Usefulness of low-cost simulation models to learning surgical techniques for placenta accreta spectrum: An observational educational study.

OBJECTIVE: To evaluate the utility of low-cost simulation models to teach surgical techniques for placenta accreta spectrum (PAS), included in a multimodal education workshop for PAS. METHODS: This was an observational, survey-based study. Participants were surveyed before and after the use of low-fidelity mannequins to simulate two surgical techniques for PAS (one-step conservative surgery [OSCS] and modified subtotal hysterectomy [MSTH]), within a multimodal educational workshop. The workshops included pre-course preparation, didactics, simulated practice of the techniques using low-cost models, and viewing live surgery. RESULTS: Six OSCS/MSTH training workshops occurred across six countries and a total of 270 participants were surveyed. The responses of 127 certified obstetricians and gynecologists (OB-GYNs) were analyzed. Participants expressed favorable impressions of all components of the simulated session. Perceived anatomical simulator fidelity, scenario realism, educational component effectiveness, and self-assessed performance improvement received ratings of 4-5 (positive end of the Likert scale) from over 90% of respondents. When asked about simulation's role in technique comprehension, comfort level in technique performance, and likelihood of recommending this workshop to others, more than 75% of participants rated these aspects with a score of 4-5 (positively) on the five-point scale. CONCLUSION: Low-cost simulation, within a multimodal education strategy, is a well-accepted intervention for teaching surgical techniques for PAS.

Is telehealth useful in the management of placenta accreta spectrum in low-resource settings? Results of an exploratory survey.

OBJECTIVE: The optimal management of placenta accreta spectrum (PAS) requires the participation of multidisciplinary teams that are often not locally available in low-resource settings. Telehealth has been increasingly used to manage complex obstetric conditions. Few studies have explored the use of telehealth for PAS management, and we aimed evaluate the usage of telehealth in the management of PAS patients in low-resource settings. METHODS: Between March and April 2023, an observational, survey-based study was conducted, and obstetricians-gynecologists with expertise in PAS management in low- and middle-income countries were contacted to share their opinion on the potential use of telehealth for the diagnosis and management of patients at high-risk of PAS at birth. Participants were identified based on their authorship of at least one published clinical study on PAS in the last 5 years and contacted by email. This is a secondary analysis of the results of that survey. RESULTS: From 158 authors contacted we obtained 65 responses from participants in 27 middle-income countries. A third of the participants reported the use of telehealth during the management obstetric emergencies (38.5%, n = 25) and PAS (36.9%, n = 24). Over 70% of those surveyed indicated that they had used "informal" telemedicine (phone call, email, or text message) during PAS management. Fifty-nine participants (90.8%) reported that recommendations given remotely by expert colleagues were useful for management of patients with PAS in their setting. CONCLUSION: Telehealth has been successfully used for the management of PAS in middle-income countries, and our survey indicates that it could support the development of specialist care in other low resource settings.

Are international guideline recommendations for the management of placenta accreta spectrum applicable in low- and middle-income countries?

OBJECTIVE: The aim of this study was to explore how obstetricians-gynecologists in low- and middle-income countries (LMICs) can apply current international clinical practice guidelines (CPGs) for the management of placenta accreta spectrum (PAS) in limited resource settings. METHODS: This was an observational, survey-based study. Clinicians with expertise in managing patients with PAS in LMICs were contacted for their evaluation of the recommendations included in four PAS clinical practice guidelines. RESULTS: Out of the 158 clinicians contacted, we obtained responses from 65 (41.1%), representing 27 middle income countries (MICs). The results of this survey suggest that the care of PAS patients in middle income countries is very different from what is recommended by international CPGs. Participants in the survey identified that their practice was limited by insufficient availability of hospital infrastructure, low resources of local health systems and lack of trained multidisciplinary teams (MDTs) and this did not enable them to follow CPG recommendations. Two-thirds of the participants surveyed describe the absence of centers of excellence in their country. In over half of the referral hospitals with expertise in managing PAS, there are no MDTs. One-third of patients with intraoperative findings of PAS are managed by the team initially performing the surgery (without additional assistance). CONCLUSION: The care of patients with PAS in middle income countries frequently deviates from established CPG recommendations largely due to limitations in local resources and infrastructure. New practical guidelines and training programs designed for low resource settings are needed.

Usefulness of a low-cost simulation model for teaching internal manual aortic compression. A survey-based mannequin evaluation.

