Introduction:
Placenta accreta spectrum (PAS) is increasing in prevalence, with an overall rate of up to 1 in 272 women in the United States in 2016. Maternal morbidity is often high due to both the potential for massive haemorrhage and its associated risks including coagulopathy and thromboembolic disease, and the inherent surgical complexity that can lead to visceral injury and need for re-operation. International guidelines recommend a multi-disciplinary approach to management of placenta accreta spectrum to reduce maternal morbidity. An essential component of the multi-disciplinary team (MDT) is the presence of an experience pelvic surgeon, often a gynaecologic oncologist. An MDT approach to PAS has been shown to improve maternal outcomes with decreased blood loss, decreased intensive care unit (ICU) stay, and decreased post operative stay.
The Mater Mother’s Hospital (MMH) is one of the largest obstetrics services in Queensland with over 10 000 births in 2022. It is also the tertiary referral centre for southern Brisbane and southwest Queensland. A PAS MDT was established at the MMH in May 2021 with the aim of providing a multi-disciplinary approach to the assessment, delivery planning and surgical management of these high risk patients. The MDT meets at regular intervals to review newly diagnosed cases, discuss ongoing cases, and give an opportunity for correlation of the pre-operative imaging, intra-operative surgical, and pathological findings for post-operative patients. The MDT members include a radiologist experienced in diagnosing PAS, maternal fetal medicine specialists, gynaecology oncology consultants, obstetricians, neonatologists, anaesthetists and senior nursing team members.
A standardised approach to PAS was developed, that can then be tailored according to the MDT findings and the patients’ circumstances. MDT documentation includes location of placenta and area of placenta accreta, type of recommended abdominal incision, use of intraoperative cell salvage, need for optimisation of haemoglobin, and planned gestation of delivery. In cases where it is felt there is a low suspicion of PAS, a recommendation is made as to whether a gynaecology oncologist is required to be present, and whether a conservative approach would be appropriate. A gynaecological oncologist and obstetrician performed all cases of known PAS.
Aims:
To evaluate the impact of a PAS MDT on outcomes in PAS in a tertiary obstetric centre
Methods:
Review of histologically confirmed PAS patients in the 2 years prior and 2 years post establishment of the PAS MDT was undertaken from April 2019 and April 2023, as well as patients reviewed through the MDT. Patient demographic data, maternal, neonatal and surgical outcomes were examined.
Results:
Between April 2019 and April 2023, 72 cases of PAS were reviewed. 40 cases of PAS occurred prior to the establishment of the MDT. 32 cases of PAS were managed through the PAS MDT. Further data to follow.
Discussion:
An MDT approach allows for a standardised approach to pre-operative planning and potentially improved maternal outcomes. Other benefits of the MDT include sharing of information and commentary on surgical techniques as well as reflection on past cases, which provides an excellent learning and clinic-radio-pathological correlation opportunity. The PAS MDT allows for an ideal platform for improving future management of PAS, for example; identification of cases where even more individualised approaches such as fertility sparing surgery are possible, further optimising timing of delivery, or improvement in recognition and diagnosis of PAS. The PAS MDT is a critical component of not only the current, but also the future management of PAS.