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OBJECTIVE: To evaluate the utility of low-cost simulation models to teach surgical techniques for placenta accreta spectrum (PAS), included in a multimodal education workshop for PAS. METHODS: This was an observational, survey-based study. Participants were surveyed before and after the use of low-fidelity mannequins to simulate two surgical techniques for PAS (one-step conservative surgery [OSCS] and modified subtotal hysterectomy [MSTH]), within a multimodal educational workshop. The workshops included pre-course preparation, didactics, simulated practice of the techniques using low-cost models, and viewing live surgery. RESULTS: Six OSCS/MSTH training workshops occurred across six countries and a total of 270 participants were surveyed. The responses of 127 certified obstetricians and gynecologists (OB-GYNs) were analyzed. Participants expressed favorable impressions of all components of the simulated session. Perceived anatomical simulator fidelity, scenario realism, educational component effectiveness, and self-assessed performance improvement received ratings of 4-5 (positive end of the Likert scale) from over 90% of respondents. When asked about simulation's role in technique comprehension, comfort level in technique performance, and likelihood of recommending this workshop to others, more than 75% of participants rated these aspects with a score of 4-5 (positively) on the five-point scale. CONCLUSION: Low-cost simulation, within a multimodal education strategy, is a well-accepted intervention for teaching surgical techniques for PAS.

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Introducción: El amniocele es una hernia del saco amniótico a través de un defecto en la pared del útero, el cual puede deberse a ruptura uterina, secundario a daños preexistentes, anomalías uterinas o en un útero sin cicatrices. Caso clínico: Presentamos el caso de una paciente de 37 años, con antecedente de dos partos por cesárea, a quien en la semana 25,5 de embarazo se le diagnostica por ecografía amniocele en la pared anterior de útero contenido por la vejiga, además de signos ecográficos de acretismo placentario. La posterior realización de resonancia magnética confirma el diagnóstico. Se realiza manejo expectante con estancia continua intrahospitalaria estricta. Resolución obstétrica a las 34 semanas por cesárea, con extracción fetal por fondo uterino sin complicaciones, con posterior realización de histerectomía con placenta in situ. Conclusiones: Este reporte de caso ilustra la importancia de la identificación temprana de esta condición por ser una complicación infrecuente, pero de grave pronóstico fetomaterno en ausencia de atención inmediata.

Introduction: Amniocele is a hernia of the amniotic sac through a defect in the uterine wall, which can be caused by uterine rupture secondary to preexisting damage, uterine anomalies, or a scarless uterus. Case report: We present a case of a 37-year-old patient with a history of two previous cesarean deliveries. At 25.5 weeks of gestation, the diagnosis of amniocele in the anterior uterine wall, contained by the bladder, along with ultrasound signs of placenta accreta, was confirmed through ultrasound. Subsequent magnetic resonance imaging further confirmed the diagnosis. Expectant management with strict continuous intrahospital stay was implemented. Obstetric resolution was achieved at 34 weeks through cesarean delivery, with uncomplicated fetal extraction through the uterine fundus. Subsequently, a hysterectomy was performed with the placenta left in situ. Conclusions: This case report illustrates the importance of early identification of this condition due to its infrequent but serious feto-maternal prognosis in the absence of immediate attention.

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OBJECTIVE: The aim of this study was to explore how obstetricians-gynecologists in low- and middle-income countries (LMICs) can apply current international clinical practice guidelines (CPGs) for the management of placenta accreta spectrum (PAS) in limited resource settings. METHODS: This was an observational, survey-based study. Clinicians with expertise in managing patients with PAS in LMICs were contacted for their evaluation of the recommendations included in four PAS clinical practice guidelines. RESULTS: Out of the 158 clinicians contacted, we obtained responses from 65 (41.1%), representing 27 middle income countries (MICs). The results of this survey suggest that the care of PAS patients in middle income countries is very different from what is recommended by international CPGs. Participants in the survey identified that their practice was limited by insufficient availability of hospital infrastructure, low resources of local health systems and lack of trained multidisciplinary teams (MDTs) and this did not enable them to follow CPG recommendations. Two-thirds of the participants surveyed describe the absence of centers of excellence in their country. In over half of the referral hospitals with expertise in managing PAS, there are no MDTs. One-third of patients with intraoperative findings of PAS are managed by the team initially performing the surgery (without additional assistance). CONCLUSION: The care of patients with PAS in middle income countries frequently deviates from established CPG recommendations largely due to limitations in local resources and infrastructure. New practical guidelines and training programs designed for low resource settings are needed.