OBJECTIVE: To evaluate the users' opinion on internal manual aortic compression (IMAC) training, using a low-cost simulation model. METHODS: An educational strategy was designed to teach IMAC, which included: (1) guided reading of educational material and viewing an explanatory video of IMAC; (2) an introductory lecture with the anatomical considerations, documentation of the cessation of femoral arterial flow during IMAC, and real clinical cases in which this procedure was used; and (3) simulated practice of IMAC with a new low-cost manikin. The educational strategy was applied during three postpartum hemorrhage workshops in three Latin American countries and the opinions of the participants were measured with a survey. RESULTS: Almost all of the participants in the IMAC workshop, including the simulation with the low-cost mannikin, highlighted the usefulness of the strategy (scores of 4/5 and 5/5 on the Likert scale) and would recommend it to colleagues. CONCLUSION: We present a low-cost simulation model for IMAC as the basis of an educational strategy perceived as very useful by most participants. The execution of this strategy in other populations and its impact on postpartum hemorrhage management should be evaluated in further studies.

Placenta accreta spectrum: treatment consensus in a resource-limited setting.

BACKGROUND: Management options for placenta accreta spectrum disorder are multiple, without a clear picture of which one is superior. Management guidelines describe the use of a wide range of human and technological resources that are not always available in resource-limited settings. OBJECTIVE: This consensus seeks agreement on general guidelines that facilitate the management of placenta accreta spectrum in low- and middle-income countries. STUDY DESIGN: Consensus was developed using the modified Delphi methodology, incorporating 3 successive rounds in which 6 dimensions of placenta accreta spectrum treatment were discussed: pathway for placenta accreta spectrum care, roles at different levels of care, organization of the interdisciplinary teams at the reference hospitals, training interdisciplinary teams, placenta accreta spectrum surgical treatment, and management of placenta accreta spectrum patients without prenatal diagnosis. RESULTS: Consensus was achieved on all questions on placenta accreta spectrum management. Specific low- and middle-income countries problems were addressed, trying to establish guidelines for the construction of trained placenta accreta spectrum interdisciplinary teams, as well as the rational use of the different therapeutic options available in a limited resources setting. In addition, it is highlighted the need to facilitate contact between patients affected by this disease and the interdisciplinary groups, overcoming administrative barriers typical of some health systems. CONCLUSION: We present a consensus on the treatment of placenta accreta spectrum in a low- and middle-income countries, based on local experts' opinions. Construction of high-quality scientific evidence is essential in settings with limited resources.

How to perform the one-step conservative surgery for placenta accreta spectrum move by move.

BACKGROUND: There are 3 treatment options for placenta accreta spectrum: cesarean delivery with hysterectomy, expectant management, and uterine-sparing surgical techniques. One-step conservative surgery is the most extensively described conservative surgical technique, and it has extensive evidence supporting its usefulness; however, few groups apply it, most likely because of the misconception that it is a complex procedure that requires extensive training and is applicable to only a few patients. OBJECTIVE: This study aimed to evaluate the clinical outcomes of patients undergoing one-step conservative surgery in 4 placenta accreta spectrum reference hospitals and provided detailed steps for successfully applying this type of surgery. STUDY DESIGN: This was a multicenter, descriptive, prospective study that described the outcomes of patients with placenta accreta spectrum treated in 4 reference hospitals for this condition. The patients were divided into those managed with one-step conservative surgery and those managed with cesarean delivery and hysterectomy. RESULTS: Overall, 75 patients were included. One-step conservative surgery was possible in 85.3% of placenta accreta spectrum cases (64 patients). Intraoperative staging and placenta accreta spectrum topographic classification allowed for the selection of one-step conservative surgery candidates. The clinical outcomes of the 2 groups were similar, except for the frequency of transfusions (81.8% in the cesarean delivery and hysterectomy group vs 67.2% in the one-step conservative surgery group) and vascular interventions (27.3% in the cesarean delivery and hysterectomy group vs 4.7% in the one-step conservative surgery group), which were both higher in patients who underwent hysterectomy. In addition, the operation time was shorter in the one-step conservative surgery group (164.4 minutes vs 216.5 minutes). CONCLUSION: One-step conservative surgery is a valid procedure in most patients with placenta accreta spectrum. It is an applicable technique even in scenarios with limited resources. However, its safe application requires knowledge of the topographic classification and the application of intraoperative staging.

Relationship between the Prenatal Diagnosis of Placenta Acreta Spectrum and Lower Use of Blood Components.

