Difficulties in the Management of Placenta Accreta Spectrum in Hospitals with Limited Resources

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.

Difficulties in the Management of Placenta Accreta Spectrum Disorders are not Confined to Low-/Middle-Income Countries: A Possible Usefulness of Simulation Training

“…The recommendation of Aguilera et al 1 is to provide periodic education for professionals who may have to deal with PAS disorders, and we believe that this is true in both LMICs and HICs. Therefore, we believe that simulation training might become an important tool.…”

“…The good patient outcomes shown by Aguilera et al 1 have impressed us: lower levels of massive bleeding, lower rate of surgical complications, and, importantly, no maternal deaths. The authors 1 considered that this was due to “experienced hands”: the obstetric surgeons in their hospital had no choice but to perform many difficult surgeries; thus, they were used to performing cesarean hysterectomy for PAS disorders. However, we believe that no surgeon begins their career with “experienced hands”.…”

“…Dear Editor, Aguilera et al 1 clearly illustrated some difficulties in the management of placenta accreta spectrum (PAS) disorders in low-/middle-income countries (LMICs), with special emphasis on the low rate of presurgical diagnosis. This naturally forced obstetric surgeons to handle "unexpected PAS disorders" on an emergency basis, and this situation may also be true in high-income countries (HICs).…”

“…2 Secondly, even though in many HICs planned surgery for diagnosed cases may now be performed by a multidisciplinary team in a well-prepared manner, presurgical diagnosis of PAS disorders is still difficult, so not all PAS disorders are diagnosed preoperatively. 2 Aguilera et al 1 reported that approximately a half of the surgeries were performed at night; this may be an extreme, but any obstetrician, including those less experienced, might encounter it incidentally during cesarean section.…”

Consenso Colombiano de Tratamiento del Espectro de Acretismo Placentario (EAP)

“…Sin embargo, el diagnóstico prenatal es considerado con frecuencia un reto, reportándose incluso falsos negativos en hospitales expertos en EAP 12 . En escenarios de recursos limitados, la tasa de falsos negativos suele ser más alta, ya que el ultrasonido es un método operador dependiente 13 . Por otra parte, también se informan falsos positivos de casos catalogados como EAP en las ecografías prenatales, pero que durante la cirugía se reclasifican como dehiscencia uterina 1 .…”