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OBJECTIVE: The optimal management of placenta accreta spectrum (PAS) requires the participation of multidisciplinary teams that are often not locally available in low-resource settings. Telehealth has been increasingly used to manage complex obstetric conditions. Few studies have explored the use of telehealth for PAS management, and we aimed evaluate the usage of telehealth in the management of PAS patients in low-resource settings. METHODS: Between March and April 2023, an observational, survey-based study was conducted, and obstetricians-gynecologists with expertise in PAS management in low- and middle-income countries were contacted to share their opinion on the potential use of telehealth for the diagnosis and management of patients at high-risk of PAS at birth. Participants were identified based on their authorship of at least one published clinical study on PAS in the last 5 years and contacted by email. This is a secondary analysis of the results of that survey. RESULTS: From 158 authors contacted we obtained 65 responses from participants in 27 middle-income countries. A third of the participants reported the use of telehealth during the management obstetric emergencies (38.5%, n = 25) and PAS (36.9%, n = 24). Over 70% of those surveyed indicated that they had used "informal" telemedicine (phone call, email, or text message) during PAS management. Fifty-nine participants (90.8%) reported that recommendations given remotely by expert colleagues were useful for management of patients with PAS in their setting. CONCLUSION: Telehealth has been successfully used for the management of PAS in middle-income countries, and our survey indicates that it could support the development of specialist care in other low resource settings.

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El espectro acretismo placentario es una patología que cursa con una alta morbimortalidad, viéndose en los últimos años un incremento en su incidencia y cobrando relevancia por la tasa de cesáreas en aumento, siendo su principal factor de riesgo. Se describe el caso de una paciente de 32 años, portadora de acretismo placentario, diagnosticado mediante ecografía a las 31 semanas de edad gestacional, donde se logró planificar paso a paso la cirugía con equipo, colocando previo a la cirugía balones en arterias hipogástricas y catéter doble Jota, haciendo una estadificación intraoperatoria detallada. A propósito del caso clínico se realiza una revisión y actualización de la patología, enfatizando en la planificación detallada de la cirugía y el abordaje con equipos de referencia.

Placenta Accreta Spectrum is a condition associated with high morbidity and mortality. In recent years, there has been an increase in its incidence, highlighting its importance due to the rising rate of cesarean sections which is its main risk factor. A case is described of a 32-year-old patient with placenta accreta, diagnosed via ultrasound at 31 weeks of gestation. The surgery was meticulously planned with the team, including the placement of balloons in the hypogastric arteries and a double-J catheter, allowing for detailed intraoperative staging. In relation to the clinical case, a review and update of the pathology is carried out, emphasizing the detailed planning of the surgery and the approach in specialized teams.

O Espectro do Acretismo Placentário é uma patologia de alta morbimortalidade, com incidência crescente nos últimos anos e ganhando relevância devido ao aumento da taxa de cesarianas, sendo este o seu principal fator de risco. Descrevemos o caso de uma paciente de 32 anos com acretismo placentário, diagnosticado por ultrassonografia com 31 semanas de idade gestacional, na qual a cirurgia foi planejada passo a passo com a equipe multidisciplinar, com a colocação de balões nas artérias hipogástricas e um cateter duplo jack antes da cirurgia e realizando um estadiamento intraoperatório detalhado. Uma revisão e atualização da bibliografia, enfatizando o planejamento detalhado da cirurgia e a abordagem em equipes composta por profissionais de várias especialidades médicas.

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SUMMARY OBJECTIVE: Placenta accreta spectrum (PAS) is defined as the attachment of the placenta to the uterine wall in varying degrees. However, the studies have explored that the underlying molecular mechanisms of the PAS are very limited. Sirtuins 1 (SIRT1) is associated with placental development by controlling trophoblast cell invasion and remodeling of spiral arteries. We aimed to determine the expression level of SIRT1 in placentas, and maternal and umbilical cord serum of patients with PAS. METHODS: In total, 30 individuals in control, 20 patients in the placenta previa group, and 30 patients in the PAS group were included in this study. The expression levels of SIRT1 in the placentas were determined by Western blot and immunohistochemistry. Serum levels of SIRT1 in maternal and umbilical cord blood were determined by ELISA. RESULTS: SIRT1 was significantly lower in placentas of the PAS. However, maternal and umbilical cord serum samples were not significantly different between groups. CONCLUSION: SIRT1 may play an important role in the pathogenesis of the PAS.