OBJECTIVE: To describe the clinical results of patients admitted and managed as cases of placenta accreta spectrum (PAS) at a Central American public hospital and the influence of the prenatal diagnosis on the condition. MATERIALS AND METHODS: A retrospective analysis of PAS patients treated at Hospital Bertha Calderón Roque, in Managua, Nicaragua, between June 2017 and September 2021. The diagnostic criteria used were those of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, in French). The population was divided into patients with a prenatal ultrasonographic diagnosis of PAS (group 1) and those whose the diagnosis of PAS was established at the time of the caesarean section (group 2). RESULTS: During the search, we found 103 cases with a histological and/or clinical diagnosis of PAS; groups 1 and 2 were composed of 51 and 52 patients respectively. Regarding the clinical results of both groups, the patients in group 1 presented a lower frequency of transfusions (56.9% versus 96.1% in group 2), use of a lower number of red blood cell units (RBCUs) among those undergoing transfusions (median: 1; interquartile range: [IQR]: 0-4 versus median: 3; [IQR]: 2-4] in group 2), and lower frequency of 4 or more RBCU transfusions (29.4% versus 46.1% in group 2). Group 1 also exhibited a non-significant trend toward a lower volume of blood loss (1,000 mL [IQR]: 750-2,000 mL versus 1,500 mL [IQR]: 1,200-1,800 mL in group 2), and lower requirement of pelvic packing (1.9% versus 7.7% in group 2). CONCLUSION: Establishing a prenatal diagnosis of PAS is related to a lower frequency of transfusions. We observed a high frequency of prenatal diagnostic failures of PAS. It is a priority to improve prenatal detection of this disease.

Relationship between the Prenatal Diagnosis of Placenta Acreta Spectrum and Lower Use of Blood Components / Relação entre o diagnóstico prenatal de espectro da placenta acreta e menor uso de hemoderivados

Abstract Objective To describe the clinical results of patients admitted and managed as cases of placenta accreta spectrum (PAS) at a Central American public hospital and the influence of the prenatal diagnosis on the condition. Materials and Methods A retrospective analysis of PAS patients treated at Hospital Bertha Calderón Roque, in Managua, Nicaragua, between June 2017 and September 2021. The diagnostic criteria used were those of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, in French). The population was divided into patients with a prenatal ultrasonographic diagnosis of PAS (group 1) and those whose the diagnosis of PAS was established at the time of the caesarean section (group 2). Results During the search, we found 103 cases with a histological and/or clinical diagnosis of PAS; groups 1 and 2 were composed of 51 and 52 patients respectively. Regarding the clinical results of both groups, the patients in group 1 presented a lower frequency of transfusions (56.9% versus 96.1% in group 2), use of a lower number of red blood cell units (RBCUs) among those undergoing transfusions (median: 1; interquartile range: [IQR]: 0-4 versus median: 3; [IQR]: 2-4] in group 2), and lower frequency of 4 or more RBCU transfusions (29.4% versus 46.1% in group 2). Group 1 also exhibited a non-significant trend toward a lower volume of blood loss (1,000 mL [IQR]: 750-2,000 mL versus 1,500 mL [IQR]: 1,200-1,800 mL in group 2), and lower requirement of pelvic packing (1.9% versus 7.7% in group 2). Conclusion Establishing a prenatal diagnosis of PAS is related to a lower frequency of transfusions. We observed a high frequency of prenatal diagnostic failures of PAS. It is a priority to improve prenatal detection of this disease.

Is There a Place for Family-centered Cesarean Delivery during Placenta Accreta Spectrum Treatment? / Existe um lugar para cesariana centrada na família durante o tratamento do espectro da placenta acreta?

ABSTRACT Objective Placenta accreta spectrum (PAS) is a cause of massive obstetric hemorrhage and maternal mortality. The application of family-centered delivery techniques (FCDTs) during surgery to treat this disease is infrequent. We evaluate the implementation of FCDTs during PAS surgeries. Methods This was a prospective, descriptive study that included PAS patients undergoing surgical management over a 12-month period. The patients were divided according to whether FCDTs were applied (group 1) or not (group 2), and the clinical outcomes were measured. In addition, hospital anesthesiologists were surveyed to evaluate their opinions regarding the implementation of FCDTs during the surgical management of PAS. Results Thirteen patients with PAS were included. The implementation of FCDTs during birth was possible in 53.8% of the patients. The presence of a companion during surgery and skin-to-skin contact did not hinder interdisciplinary management in any case. Conclusion Implementation of FCDTs during PAS care is possible in selected patients at centers with experience in managing this disease.

