é feito no periparto, dificultando sua abordagem adequada. O tratamento pode ser conservador com o uso do metrotexato ou embolização das artérias uterinas, sendo realizado, em geral, pela remoção cirúrgica da placenta ou histerectomia.

Placenta accreta is a severe complication involving an abnormally deep attachment of the, through the and into the, and it is a important cause of maternal morbimortality, due the great risk of. The prenatal diagnosis, mainly through US, is the ideal, because a individual conduct can be done. But it is rarely recognised before birth, what dificults the treatment of this complication. The treatment can be conservative with methotrexato use or uterine artery embolization but, commonly requires, with the placenta resection or hysterectomy.

Conceito, diagnóstico e tratamento de placenta prévia acreta com invasão de bexiga: revisão sistemática da literatura / Concept, diagnosis and treatment of placenta previa accreta with urinary bladder invasion: systematic revision of literature

A placenta prévia consiste na implantação placentária no segmento inferior, distando no máximo 7 cm do colo do útero. Ao aderir-se diretamente ao miométrio, denomina-se placenta acreta; ao estender-se mais profundamente, placenta increta, e ao invadir a serosa uterina ou órgãos adjacentes, percreta. A incidência de placenta prévia varia de 0,3 a 1,7%, e a incidência do acretismo varia de 1:540 a 1:93.000 partos. Essa com acretismo é relacionada à alta morbimortalidade materna e, maior necessidade de terapêutica transfusional; a complicações durante a cesárea e à infecção. O acretismo é diagnosticado por ultrassom, ressonância magnética e, ultrassom com Doppler. A adequada detecção do acretismo permitirá o planejamento da via de parto e das medidas de segurança, com consequente redução da mortalidade materna. Feito o diagnóstico antenatal de acretismo placentário e invasão da bexiga, a conduta será a cesárea eletiva às 35 semanas com posterior histerectomia total abdominal, sempre com necessidade de uma equipe multidisciplinar (anestesistas, obstetras, cirurgião vascular intervencionista e urologista)

The placenta previa consists of a placental implantation in the inferior segment, distant at the most 7 cm of the cervix uteri. When adhering directly to the myometrium, it is called placenta accreta; when extending more deeply, increta and when invading the uterine's serous or even adjacent organs, the percreta. The placenta previa incidence varies from 0,3 to 1,7%, and the accretism from 1:540 to 1:93.000 childbirths. The placenta previa accreta is associated with high maternal morbidity and mortality, need of blood transfusion, complications during cesarean section and infection. The accretism is diagnosed by ultrasound, magnetic resonance and, ultrasound with Doppler. The appropriate detection of the accretism will allow the childbirth planning and safety's measures, with consequent reduction of maternal mortality. When the antenatal diagnosis of placenta accreta and invasion of the bladder are made, the conduct will be the elective cesarean section to the 35 weeks with subsequent abdominal total hysterectomy, with the aid of a team (anesthetists, obstetricians, surgeon vascular and urologist)

unusual presentation of placenta percreta

Morbidly adherent placenta is a rare clinical condition resulting from abnormally invasive implantation of the placenta into the uterine substance and potentially into the surrounding organs [percreta]. We report a case of invasive placentation extending through the uterine wall into the bladder and causing primary and recurrent secondary postpartum hemorrhage. It is emphasized that to avoid catastrophic complications, efforts to reach an early antenatal diagnosis should be made through various imaging modalities available in patients with a history of lower segment caesarean section

Actualidad en el diagnóstico y manejo del acretismo placentario / Update on the diagnosis and treatment of placenta accreta

El acretismo placentario es una entidad que incrementa considerablemente la morbimortalidad materna y fetal. Gracias al advenimiento de nuevos métodos diagnósticos como la resonancia magnética, la cistoscopia, los marcadores séricos, el ultrasonido doppler, etc., el diagnóstico prenatal es factible. El manejo del acretismo placentario de forma tradicional supone la realización de histerectomía multidisciplinaria, involucrando a cirujanos generales, oncoginecólogos o uroginecólogos. Algunos autores han propuesto al manejo conservador como una solución adecuada en ciertos casos, ya sea con el uso de diversos medicamentos que incluyen quimioterápicos o bien de forma expectante. Sin embargo, aún no existe evidencia sólida que determine si el manejo conservador o tradicional es el mejor.