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Abstract Objective To describe a cohort of placenta accreta spectrum (PAS) cases from a tertiary care institution and compare the maternal outcomes before and after the creation of a multidisciplinary team (MDT). Methods Retrospective study using hospital databases. Identification of PAS cases with pathological confirmation between 2010 and 2021. Division in two groups: standard care (SC) group - 2010-2014; and MDT group - 2015-2021. Descriptive analysis of their characteristics and maternal outcomes. Results During the study period, there were 53 cases of PAS (24 - SC group; 29 - MDT group). Standard care group: 1 placenta increta and 3 percreta; 12.5% (3/24) had antenatal suspicion; 4 cases had a peripartum hysterectomy - one planned due to antenatal suspicion of PAS; 3 due to postpartum hemorrhage. Mean estimated blood loss (EBL) was 2,469 mL; transfusion of packed red blood cells (PRBC) in 25% (6/24) - median 7.5 units. Multidisciplinary team group: 4 cases of placenta increta and 3 percreta. The rate of antenatal suspicion was 24.1% (7/29); 9 hysterectomies were performed, 7 planned due to antenatal suspicion of PAS, 1 after intrapartum diagnosis of PAS and 1 after uterine rupture following a second trimester termination of pregnancy. The mean EBL was 1,250 mL, with transfusion of PRBC in 37.9% (11/29) - median 2 units. Conclusion After the creation of the MDT, there was a reduction in the mean EBL and in the median number of PRBC units transfused, despite the higher number of invasive PAS disorders.

Resumo Objetivo Descrever uma coorte de casos do espectro do acretismo placentário (PAS) de uma instituição terciária e comparar os resultados maternos antes e depois da criação de uma equipa multidisciplinar (MDT). Métodos Estudo retrospectivo utilizando bancos de dados hospitalares. Identificação de casos de PAS com confirmação patológica entre 2010 e 2021. Divisão em dois grupos: grupo Standard Care (SC) - 2010-2014; e grupo MDT - 2015-2021. Análise descritiva de suas características e desfechos maternos. Resultados Durante o período do estudo, houve 53 casos de PAS (24 - grupo SC; 29 - grupo MDT). Grupo Standard Care: 1 placenta increta e 3 percretas; 12,5% (3/24) tiveram suspeita anteparto; 4 casos tiveram histerectomia periparto - uma eletiva devido à suspeita anteparto de PAS; 3 devido a hemorragia pós-parto. A média de perda hemática estimada (EBL) foi de 2.469 mL; transfusão de concentrado eritrocitário (PRBC) em 25% (6/24) - mediana 7,5 unidades. Equipa multidisciplinar: 4 casos de placenta increta e 3 percretas. A taxa de suspeita anteparto foi de 24,1% (7/29); foram realizadas 9 histerectomias, 7 eletivas por suspeita anteparto de PAS, 1 após diagnóstico intraparto de PAS e 1 após rotura uterina após interrupção da gravidez no segundo trimestre. A EBL média foi de 1.250 mL, com transfusão de PRBC em 37,9% (11/29) - mediana de 2 unidades. Conclusão Após a criação da MDT, houve redução na média de EBL e na mediana do número de unidades de PRBC transfundidas, apesar do maior número de PAS invasivos.

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Objetivos: Describir las características clínicas y el tratamiento del embarazo ectópico implantado en la cicatriz de cesárea, así como las complicaciones y el pronóstico obstétrico. Materiales y métodos: Estudio de cohorte retrospectivo de gestantes con diagnóstico de embarazo ectópico implantado en la cicatriz de cesárea según los criterios de la Sociedad de Medicina Materno-Fetal, atendidas entre enero de 2018 y marzo de 2022 en dos instituciones de alta complejidad, pertenecientes a la seguridad social, ubicadas en Lima, Perú. Se hizo un muestreo consecutivo. Se midieron variables sociodemográficas y clínicas de ingreso, diagnóstico, tipo de tratamiento, complicaciones y pronóstico obstétrico. Se hace un análisis descriptivo. Resultados: Se incluyeron 17 pacientes, de 29.919 partos. De estas, el 41,2 % recibió tratamiento médico y el resto recibió tratamiento quirúrgico. Se realizó un manejo local exitoso con metotrexato en el saco gestacional en dos pacientes con ectópico tipo 2. Cuatro de las pacientes requirieron histerectomía total. Seis pacientes experimentaron una gestación después del tratamiento, y 4 de ellas culminaron el embarazo con una madre y un neonato saludables. Conclusiones: El embarazo ectópico implantado en la cicatriz de una cesárea es una entidad poco frecuente, para la cual se cuenta con alternativas de manejo médico y quirúrgico con aparentes buenos resultados. Se requieren más estudios con mayor calidad metodológica de asignación aleatoria que ayuden a caracterizar la seguridad y la efectividad de las diferentes alternativas terapéuticas para las mujeres con sospecha de esta patología.