Resumo Objetivo O espectro da placenta acreta (do inglês placenta accreta spectrum - PAS) é causa de hemorragia obstétrica maciça e mortalidade materna. A aplicação de técnicas de parto centrado na família (do inglês family-centered delivery techniques - FCDTs) durante a cirurgia para tratar esta doença é pouco frequente. Avaliamos a implementação das FCDTs durante as cirurgias do PAS. Métodos Estudo prospectivo e descritivo que incluiu pacientes com PAS submetidos a tratamento cirúrgico durante um período de 12 meses. Os pacientes foram divididos de acordo com a aplicação de FCDTs (grupo 1) ou não (grupo 2), e os resultados clínicos foram medidos. Além disso, anestesiologistas hospitalares foram entrevistados para avaliar suas opiniões sobre a implementação das FCDTs durante o manejo cirúrgico do PAS. Resultados Foram incluídos 13 pacientes com PAS. A implementação de FCDTs durante o parto foi possível em 53,8% das pacientes. A presença do acompanhante durante a cirurgia e o contato pele a pele não prejudicou o manejo interdisciplinar em nenhum caso. Conclusão A implementação de FCDTs durante o atendimento do PAS é possível em pacientes selecionados em centros com experiência no manejo dessa doença.

Placenta Accreta Spectrum Prenatal Diagnosis Performance: Are Ultrasound False-positive Results Acceptable in Limited-resources Settings?

OBJECTIVE: The immediate referral of patients with risk factors for placenta accreta spectrum (PAS) to specialized centers is recommended, thus favoring an early diagnosis and an interdisciplinary management. However, diagnostic errors are frequent, even in referral centers (RCs). We sought to evaluate the performance of the prenatal diagnosis for PAS in a Latin American hospital. METHODS: A retrospective descriptive study including patients referred due to the suspicion of PAS was conducted. Data from the prenatal imaging studies were compared with the final diagnoses (intraoperative and/or histological). RESULTS: A total of 162 patients were included in the present study. The median gestational age at the time of the first PAS suspicious ultrasound was 29 weeks, but patients arrived at the PAS RC at 34 weeks. The frequency of false-positive results at referring hospitals was 68.5%. Sixty-nine patients underwent surgery based on the suspicion of PAS at 35 weeks, and there was a 28.9% false-positive rate at the RC. In 93 patients, the diagnosis of PAS was ruled out at the RC, with a 2.1% false-negative frequency. CONCLUSION: The prenatal diagnosis of PAS is better at the RC. However, even in these centers, false-positive results are common; therefore, the intraoperative confirmation of the diagnosis of PAS is essential.

OBJETIVO: Recomenda-se o encaminhamento imediato de pacientes com fatores de risco para espectro placentário acreta (PAS, na sigla em inglês) para centros especializados, favorecendo assim o diagnóstico precoce e o manejo interdisciplinar. No entanto, erros diagnósticos são frequentes, mesmo em centros de referência (CRs). Buscou-se avaliar o desempenho do diagnóstico pré-natal para PAS em um hospital latino-americano. MéTODOS: Um estudo descritivo retrospectivo incluindo pacientes encaminhados por suspeita de SAP foi realizado. Os dados dos exames de imagem do pré-natal foram comparados com os diagnósticos finais (intraoperatórios e/ou histológicos). RESULTADOS: Foram incluídos 162 pacientes no presente estudo. A idade gestacional mediana no momento da primeira ultrassonografia suspeita de PAS foi de 29 semanas, mas as pacientes chegaram ao CR de PAS com 34 semanas. A frequência de resultados falso-positivos nos hospitais de referência foi de 68,5%. Sessenta e nove pacientes foram operadas com base na suspeita de PAS com 35 semanas e houve 28,9% de falso-positivos no CR. Em 93 pacientes, o diagnóstico de PAS foi descartado no CR, com frequência de falso-negativos de 2,1%. CONCLUSãO: O diagnóstico pré-natal de PAS é melhor no CR. Entretanto, mesmo nestes centros, resultados falso-positivos são comuns; portanto, a confirmação intraoperatória do diagnóstico de SAP é essencial.

Is There a Place for Family-centered Cesarean Delivery during Placenta Accreta Spectrum Treatment?

