ABSTRACT
Abstract Objective Placenta accreta spectrum (PAS) is a serious diseases, and the recommendation is that the treatment is conducted in centers of excellence. Such hospitals are not easy to find in low- and middle-income countries. We seek to describe the process of prenatal diagnosis, surgical management, and postnatal histological analysis in a low-income country referral hospital with limited resources. Methods A descriptive, retrospective study was carried out including patients with a pre- or intraoperative diagnosis of PAS. The clinical results of the patients were studied as well as the results of the prenatal ultrasound and the correlation with the postnatal pathological diagnosis. Results In total, 129 patients were included. Forty-eight of them had a prenatal PAS ultrasound diagnosis (37.2%). In the remaining 81 (62.8%), the diagnosis was intraoperative. Although hysterectomy was performed in all cases, one-third of the patients (31%) did not have a histological study of the uterus. In 40% of the patients who had a histological study, PAS was not reported by the pathologist. Conclusion The frequency of prenatal diagnosis and the availability of postnatal histological studies were very low in the studied population. Surgical skill, favored by a high flow of patients, is an important factor to avoid complications in settings with limited resources.
Resumo Objetivo O espectro da placenta accreta é uma patologia grave, cujo tratamento é recomendado emcentros de excelência. Esses hospitais não são fáceis de encontrar em países de baixa e média renda. Procuramos descrever o processo de diagnóstico prénatal, tratamento cirúrgico, e análise histológica pós-natal em um hospital de referência de baixa renda com recursos limitados. Métodos Foi realizado um estudo descritivo, retrospectivo, incluindo pacientes com diagnóstico pré ou intraoperatório de espectro da placenta accreta. Foram estudados os resultados clínicos das pacientes, bem como os resultados da ultrassonografia prénatal e a correlação com o diagnóstico patológico pós-natal. Resultados No total, 129 pacientes foram incluídas. Quarenta e oito delas tiveramum diagnóstico de ultrassom do espectro da placenta accreta pré-natal (37,2%). Nos 81 (62,8%) restantes, o diagnóstico foi intraoperatório. Embora a histerectomia tenha sido realizada em todos os casos, um terço deles (31%) não tinha estudo histológico do útero. Em 40% dos pacientes que tiveram estudo histológico, o espectro da placenta accreta não foi relatado pelo patologista. Conclusão A frequência do diagnóstico pré-natal e a disponibilidade de estudos histológicos pós-natais foram muito baixas na população estudada. A habilidade cirúrgica, favorecida por um alto fluxo de pacientes, é um fator importante para evitar complicações em ambientes com recursos limitados.
Subject(s)
Humans , Female , Pregnancy , Placenta Accreta/surgery , Placenta Accreta/diagnosisABSTRACT
BACKGROUND: The placenta accreta spectrum disorder may lead to severe complications. Helpful interventions to prevent placenta accreta spectrum bleeding include vascular control procedures in the aorta or pelvic vessels. Although these procedures are related to lower intraoperative bleeding, they are associated with complications, so the possibility of selecting patients at highest risk of bleeding while avoiding vascular procedures for all cases is attractive. OBJECTIVE: We describe an intraoperative staging protocol whose objective is to identify the need to use vascular control procedures in patients with placenta accreta spectrum. We also describe the results of its application in a placenta accreta spectrum referral hospital. STUDY DESIGN: This descriptive, retrospective study included patients with suspected prenatal placenta accreta spectrum treated at a referral center for placenta accreta spectrum between April 2016 and June 2020. The use of the resuscitative endovascular balloon occlusion of the aorta allowed the prevention and treatment of excessive bleeding; its application was performed according to 3 approaches: (1) presurgical use in all placenta accreta spectrum patients (Group 1), (2) according to the prenatal placenta accreta spectrum topography (Group 2), and (3) according to the "intraoperative staging" (Group 3). In addition, the frequency of use of resuscitative endovascular balloon occlusion of the aorta and the clinical results in the management of placenta accreta spectrum were described in the 3 groups. RESULTS: Seventy patients underwent surgery for a prenatal suspicion of placenta accreta spectrum. Of these, 16 underwent intraoperative staging (Group 3); in 20 cases, resuscitative endovascular balloon occlusion of the aorta was used based on the prenatal imaging topographic classification (Group 2), and in the remaining 34 patients (Group 1), it was always used before the laparotomy. The frequency of use of resuscitative endovascular balloon occlusion of the aorta was progressively lower in Groups 1 (32 patients, 94.1% of cases), 2 (11 patients, 75% of cases), and 3 (4 patients, 25% of cases). Similarly, resuscitative endovascular balloon occlusion of the aorta went from being applied predominantly before the laparotomy (all cases in Group 1) to being applied after intraoperative staging (all cases in Group 3). The percentage of endovascular devices applied but not used, decreased from 23.5% in Group 1 to 0% in Group 3. Complications related to the resuscitative endovascular balloon occlusion of the aorta were seen in 4 patients (2 women in Group 1, and 1 woman each in Groups 2 and 3). CONCLUSION: The "intraoperative staging" of placenta accreta spectrum allows the optimization of the use of resuscitative endovascular balloon occlusion of the aorta, which decreases the frequency of its use without increasing the volume of blood loss.