Objectives: To describe the clinical characteristics and treatment of ectopic pregnancy arising in the cesarean section scar, as well as its complications and obstetric prognosis. Material and methods: Retrospective cohort study of pregnant women with the diagnosis of a scar pregnancy in accordance with Maternal-Fetal Medicine Society criteria, seen between January 2018 and March 2022 in two high complexity institutions of the social security system, located in Lima, Peru. Consecutive sampling was used. Baseline sociodemographic and clinical variables were measured, including diagnosis, type of treatment, complications and obstetric prognosis. A descriptive analysis was performed. Results: Out of 29,919 deliveries, 17 patients were included. Of these, 41.2 % received medical management and the rest were treated surgically. Successful management with intra-gestational sac methotrexate was performed in two patients with ectopic pregnancy type 2. Four patients required total hysterectomy. Six patients became pregnant after the treatment and 4 completed their pregnancy with healthy mother and neonate pairs. Conclusions: Ectopic pregnancy implanted in a cesarean section scar is an infrequent occurrence for which medical and surgical management options are available with apparently good outcomes. Further studies of better methodological quality and random assignment are needed in order to help characterize the safety and effectiveness of the various therapeutic options for women with suspected scar pregnancy.

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OBJECTIVE: Describe the clinical-surgical results of patients with PAS in the low-posterior cervical-trigonal space associated with fibrosis (PAS type 4) compared with PAS types in other locations (Types 1, upper bladder, 2 in upper parametrium) and in particular with PAS type 3, corresponding to dissectible cervical-trigonal invasion. The clinical-surgical results of using a standard hysterectomy were analyzed with a modified subtotal hysterectomy (MSTH) in patients with PAS type 4. MATERIAL AND METHODS: A descriptive, retrospective, multicenter study included 337 patients of PAS; thirty-two corresponding to PAS type 4, from three PAS reference hospitals, CEMIC, Buenos Aires, Argentina, Fundación Valle de Lili, Cali, Colombia, and Dr. Soetomo General Hospital, Surabaya, Indonesia, between January 2015 and December 2020. PAS was diagnosed by abdominal and transvaginal ultrasound and topographically characterized by ultrafast T2 weighted MRI. In persistent macroscopic hematuria after MSTH, the surgeon performs an intentional cystotomy and uses a square compression suture to achieve the hemostasis inside the bladder wall.According to a PAS topographical classification, the patients with low-vesical cervical involvement compared with PAS located in relation with the upper blader (type1), upper parametrium (type 2 upper), and also with PAS situated in the lower vesical-trigon space (type 3). PAS 3 and 4 are located in identical area, but in type 3, group A, the vesicouterine space was dissectible, and in type 4, group B, significant fibrosis made surgical dissection extremely challenging. Furthermore, group B was divided into patients treated with total hysterectomy (HT) and those treated with a modified subtotal hysterectomy (MSTH). The surgical requirements to perform an MSHT included the availability of proximal vascular control at the aortic level (internal manual aortic compression, aortic endovascular balloon, aortic loop, or aortic cross-clamping). Then surgeon performed an upper segmental hysterotomy, avoiding the abnormal placenta invasion area; after that, the fetus was delivered, and the umbilical cord was ligated.After uterine exteriorization, the surgeon applies a continuous circular suture with number 2 polyglactin 910, taking some portions of the myometrium -to avoid unintentional slipping- around the lower uterine segment and a 3-4 cm proximal to the abnormal adhesion of the placenta. After tightening hard the circular suture, the uterine segment was circumferentially cut, three centimeters proximal to the circular hemostatic sutures. Next, the surgery follows the upper steps of conventional hysterectomy without changes. Additionally, the histological presence of fibrosis was examined in all samples. RESULTS: Modified subtotal hysterectomy in patients with PAS type 4 (cervical-trigonal fibrosis) resulted in a significant clínico-surgical improvement over total hysterectomy. The median operative time and intraoperative bleeding were 140 min (IQR 90--240) and 1895 mL (IQR 1300-2500) in patients undergoing modified subtotal hysterectomy, and 260 min (IQR 210-287) and 2900 mL (IQR 2150-5500) in patients treated with total hysterectomy, respectively. The complication rate was 20% for MSHT and 82.3% for patients with a total hysterectomy. CONCLUSIONS: PAS in the cervical trigonal area associated with fibrosis implies a greater risk of complications due to uncontrollable bleeding and organ damage. MSTH is associated with lower morbidity and difficulties in PAS type 4. Prenatal or intrasurgical diagnosis is essential to plan surgical alternatives to improve the results.