OBJECTIVE: Placenta accreta spectrum (PAS) is a cause of massive obstetric hemorrhage and maternal mortality. The application of family-centered delivery techniques (FCDTs) during surgery to treat this disease is infrequent. We evaluate the implementation of FCDTs during PAS surgeries. METHODS: This was a prospective, descriptive study that included PAS patients undergoing surgical management over a 12-month period. The patients were divided according to whether FCDTs were applied (group 1) or not (group 2), and the clinical outcomes were measured. In addition, hospital anesthesiologists were surveyed to evaluate their opinions regarding the implementation of FCDTs during the surgical management of PAS. RESULTS: Thirteen patients with PAS were included. The implementation of FCDTs during birth was possible in 53.8% of the patients. The presence of a companion during surgery and skin-to-skin contact did not hinder interdisciplinary management in any case. CONCLUSION: Implementation of FCDTs during PAS care is possible in selected patients at centers with experience in managing this disease.

OBJETIVO: O espectro da placenta acreta (do inglês placenta accreta spectrum - PAS) é causa de hemorragia obstétrica maciça e mortalidade materna. A aplicação de técnicas de parto centrado na família (do inglês family-centered delivery techniques - FCDTs) durante a cirurgia para tratar esta doença é pouco frequente. Avaliamos a implementação das FCDTs durante as cirurgias do PAS. MéTODOS: Estudo prospectivo e descritivo que incluiu pacientes com PAS submetidos a tratamento cirúrgico durante um período de 12 meses. Os pacientes foram divididos de acordo com a aplicação de FCDTs (grupo 1) ou não (grupo 2), e os resultados clínicos foram medidos. Além disso, anestesiologistas hospitalares foram entrevistados para avaliar suas opiniões sobre a implementação das FCDTs durante o manejo cirúrgico do PAS. RESULTADOS: Foram incluídos 13 pacientes com PAS. A implementação de FCDTs durante o parto foi possível em 53,8% das pacientes. A presença do acompanhante durante a cirurgia e o contato pele a pele não prejudicou o manejo interdisciplinar em nenhum caso. CONCLUSãO: A implementação de FCDTs durante o atendimento do PAS é possível em pacientes selecionados em centros com experiência no manejo dessa doença.

Placenta Accreta Spectrum Prenatal Diagnosis Performance: Are Ultrasound False-positive Results Acceptable in Limited-resources Settings? / Desempenho do diagnóstico pré-natal do espectro da placenta acreta: Os resultados falso-positivos do ultrassom são aceitáveis em ambientes com recursos limitados?

Abstract Objective The immediate referral of patients with risk factors for placenta accreta spectrum (PAS) to specialized centers is recommended, thus favoring an early diagnosis and an interdisciplinary management. However, diagnostic errors are frequent, even in referral centers (RCs). We sought to evaluate the performance of the prenatal diagnosis for PAS in a Latin American hospital. Methods A retrospective descriptive study including patients referred due to the suspicion of PAS was conducted. Data from the prenatal imaging studies were compared with the final diagnoses (intraoperative and/or histological). Results A total of 162 patients were included in the present study. The median gestational age at the time of the first PAS suspicious ultrasound was 29 weeks, but patients arrived at the PAS RC at 34 weeks. The frequency of false-positive results at referring hospitals was 68.5%. Sixty-nine patients underwent surgery based on the suspicion of PAS at 35 weeks, and there was a 28.9% false-positive rate at the RC. In 93 patients, the diagnosis of PAS was ruled out at the RC, with a 2.1% false-negative frequency. Conclusion The prenatal diagnosis of PAS is better at the RC. However, even in these centers, false-positive results are common; therefore, the intraoperative confirmation of the diagnosis of PAS is essential.

Resumo Objetivo Recomenda-se o encaminhamento imediato de pacientes com fatores de risco para espectro placentário acreta (PAS, na sigla em inglês) para centros especializados, favorecendo assim o diagnóstico precoce e o manejo interdisciplinar. No entanto, erros diagnósticos são frequentes, mesmo em centros de referência (CRs). Buscou-se avaliar o desempenho do diagnóstico pré-natal para PAS em um hospital latino-americano. Métodos Um estudo descritivo retrospectivo incluindo pacientes encaminhados por suspeita de SAP foi realizado. Os dados dos exames de imagem do pré-natal foram comparados com os diagnósticos finais (intraoperatórios e/ou histológicos). Resultados Foram incluídos 162 pacientes no presente estudo. A idade gestacional mediana no momento da primeira ultrassonografia suspeita de PAS foi de 29 semanas, mas as pacientes chegaram ao CR de PAS com 34 semanas. A frequência de resultados falso-positivos nos hospitais de referência foi de 68,5%. Sessenta e nove pacientes foram operadas com base na suspeita de PAS com 35 semanas e houve 28,9% de falso-positivos no CR. Em 93 pacientes, o diagnóstico de PAS foi descartado no CR, com frequência de falso-negativos de 2,1%. Conclusão O diagnóstico pré-natal de PAS é melhor no CR. Entretanto, mesmo nestes centros, resultados falso-positivos são comuns; portanto, a confirmação intraoperatória do diagnóstico de SAP é essencial.

