Colombian Consensus on the Treatment of Placenta Accreta Spectrum (PAS)
DOI:
https://doi.org/10.18597/rcog.3877Keywords:
Placenta accreta, consensus conference, developing countries, healthcare resourcesAbstract
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 draftedfive 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.
Author Biographies
Albaro José Nieto-Calvache, Fundación Valle de Lili, Cali (Colombia).
Clínica de Espectro de Acretismo Placentario, Fundación Valle de Lili, Cali (Colombia).
José Enrique Sanín-Blair, Clínica el Rosario, Medellín (Colombia).
Unidad de Medicina Materno Fetal, Clínica Universitaria Bolivariana / Clínica el Rosario, Medellín (Colombia).
Haidi Marcela Buitrago-Leal, ASBOG, Bogotá (Colombia).
Medicina Materno Fetal - Epidemiología. Departamento de Gineco Obstetricia, División de Medicina Materno Fetal, Clínica de la Mujer Grupo Quirón Salud/Country/Colina. Bogotá (Colombia). Coordinadora Comité Salud Materno Perinatal – ASBOG, Bogotá (Colombia).
Jesús Andrés Benavides-Serralde, Fundación Universitaria Autónoma de las Américas, Pereira (Colombia).
Unidad de Medicina Materno Fetal Perinatal Care IPS. Servicio de Ginecología y Obstetricia, Clínica San Rafael. Departamento de Ginecología y Obstetricia, Fundación Universitaria Autónoma de las Américas, Pereira (Colombia).
Juliana Maya-Castro, Universidad ICESI, Cali (Colombia).
Facultad de Ciencias de la Salud, Universidad ICESI, Cali (Colombia).
Adda Piedad Rozo-Rangel, Fundación Universitaria de Ciencias de la Salud, Bogotá (Colombia).
Hospital San José, Fundación Universitaria de Ciencias de la Salud, Bogotá (Colombia).
Adriana Messa-Bryon, Fundación Valle de Lili, Cali (Colombia).
Clínica de Espectro de Acretismo Placentario, Fundación Valle de Lili, Cali (Colombia).
Alejandro Colonia-Toro, Hospital General de Medellín, Medellín (Colombia).
Hospital General de Medellín, Medellín (Colombia).
Armando Rafael Gómez-Castro, Clínica la Misericordia, Barranquilla (Colombia).
Clínica la Misericordia, Barranquilla (Colombia).
Arturo Cardona-Ospina, Clínica del Prado, Grupo Quirón Salud, Medellín (Colombia).
Clínica del Prado, Grupo Quirón Salud, Medellín (Colombia).
Carlos Eduardo Caicedo-Cáceres, Universidad Antonio Nariño, Bogotá (Colombia).
Subred integrada de Servicios de Salud Centro Oriente E.S.E., Universidad Antonio Nariño, Bogotá (Colombia).
Elkin Fabian Dorado-Roncancio, Hospital Federico Lleras Acosta, Ibagué (Colombia).
Hospital Federico Lleras Acosta, Ibagué (Colombia).
Jaime Luis Silva, Pontificia Universidad Javeriana, Bogotá (Colombia).
Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá (Colombia).
Javier Andrés Carvajal-Valencia, Fundación Valle de Lili, Cali (Colombia).
Clínica de Espectro de Acretismo Placentario, Fundación Valle de Lili, Cali (Colombia).
Jesús Arnulfo Velásquez-Penagos, Universidad de Antioquia, Medellín (Colombia).
Hospital Universitario San Vicente Fundación, Universidad de Antioquia, Medellín (Colombia).
Jorge Ernesto Niño-González, Hospital Universitario Clínica San Rafael, Bogotá (Colombia).
Hospital Universitario Clínica San Rafael, Bogotá (Colombia).
Juan Manuel Burgos-Luna, Fundación Valle de Lili, Cali (Colombia).
Clínica de Espectro de Acretismo Placentario, Fundación Valle de Lili, Cali (Colombia).
Juan Carlos Rincón-García, Hospital Universitario San Rafael, Clínica Medilaser, Tunja (Colombia).
Hospital Universitario San Rafael, Clínica Medilaser, Tunja (Colombia).
Lía Matera-Torres, Universidad de Cartagena, Cartagena (Colombia).
Centro Hospitalario Serena del Mar, Universidad de Cartagena, Cartagena (Colombia).
Orlando Afranio Villamizar-Galvis, Clínica Santa Ana, Cúcuta (Colombia).
Clínica Santa Ana, Cúcuta (Colombia).
Sandra Ximena Olaya-Garay, Hospital Universitario SES de Caldas, Manizales (Colombia).
Hospital Universitario SES de Caldas, Manizales (Colombia).
Virna Patricia Medina-Palmezano, Clínica Imbanaco Grupo Quirón Salud, Cali (Colombia).
Clínica Imbanaco Grupo Quirón Salud, Cali (Colombia).
Jimmy Castañeda, Federación Colombiana de Obstetricia y Ginecología (FECOLSOG), Bogotá (Colombia).
Jimmy Castañeda, MD. Director de Educación, Federación Colombiana de Obstetricia y Ginecología (FECOLSOG), Bogotá (Colombia).
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