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Objectives: To describe the clinical characteristics and treatment of ectopic pregnancy arising in the cesarean section scar, as well as its complications and obstetric prognosis. Material and methods: Retrospective cohort study of pregnant women with the diagnosis of a scar pregnancy in accordance with Maternal-Fetal Medicine Society criteria, seen between January 2018 and March 2022 in two high complexity institutions of the social security system, located in Lima, Peru. Consecutive sampling was used. Baseline sociodemographic and clinical variables were measured, including diagnosis, type of treatment, complications and obstetric prognosis. A descriptive analysis was performed. Results: Out of 29,919 deliveries, 17 patients were included. Of these, 41.2 % received medical management and the rest were treated surgically. Successful management with intra-gestational sac methotrexate was performed in two patients with ectopic pregnancy type 2. Four patients required total hysterectomy. Six patients became pregnant after the treatment and 4 completed their pregnancy with healthy mother and neonate pairs. Conclusions: Ectopic pregnancy implanted in a cesarean section scar is an infrequent occurrence for which medical and surgical management options are available with apparently good outcomes. Further studies of better methodological quality and random assignment are needed in order to help characterize the safety and effectiveness of the various therapeutic options for women with suspected scar pregnancy.

Objetivos: describir las características clínicas y el tratamiento del embarazo ectópico implantado en la cicatriz de cesárea, así como las complicaciones y el pronóstico obstétrico. Materiales y métodos: estudio de cohorte retrospectivo de gestantes con diagnóstico de embarazo ectópico implantado en la cicatriz de cesárea según los criterios de la Sociedad de Medicina Materno-Fetal, atendidas entre enero de 2018 y marzo de 2022 en dos instituciones de alta complejidad, pertenecientes a la seguridad social, ubicadas en Lima, Perú. Se hizo un muestreo consecutivo. Se midieron variables sociodemográficas y clínicas de ingreso, diagnóstico, tipo de tratamiento, complicaciones y pronóstico obstétrico. Se hace un análisis descriptivo. Resultados: se incluyeron 17 pacientes, de 29.919 partos. De estas, el 41,2 % recibió tratamiento médico y el resto recibió tratamiento quirúrgico. Se realizó un manejo local exitoso con metotrexato en el saco gestacional en dos pacientes con ectópico tipo 2. Cuatro de las pacientes requirieron histerectomía total. Seis pacientes experimentaron una gestación después del tratamiento, y 4 de ellas culminaron el embarazo con una madre y un neonato saludables. Conclusiones: el embarazo ectópico implantado en la cicatriz de una cesárea es una entidad poco frecuente, para la cual se cuenta con alternativas de manejo médico y quirúrgico con aparentes buenos resultados. Se requieren más estudios con mayor calidad metodológica de asignación aleatoria que ayuden a caracterizar la seguridad y la efectividad de las diferentes alternativas terapéuticas para las mujeres con sospecha de esta patología.

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La placenta acreta se define como una invasión trofoblástica anormal de una parte o de toda la placenta a nivel de las paredes miometriales del útero. La incidencia de acretismo placentario viene cada vez más y más en aumento. El factor de riesgo más común es la presencia de cesárea y la posibilidad de cursar con acretismo placentario aumenta entre más cesáreas tenga la paciente. Hay pocos datos acerca de acretismo placentario localizado en mioma uterino, sobre todo en el contexto de una paciente primigestante. Se presenta el caso de una primigestante tardía, quien cursó con embarazo de alto riesgo dado por acretismo placentario localizado en mioma intramural; asimismo, hacemos una revisión de la literatura acerca del diagnóstico oportuno y pronóstico de esta condición. (provisto por Infomedic International)

Placenta accreta is defined as an abnormal trophoblastic invasion of part or all of the placenta at the level of the myometrial walls of the uterus. The incidence of placental accreta is increasingly on the rise. The most common risk factor is the presence of cesarean section and the likelihood of placental accreta increases the more cesarean sections the patient has. There is little data on placental accreta located in uterine myoma, especially in the context of a primigestational patient. We present the case of a late primigestation, who had a high-risk pregnancy due to placental accreta located in an intramural myoma; we also review the literature on the timely diagnosis and prognosis of this condition. (provided by Infomedic International)

