Jonathan Stanleigh, Dvora Yahav, Shunit Armon, Faiz Hatib, Boris Zuckerman, Michael Shaya, Alex Ioscovitch, Rivka Farkash, Aron Tevet, Ofer Sheinfeld, Arnon Samueloff, Sorina Grisaru Granovsky
Hebrew University Faculty of Medicine, Jerusalem, Israel Shaare ZedeK MC
Background: Morbidly Adherent Placenta (MAP) has become a serious concern in the obstetrics and source of maternal and neonatal morbidity.
Aim: To evaluate whether outcomes of women and neonates with MAP improve with the implementation of a pro-active peripartum multidisciplinary approach (PA-MA).
Study Design: Prospective observational study. All pregnancies with a diagnosis of MAP managed in a single tertiary center between 2005-2016. Cases were registered beginning with the implementation of the PA-MA protocol epoch, February 2014-December 2016 (E2) and compared with those in the pre/PA-MA epoch, 2005- December 2013 (E1) when cases were treated by ad hoc team recruitment. The PA-MA protocol: MAP risk assessment based on clinical history and antepartum ultrasound/MRI, initiation of antenatal surgical, anesthesia, urological consult and planned activation of the team for elective surgery at 34-35 wks . Surgery protocol: massive transfusion protocol activation, insertion of ureteral catheters, visual assessment of uterineabnormal vascular pattern, vertical non transplacental uterine incision,delivery of the neonate, placement of vessel loops on the iliac vessels, avoidance of active placenta delivery, , observation for spontaneous placenta detachment followed by decision of urinary bladder flap and hysterectomy or closure of uterus. Outcomes variables: massive transfusion (>4PC) unit of PChysterectomy, hollow viscus injury, respiratory complications (ARDS/TRALI) and neonatal gestational age at birth, birth weight and neonatal hospitalization days.
Results: During the study period 158,438 deliveries (13,206 deliveries per year). A total of 72 pregnancies (0.05 %) were identified: 50(69.4%) in E1 and 22 (30.6%) in E2. Baseline patient charactersitics were similar among epochs (Table). All the same, we observed no significant difference in the rate of ‘ working hours“ surgery. Patients in E2 were transfused significantly less RBC-PC units median 4 vs. 1.5, p=0.012, as well as significantly less events of massive blood transfusions 36.0% vs. 13.6%,p=0.05. All repeated hemorrhagic control re-laparotomies occurred in E1, as well as cases of ARDS/TRALI (6 cases, 12% and 6 cases, 12% respectively). The rates of hollow viscus injury and hysterectomy were comparable (26% vs. 22%; 72% vs 63.7%, respectively). Neonatal outcome was favorable and similar among the epoch (Table).
Conclusions: Institution of PAMA protocol resulted in significant improvement of maternal hemorrhagic and acute respiratory morbidity Not withstanding the planned early delivery was safe for the neonates. Centralized PAMA may prove cost effective and lessen the burden on regular maternity units.