How to identify patients who require aortic vascular control in placenta accreta spectrum disorders?

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.

Telemedicine facilitates surgical training in placenta accreta spectrum.

OBJECTIVE: The training of groups responsible for managing patients with placenta accreta spectrum (PAS) is complex because of the lack of hospitals with a high flow of patients and absence of formal educational programs. We report here the results of a virtual training program (VTP) that implemented one-step conservative surgery (OSCS). METHODS: A prospective observation study of OSCS VTP between three expert groups and PAS reference hospitals without experience in OSCS was performed. Accessible or cost-efficient web meeting platforms were used to implement the VTP components: baseline observation of the participant's prior knowledge; instructions about essential PAS surgery topics; case selection and joint planning of surgery; expert group "telepresence" during surgery and postoperative debriefing. RESULTS: One-step conservative surgery was performed successfully at six hospitals. All patients had increta/percreta with a median intraoperative bleeding of 1300 ml (IQR 825-2325) and surgical time of 184 min (IQR 113-240). All groups considered the VTP very useful (n = 33, 97%) or useful (n = 1, 3%), they would use it again (definitely: n = 27, 81.8%; or probably: n = 6, 18.2%), and they would recommend it to other colleagues. CONCLUSION: Tele education and telepresence during PAS surgery facilitates the implementation of OSCS in selected cases.

Diagnostic performance of two different maternal near-miss approaches in a High Obstetric Risk Unit.

Maternal near-miss (MNM) is a maternal quality care indicator. The World Health Organization (WHO) defines it as a state in which a woman nearly dies but survives due to a complication during pregnancy, birth, or puerperium. The Latin American Federation of Obstetrics and Gynecology (FLASOG) and the Colombian National Health Institute (INS) established recommendations for the event's epidemiological surveillance; nonetheless, the operational definitions of the cases are different. This retrospective study examined the approaches of FLASOG and INS versus the WHO approach (gold standard) for the assessment of MNM in a high obstetric risk unit. Patients admitted with at least one criterion of the WHO, FLASOG, or INS approach for the definition of MNM from March 2016 to March 2017 were included. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were evaluated, as well as the Receiver Operating Characteristics (ROC) curve of the FLASOG and INS. MNM classification compared to WHO system as reference. The results highlight that the WHO classification establishes very high boundaries for some of the diagnostic criteria and the lack of standardization of the MNM criteria among the different proposals in Latin America hinders the applicability in Colombia and other countries with a similar situation.

Detection of mycobacteria in paraffin-embedded Ziehl-Neelsen-Stained tissues using digital pathology.

INTRODUCTION: Early diagnosis of paucibacillary tuberculosis represents a challenge, even with direct tissue examination. Digital pathology allows the digital analysis of tissues to identify microorganisms. We aim to develop a program to detect and quantify typical and atypical mycobacteria in paraffin-embedded Ziehl-Neelsen-stained tissues. MATERIAL AND METHODS: Program development: The building of the program, named Pat-Scan, included pathology, systems engineering, and scientific applications. The iScan Coreo Au scanner® was used, and 9 variables were adjusted. Ten Ziehl-Neelsen-stained samples were fragmented into 2000 images and analyzed to validate the reproducibility of the bacilli images in the tissue, as detected by the software. RESULTS: Pat-Scan included software and a scanner that were used to detect and quantify bacilli in paraffin-embedded Ziehl-Neelsen-stained tissues. All samples containing mycobacteria were successfully analyzed by the scanner, and the bacilli could be detected; these results were validated by expert pathologists by microscopy examination, and the presence of bacilli was confirmed in all cases. CONCLUSIONS: Pat-Scan allowed the identification and quantification of mycobacteria in paraffin-embedded Ziehl-Neelsen-stained tissues, offering a reproducible diagnostic method that reduces the time for diagnosis and does not affect precision. Further validation is needed for application in the clinical setting.