BACKGROUND AND PURPOSE:

• Melber et al. (AJOG, 2021) assessed a novel multidisciplinary protocol for the treatment of placenta accreta spectrum that included multivessel uterine embolization followed by cesarean hysterectomy

METHODS:

• Matched pre-post study
  • Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization (PASTIME) study protocol 
• Participants
  • Placenta accrete spectrum cases
• Exposures
  • Before PASTIME (2010 to 2017): PAS cases managed with internal iliac artery balloon placement in selected cases with inflation at the discretion of surgeon
  • After PASTIME (2018 to 2021): Cesarean delivery, multivessel uterine embolization, and hysterectomy in a single procedure within a hybrid operative suite (surgical and interventional radiology equipment)
• Study design
  • PASTIME cases were compared with historical cases in a 1:2 ratio matched on the basis of PAS severity and surgical urgency
• Primary outcome
  • A requirement for transfusion with packed red blood cells
• Secondary outcome
  • Estimated surgical blood loss
  • Operative and postoperative complications
  • Procedural time
  • Length of stay
  • Neonatal outcomes

RESULTS:

• Historical cases: 30 | PASTIME cases: 15
• PASTIME cases required fewer (median) units of packed red blood cells (P=0.045)
  • Historical cases: 2 (IQR 0 to 4.5) units
  • PASTIME cases: 0 (IQR 0 to 2) units
• No differences in requirement of any blood transfusions between the groups (P=0.11)
  • Historical cases: 63.3%
  • PASTIME cases: 33.3%
• Estimated blood loss (median) was significantly less in PASTIME group (P=0.003)
  • Historical: 1750 (IQR 1050 to 2500) mL
  • PASTIME: 750 (IQR 450 to 1050) mL
• There was no significant difference in the number of cases requiring massive transfusion (≥10 red blood cell units in 24 hours) (P=0.15)
  • Historical: 16.7%
  • PASTIME: 0%
• Intraoperative deaths from hemorrhagic shock
  • Historical: 2 cases
  • PASTIME: 0 cases
• Mean duration of the interventional radiology procedure was longer in the PASTIME (P=0.002)
  • Historical: 34.1 minutes
  • PASTIME: 67.8 minutes
• The following were not significantly different between groups
  • ICU admission
  • Postpartum length of stay
  • Surgical and postoperative complications
  • Gestational age
  • Neonatal birthweights
• The neonatal length of stay was longer in the PASTIME group (P=0.02)
  • Historical: median duration 15 days
  • PASTIME: 32 days
• There was a trend towards low 5-minute Apgar score (<7) in the PASTIME group (P=0.06)
  • Historical: 38.5%
  • PASTIME: 76.9%
• There were no significant differences in the
  • Incidence of arterial umbilical cord blood pH <7.2
  • Incidence of respiratory distress syndrome
  • Intubation rates

CONCLUSION:

• A multidisciplinary protocol for the treatment of placenta accreta spectrum that included a single-surgery protocol with multivessel uterine embolization was associated with reduced need for blood transfusion and lower estimated blood loss
• There were no increases in adverse operative outcomes
• Lower Apgar score trend in the PASTIME group was attributed to a longer fetal exposure to general anesthesia during femoral line placement
• Longer length of neonatal stay may be related to specific fetal or neonatal diagnoses
• The authors conclude

The techniques described in the PASTIME protocol warrant consideration by other centers specializing in PAS treatment

Learn More – Primary Sources:

Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization: the PASTIME protocol

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