Placenta accreta supposes a special situation that increases the fetal and maternal mo rb i mortality of considerable form. Thanks all new arrival methods as the image of magnetic resonance, the cystoscopy, serum markers, doppler ultrasound, etc., the prenatal diagnostic is feasible. The management of placenta accreta of traditional form supposes a multidisciplinary approach form hysterectomy execution, involving general surgeons, oncogynecologist or urogynecologist. Some authors have proposed the conservative management as an adequate solution in certain cases, whether with the use of several drugs including chemotherapy or expectant form. Nevertheless, not yet solid evidence exists if the surgical traditional approach or the conservative management is the best option.

Manejo exitoso de la hemorragia postparto por acretismo placentario mediante tamponamiento con balón de Bakri / Treatment of postpartum haemorrhage due to placenta accreta with Bakri balloon

Antecedentes: La hemorragia del postparto es una de las complicaciones de mayor morbimortalidad materna. Objetivo: Comunicar el uso exitoso del balón de Bakri en un caso de metrorragia del postparto. Metodología: Se presenta el dispositivo utilizado. Resultado: Control eficiente de la metrorragia postparto por acretismo placentario mediante el uso del balón de Bakri, que permitió conservar el útero. Conclusión: El balón de Bakri es una alternativa no quirúrgica para el control de la hemorragia del postparto.

aftermath of scarred uterus: placenta praevia accreta of different grades

There is a well-known association between repeated cesarean sections and placenta praevia accreta. Bladder invasion is a rare, advanced grade of this type of placenta that represents a tremendous hazard to both the mother and fetus. Two patients with placenta praevia accreta are reported here as well as general statistics of the incidence of placenta accreta at Kuwait's Maternity Hospital. One case, managed conservatively, had a good outcome, while the other case with placenta percreta invading the bladder died. Also included is a review of the literature with special emphasis on antenatal diagnosis, intra-operative and postoperative management. The treatment of such cases, varying from a conservative approach to a radical approach, is guided by the severity of placental involvement, the grade of placental invasion, and the clinical experience of the surgeon. In either approach, the aim is to control bleeding and maintain continuous support to the quickly depleting intravascular volume secondary to the profuse hemorrhage

Acretismo placentario: estudio realizado durante los años 1980-1986 en el Hospital Maternidad de Lima / Placenta accreta: study during 1980-1986 in the Hospital Maternidad de Lima

Se revisaron 41 casos de acretismo placentario en el Hospital Maternidad de Lima durante los años 1980-1986. La incidencia fué de 1/3,995; encontrándose como los factores asociados mas frecuentes la multigravidez, la cesárea previa y el curetaje post aborto. La sospecha diagnóstica es pobre al ingreso hospital hospitalario, por ser el cuadro clínico del acretismo placentario característico del II período del parto; con retención de placenta y hemorragia. El hallazgo de acretismo placentario fué realizado en su mayoría en la sala de operaciones. El tratamiento radical fué el mas utilizado. En el 80.49 por ciento fueron necesarias las transfusiones de sangre. En el diagnóstico post peratorio se halló la asociación con placenta previa en el 26.83 por ciento de las pacientes. El acretismo placentario tiene un potencial reconocido de muerte materna, siendo la incidencia hallada de 4.88 por ciento, a causa de la hemorragia. Se encontró 9.76 por ciento de óbitos fetales, atribuibles a la ruptura uterina y hemorragia materna. Hubo un 12.20 por ciento de recién nacidos con malformaciones congénitas. El exámen anatomopatológico de las muestras de pacientes histrectomizadas arrojó una mayor frecuencia de placenta accreta vera e igual incidencia de placenta increta y percreta.Las complicaciones post operatorias mas comunes fueron la endometritis y la anemia severa