The multidisciplinary management of placenta accreta spectrum (PAS) within a single tertiary centre: A ten-year experience.

INTRODUCTION: Placenta accreta spectrum (PAS) covers a spectrum of placental adherence abnormalities: placenta accreta, increta and percreta. PAS is associated with significant maternal morbidity and mortality. Studies have shown the importance of multidisciplinary teamwork in the management of PAS. AIM: This study was designed to describe the maternal and neonatal morbidity and mortality associated with PAS in our centre over a ten-year period. METHODS: A retrospective cohort study was conducted of pregnancies complicated by PAS between February 2006 and January 2016 at Flinders Medical Centre (FMC), South Australia. Electronic and medical records were examined to obtain patient demographics, antenatal and surgical, findings and postnatal outcomes. RESULTS: There were 67 PAS cases with an overall incidence of 2.3 per 1000 deliveries. Three cases were excluded due to incomplete information. Of the remaining 64 cases, 56 women were antenatally diagnosed. Sixty cases were confirmed to be invasive at delivery; 28 accreta (superficial) and 32 increta/percreta (deep) cases. The four cases with no invasion at delivery were suspected antenatally to have PAS. The median (Q1, Q3) number of caesarean sections in this cohort was 2 (1, 3). Deep invasion is significantly associated with increased bleeding, intensive care unit admission, surgical complications and an extended postpartum stay. CONCLUSION: The incidence of PAS at FMC is high as it is the state's tertiary referral centre. While PAS is associated with increased morbidity, thorough perioperative planning by a multidisciplinary team is crucial for excellent patient outcomes.

Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors.

BACKGROUND: Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants. METHOD: Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records' review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays. FINDINGS: The root causes were found in poor quality of care, which caused hospital to be unprepared to manage deteriorating patients. In hospital, poor implementation of standard operating procedures was rooted in inadequate skills, lack of forward planning, ineffective communication, and unavailability of essential services. In primary care, root causes included inadequate risk management, referrals to facilities where needed services are not available, and lack of coordination between primary healthcare and hospitals. CONCLUSION: There is an urgent need for a shift in focus to quality of care through knowledge, skills, and support for consistent application of protocols, making essential services available, effective risk assessment and management, and facilitating timely referrals to facilities that are adequately equipped.