Depuy, Amy M, MD

Flicker, Amanda B, MD

Hesham, Helai, MD

Pascual, Ana-Liza

Qureshy, Emma, MS1

Scorza, William E, MD

Smulian, John C, MD, MPH

Thomas, M Bijoy, MD

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of Obstetrics & GynecologyInvasive Placental Disease: The Impact of a Multi-Disciplinary Approach to ManagementJohn C. Smulian MD, MPHLehigh Valley Health Network, john.smulian@lvhn.orgAna-Liza PascualLehigh Valley Health NetworkHelai Hesham MDLehigh Valley Health Network, helai.hesham@lvhn.orgEmma Qureshy MS1Lehigh Valley Health Network, Emma.Qureshey@lvhn.orgM Bijoy Thomas MDLehigh Valley Health Network, M_Bijoy.Thomas@lvhn.orgSee next page for additional authorsFollow this and additional works at: https://scholarlyworks.lvhn.org/obstetrics-gynecologyPart of the Obstetrics and Gynecology CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtSmulian, JC., Pascual, A., H. Hesham, H., Qureshey, E.,Thomas, MB., Depuy, AM., Flicker, AB., & Scorza, WE. (2016, January 31).Invasive Placental Disease: The Impact of a Multi-Disciplinary Approach to Management. Poster presented at: Society of Maternal FetalMedicine Annual Scientific Meeting, Atlanta, GA.AuthorsJohn C. Smulian MD, MPH; Ana-Liza Pascual; Helai Hesham MD; Emma Qureshy MS1; M Bijoy ThomasMD; Amy M. Depuy MD; Amanda B. Flicker MD; and William E. Scorza MDThis poster is available at LVHN Scholarly Works: https://scholarlyworks.lvhn.org/obstetrics-gynecology/386•  Single center retrospective cohort study (12/2007 - 6/2014•  All peripartum hysterectomies for IPD•  IPD confirmed in specimen•  Control group (12/2007 – 9/2012)   –  Pre-multidisciplinary committee planning (No MDC)•  Study group (10/2012 – 6/2014)   –  Post-multidisciplinary committee planning (MDC)   –  MDC plan must have been followed•  Comparison of demographics, risk factors and outcomes•  MDC team   –  Maternal Fetal Medicine, Gynecologic Oncology, Urology, Interventional Radiology, Anesthesiology, Neonatology, nursing, and operating room staff© 2016 Lehigh Valley Health NetworkConclusions•  Cases of IPD managed using an MDC approach were associated with less placenta removal attempts, less blood loss, less blood product use, and higher intraoperative mean arterial pressures.•  These improvements suggest that although surgical times were increased (likely related to greater use of interventional radiology procedures and ureteral stent placements), the MDC cases were more stable intraoperatively, which over a larger number of patients, should translate into improved outcomes.HypothesisA peripartum hysterectomy for invasive placental disease (IPD) can be a planned or an unexpected emergency procedure. Unplanned hysterectomies are associated with significant morbidity and mortality when compared with planned procedures. Identifying women likely to have IPD allows physicians the opportunity to integrate a multidisciplinary, multispecialty approach for delivery in order to collectively construct an optimal management plan. LVHN implemented a formal multidisciplinary team process for suspected IPD cases in 10/2012.ABSTRACTObjective: There are current recommendations to refer pregnancies complicated by invasive placental disease (IPD-accreta, increta and percreta), to special centers with the resources and experience to optimize care. However, the specific management approach may influence outcomes. We examined the impact of implementing a structured multi-disciplinary plan for management of IPD that was strictly followed with a specified team at our tertiary referral center.Study Design: Women having peripartum hysterectomies were identified and charts were reviewed to identify all cases with clinical and/or pathologic confirmation of IPD over a 6.5 year period. For the most recent 2.5 years, a structured multidisciplinary committee (MDC) reviewed each suspected case, created a management plan, and implemented that plan. Core team members included Maternal Fetal Medicine, Gynecologic Oncology, Urology, Interventional Radiology, Anesthesiology, Neonatology, nursing, and operating room staff. Outcomes were compared between cases delivered prior to and after the MDC process was started. To be included in the MDC group for analysis, the plan that was established must have been followed.Results: There were 44 pregnancies with IPD, of which 28 (63.6%) were suspected antenatally and 37 (84.1%) had a prior uterine surgery. An MDC approach was performed in 17(38.6%) cases. There was a borderline higher rate of placenta previa in the MDC group, 14 (87.5%) vs 17 (60.7%), P=0.06. Delivery situation was