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OBJECTIVES: To evaluate surgical outcomes of using a double uterine segment tourniquet in obstetric hysterectomy for bleeding control in patients with placenta accreta spectrum. METHODS: Retrospective case-control study conducted at the Central Hospital of San Luis Potosi, Mexico. Patients with the diagnosis of placenta accreta spectrum who underwent obstetric hysterectomy were included. Two groups were formed: in the first, a double uterine segment tourniquet was used; and in the second, the hysterectomy was performed without a tourniquet. Primary surgical outcomes were compared. RESULTS: Forty patients in each group were included. The use of a double uterine segment tourniquet had lower total blood loss compared with the non-tourniquet group (1054.00 ± 467.02 vs. 1528.75 ± 347.12 mL, P = 0.0171) and a lower drop in hemoglobin (1.74 ± 1.10 vs. 2.60 ± 1.25 mg/dL, P = 0.0486). Ten patients (23.80%) in the double tourniquet group required blood transfusion, compared with 26 (65.00%) in the non-tourniquet group (P = 0.0003). Surgical time did not show a statistical difference between groups. CONCLUSION: The use of a uterine segment tourniquet in obstetric hysterectomy may improve surgical outcomes in patients with placenta accreta spectrum with no difference in surgical time and urinary tract lesions.

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SUMMARY OBJECTIVE: This study aimed to investigate the expression levels of sirtuin 2 and sirtuin 7 in the placenta accreta spectrum to reveal their role in its pathogenesis. METHODS: A total of 30 placenta accreta spectrum, 20 placenta previa, and 30 controls were experienced. The sirtuin 2 and sirtuin 7 expression levels in the placentas of these groups were determined by Western blot. sirtuin 2 and sirtuin 7 serum levels in the maternal and fetal cord blood were examined by enzyme-linked immunosorbent assay. RESULTS: It was found that sirtuin 7 in placenta accreta spectrum was significantly lower in the placenta compared to the control and placenta previa groups (p<0.05). However, a significant difference was not observed between the sirtuin 2 and sirtuin 7 levels in the maternal and fetal cord serum samples of those three groups (p>0.05). CONCLUSION: Sirtuin 7 may play an important role in the formation of placenta accreta spectrum. The effect of decreased expression of sirtuin 7 might be tissue-dependent in the placenta accreta spectrum and needs to be investigated further.

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Resumen ANTECEDENTES: Las malformaciones müllerianas son consecuencia de una alteración en la formación de los conductos de Müller durante el desarrollo del feto. El momento en que sucede la alteración determina el tipo de malformación. La clasificación actual es la de la American Society for Reproductive Medicine ASMR que se asocia con múltiples complicaciones obstétricas, entre las más graves está la ruptura uterina. CASO CLÍNICO: Paciente primigesta de 23 años, con 39.1 semanas de embarazo, sin antecedentes personales patológicos para el padecimiento actual, sin control prenatal, con dolor abdominal intenso generalizado y disminución de los movimientos fetales desde 12 horas previas a su valoración. Al ingreso de la paciente al hospital su feto se encontró muerto; hemoglobina de 7.9 g/dL, tensión arterial de 96-53 mmHg, taquicárdica, con datos clínicos de irritación peritoneal. En la laparotomía exploradora el feto se encontró muerto, en la cavidad abdominal. Hemoperitoneo de 1300 mL, útero didelfo, con ruptura uterina hacia el fondo. Datos de acretismo placentario. Por lo anterior, se procedió a la histerectomía obstétrica, con sangrado de 2000 cc. Fue necesaria la reanimación y la permanencia de 24 horas en la unidad de cuidados intensivos. La TAC abdomino-pélvica se reportó sin alteraciones renales, con una tumoración adherida cerca del peritoneo parietal sugerente de riñón ectópico. El puerperio trascurrió sin contratiempos por lo que fue dada de alta del hospital. CONCLUSIÓN: En el embarazo, las malformaciones müllerianas son causa de complicaciones obstétricas graves, entre ellas la ruptura uterina. El diagnóstico oportuno es decisivo para la prevención de complicaciones y el control prenatal.

Abstract BACKGROUND: Müllerian malformations are the consequence of an alteration in the formation of the Müllerian ducts during fetal development. The time at which the alteration occurs determines the type of malformation. The current classification is that of the American Society for Reproductive Medicine ASMR, which is associated with multiple obstetric complications, among the most serious of which is uterine rupture. CLINICAL CASE: A 23-year-old primigravid patient, 39.1 weeks pregnant, with no personal pathological history for the current condition, without prenatal control, with severe generalized abdominal pain and decreased fetal movements for 12 hours prior to her evaluation. On the patient admission to the hospital her fetus was found dead; hemoglobin 7.9 g/dL, blood pressure 96-53 mmHg, tachycardic, with clinical data of peritoneal irritation. At exploratory laparotomy the fetus was found dead, in abdominal cavity. Hemoperitoneum of 1300 mL, didelphic uterus, with uterine rupture towards the fundus. Data of placental accretism. Therefore, obstetric hysterectomy was performed, with bleeding of 2000 cc. Resuscitation and a 24-hour stay in the intensive care unit was necessary. The abdomino-pelvic CT scan showed no renal alterations, with an adherent tumor near the parietal peritoneum suggestive of ectopic kidney. The puerperium was uneventful, and she was discharged from the hospital. CONCLUSION: In pregnancy, Müllerian malformations are a cause of serious obstetric complications, including uterine rupture. Timely diagnosis is decisive for the prevention of complications and prenatal management.

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Abstract Objective To describe the clinical results of patients admitted and managed as cases of placenta accreta spectrum (PAS) at a Central American public hospital and the influence of the prenatal diagnosis on the condition. Materials and Methods A retrospective analysis of PAS patients treated at Hospital Bertha Calderón Roque, in Managua, Nicaragua, between June 2017 and September 2021. The diagnostic criteria used were those of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, in French). The population was divided into patients with a prenatal ultrasonographic diagnosis of PAS (group 1) and those whose the diagnosis of PAS was established at the time of the caesarean section (group 2). Results During the search, we found 103 cases with a histological and/or clinical diagnosis of PAS; groups 1 and 2 were composed of 51 and 52 patients respectively. Regarding the clinical results of both groups, the patients in group 1 presented a lower frequency of transfusions (56.9% versus 96.1% in group 2), use of a lower number of red blood cell units (RBCUs) among those undergoing transfusions (median: 1; interquartile range: [IQR]: 0-4 versus median: 3; [IQR]: 2-4] in group 2), and lower frequency of 4 or more RBCU transfusions (29.4% versus 46.1% in group 2). Group 1 also exhibited a non-significant trend toward a lower volume of blood loss (1,000 mL [IQR]: 750-2,000 mL versus 1,500 mL [IQR]: 1,200-1,800 mL in group 2), and lower requirement of pelvic packing (1.9% versus 7.7% in group 2). Conclusion Establishing a prenatal diagnosis of PAS is related to a lower frequency of transfusions. We observed a high frequency of prenatal diagnostic failures of PAS. It is a priority to improve prenatal detection of this disease.