unscheduled, scheduled-delivered emergent and scheduled-delivered per plan in 6.3%, 25.0% and 68.8% for the MDC group and 28.6%,10.7% and 60.7% in the No-MDC group, P=0.14. No differences were found for ICU admissions, hospital length of stay, bladder/ureteral/bowel injuries or neonatal outcomes. Conclusion: Cases of IPD managed using an MDC approach were associated with less placenta removal attempts, blood loss, fewer blood product transfusions, and higher intraoperative mean arterial pressures. These improvements suggest that although surgical times were increased (likely related to greater use of interventional radiology procedures and ureteral stent placements), the MDC cases were more stable intraoperatively, which over a larger number of patients, should translate into improved outcomes.FIGURE 1.  Intraoperative appearance of placenta previa with an invasive placenta.For women requiring a peripartum hysterectomy for IPD, having a structured multi-disciplinary plan for surgical management using a specified team is associated with improved operative outcomes.Study DesignBackground•  44 pregnancies with IPD    –  28 (63.6%) were suspected antenatally   –  37 (84.1%) had a prior uterine surgery   –  An MDC approach was performed in 16 (36.4%) cases.ResultsDepartment of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PAInvasive Placental Disease: The Impact of a Multi-Disciplinary Approach to Management Table 1: Demographics and Risk Factors   MDC(N=16)No MDC(N=28) PAge (years) 34.0  ± 5.5 34.1 ±  5.4 0.95Gravidity 5 (1,10) 4 (1,11) 0.07Parity 2 (0,5) 2 (0,7) 0.04Race 0.24   Caucasian 10  (62.5%) 19 (67.9%)   Hispanic, not African American 4 (25.0%) 8 (28.6%)   African American 2 (12.5%) 0   Other 0 1 (3.6%)BMI (kg/m2) 28.3 + 5.9 28.3 + 7.6 0.93ART 1 (6.3%) 4 (14.3%) 0.64Prior C-Section 13 (81.3%) 16 (57.1%) 0.10Prior D&C 8 (50.0%) 12 (42.9%) 0.79Any Uterine Surgery 16 (100%) 21 (75.0%) 0.03Elevated MSAFP 2/12 (16.7%) 4/20 (20.0%) 0.82Prior Postpartum Hemorrhage 2 (12.5%) 7 (25.0%) 0.27Prior Retained POC 1 (6.3%) 3 (10.7%) 0.57Comorbidities 10 (62.5 %) 15 (53.6%) 0.57Antenatal Bleeding 9 (56.3%) 14 (50.0%) 0.69Placenta Previa 14 (87.5%) 17 (60.7%) 0.05IPD Suspected Antepartum 16 (100%) 12 (42.9%) 0.0002J.C. Smulian, A. Pascual, H. Hesham, E. Qureshey, M.B. Thomas, A.M. Depuy, A.B. Flicker, W.E. ScorzaTable 2: Intraoperative Outcomes  MDC(N=16)No MDC(N=28) PEGA Admission (wks) 32.5 ± 4.2 34.4 ± 5.2 0.20EGA Delivery (wks) 33.1 ± 4.2 35.1 ± 4.7 0.17Delivery Situation   0.14   Unscheduled 1 (6.3%) 8 (28.6%)     Scheduled-Emerg 4 (25.0%) 3 (10.7%)   Scheduled-Planned 11 (68.8%) 17 (60.7%)Cesarean Section 16 (100%) 24 (85.7%) 0.28Surgical Time (min) 249 ± 66 181 ± 57 0.001Lowest Temp (C) 35.7 ± 1.2 35.3 ± 1.5 0.51Lowest MAP (mmHg) 58 (47, 94) 48 (21, 98) 0.05EBL (ml) 1250 (500, 7000) 2500  (300, 10000) 0.03Crystalloid (ml) 6,100 (2,000-13,000) 5450 (2,000-13,000) 0.66Blood Products 8 (50.0%) 24 (85.7%) 0.01   PRBC (units) 0 (0, 16) 4 (0, 25) 0.07   FFP (units) 0 (0, 16) 0 (0, 12) 0.83   Platelets (SD packs) 0 (0, 3) 0 (0, 3) 0.45   Cryoprecip (units) 0 (0, 0) 0 (0, 20) 0.12   Factor VII (doses) 0 (0, 1) 0 (0, 3) 0.18Table 3: Complications and Maternal Outcomes  MDC(N=16)No MDC(N=28) PPlacenta Removal Attempted 2 (12.5%) 20 (71.4%) 0.004IR Procedure 9 (56.3%) 4 (14.3%) 0.006Ureteral Stents Placed 12 (75.0%) 6 (21.4%) 0.001Bladder Injury/*intentional 4/*3 (25.0%) 5/*1 (17.9%) 0.70Ureter Injury 0 1 (3.6%) 0.99Ventilator >12 hrs 2 (12.5%) 7 (25.9%) 0.45Pulmonary Edema 0 2 (7.1%) 0.53ICU Admission 8 (50.0%) 17 (63.0%) 0.40ICU Length of Stay (days) 0.5 (0, 4) 1 (0, 8) 0.13Total Length of Stay (days) 6.5 (4, 18) 5 (2, 34) 0.36PP Length of Stay (days) 4 (3, 7) 4 (2, 14) 0.49Table 4: Neonatal Outcomes  MDC(N=16)No MDC(N=28) PBirthweight (g) 2348 ± 600 2657 ± 699 0.15Apgars at 5 min 8 (4, 9) 9 (2, 9) 0.31pH 7.27 ± 0.08 7.26 ± 0.07 0.87Base Deficit 2.3 (0, 8.8) 1.8 (0.2, 10.3) 0.71NICU admission 11 (68.8%) 13 (50.0%) 0.23NICU length of stay (days) 6 (0, 55) 0.5 (0, 38) 0.12  MDC No MDC p-valueDelivery EGA (wks) 33.1 35.1 0.17Placenta removal attempt 2 (12.5%) 20 (71.4%) 0.004IR embolization 9 (56.3%) 4 (14.3%) 0.006Ureteral stent 12 (75%) 6 (21.4%) 0.001Surgical time (min) 249 181 0.001EBL (ml) 1250 2500 0.03Blood product given 8 (50%) 24 (85.7% 0.01Lowest MAP 59.1 49.7 0.05

Invasive Placental Disease: The Impact of a Multi-Disciplinary Approach to Management

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Invasive Placental Disease: The Impact of a Multi-Disciplinary Approach to Management

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