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Introduction: Placenta accreta spectrum (PAS) is a condition associated with massive postpartum bleeding and maternal mortality. Management guidelines published in high income countries recommend the participation of interdisciplinary teams in hospitals with sufficient resources for performing complex procedures. However, some of the recommendations contained in those guidelines are difficult to implement in low and medium income countries. Objectives: The aim of this consensus is to draft general recommendations for the treatment of PAS in Colombia. Materials and methods: Twenty-three panelists took part in the consensus with their answers to 31 questions related to the treatment of PAS. The panelists were selected based on participation in two surveys designed to determine the resolution capabilities of national and regional hospitals. The modified Delphi methodology was used, introducing two successive discussion rounds. The opinions of the participants, with a consensus of more than 80%, as well as implementation barriers and facilitators, were taken into consideration in order to issue the recommendations. Results: The consensus draftedfive recommendations, integrating the answers of the panelists. Recommendation 1. Primary care institutions must undertake active search of PAS in patients with risk factors: placenta praevia and history of myomectomy or previous cesarean section. In case of ultrasound signs suggesting PAS, patients must be immediately referred, without a minimum gestational age, to hospitals recognized as referral centers. Online communication and care modalities may facilitate the interaction between primary care institutions and referral centers for PAS. The risks and benefits of telemedicine modalities must be weighed. Recommendation 2. Referral hospitals for PAS need to be defined in each region of Colombia, ensuring coverage throughout the national territory. It is advisable to concentrate the flow of patients affected by this condition in a few hospitals with surgical teams specifically trained in PAS, availability of specialized resources, and institutional efforts at improving quality of care with the aim of achieving better health outcomes in pregnant women with this condition. To achieve this goal, participants recommend that healthcare regulatory agencies at a national and regional level should oversee the process of referral for these patients, expediting administrative pathways in those cases in which there is no prior agreement between the insurer and the selected hospital or clinic. Recommendation 3. Referral centers for patients with PAS are urged to build teams consisting of a fixed group of specialists (obstetricians, urologists, general surgeons, interventional radiologists) entrusted with the care of all PAS cases. It is advisable for these interdisciplinary teams to use the "intervention bundle" model as a guidance for building PAS referral centers. This model comprises the following activities: service preparedness, disease prevention and identification, response to the occurrence of the disease, and debriefing after every event. Telemedicine facilitates PAS treatment and should be taken into consideration by interdisciplinary teams caring for this disease. Recommendation 4. Obstetrics residents must be instructed in the performance of maneuvers that are useful for the prevention and treatment of massive intraoperative bleeding due to placenta praevia and PAS, including manual aortic compression, uterine tourniquet, pelvic packing, retrovesical bypass, and Ward maneuver. Specialization Obstetrics and Gynecology programs in Colombia must include the basic concepts of the diagnosis and treatment of PAS. Referral centers for PAS must offer online and in-person training programs for professionals interested in improving their competencies in PAS. Moreover, they must offer permanent remote support (telemedicine) to other hospitals in their region for patients with this condition. Recommendation 5. Patients suspected of having PAS and placenta praevia based on imaging, with no evidence of active vaginal bleeding, must be delivered between weeks 34 and 36 6/7. Surgical treatment must include sequential interventions that may vary depending on the characteristics of the lesion, the clinical condition of the patient and the availability of resources. The surgical options (total and subtotal hysterectomy, one-stage conservative surgical management and watchful waiting) must be included in a protocol known by the entire interdisciplinary team. In situations in which an antepartum diagnosis is lacking, that is to say, in the face of intraoperative finding of PAS (evidence of purple bulging or neovascularization of the anterior aspect of the uterus), and the participation of untrained personnel, three options are considered: Option 1: In the absence of indication of immediate delivery or of vaginal delivery, the recommendation is to postpone the cesarean section (close the laparotomy before incising the uterus) until the recommended resources for safe surgery are secured. Option 2: If there is an indication for immediate delivery (e.g., non-reassuring fetal status) but there is absence of vaginal bleeding or indication for immediate PAS management, a two-stage management is suggested: cesarean section avoiding placental incision, followed by uterine repair and abdominal closure, until the availability of the recommended resources for safe surgery is ascertained. Option 3: In the event of vaginal bleeding that prevents definitive PAS management, the fetus must be delivered through the uterine fundus, followed by uterine repair and reassessment of the situation. Sometimes, fetal delivery diminishes placental flow and vaginal bleeding is reduced or disappears, enabling the possibility to postpone definitive management of PAS. In case of persistent significant bleeding, hysterectomy should be performed, using all available resources: manual aortic compression, immediate call to the surgeons with the best available training, telemedicine support from expert teams in other hospitals. If a patient with risk factors for PAS (e.g., myomectomy or previous cesarean section) has a retained placenta after vaginal delivery, it is advisable to confirm the possibility of such diagnosis (by means of ultrasound, for example) before proceeding to manual extraction of the placenta. Conclusions: It is our hope that this first Colombian consensus on PAS will serve as a basis for additional discussions and collaborations that can result in improved clinical outcomes for women affected by this condition. Additional research will be required in order to evaluate the applicability and effectiveness of these recommendations.

Introducción: el espectro de acretismo placentario (EAP) es una condición asociada a sangrado masivo posparto y mortalidad materna. Las guías de manejo publicadas en países de altos ingresos recomiendan la participación de grupos interdisciplinarios en hospitales con recursos suficientes para realizar procedimientos complejos. Sin embargo, algunas de las recomendaciones de estas guías resultan difíciles de aplicar en países de bajos y medianos ingresos. Objetivos: este consenso busca formular recomendaciones generales para el tratamiento del EAP en Colombia. Materiales y métodos: en el consenso participaron 23 panelistas, quienes respondieron 31 preguntas sobre el tratamiento de EAP. Los panelistas fueron seleccionados con base en la participación en dos encuestas realizadas para determinar la capacidad resolutiva de hospitales en el país y la región. Se utilizó la metodología Delphi modificada, incorporando dos rondas sucesivas de discusión. Para emitir las recomendaciones el grupo tomó en cuenta la opinión de los participantes, que lograron un consenso mayor al 80 %, así como las barreras y los facilitadores para su implementación. Resultados: el consenso formuló cinco recomendaciones integrando las respuestas de los panelistas. Recomendación 1. Las instituciones de atención primaria deben realizar búsqueda activa de EAP en pacientes con factores de riesgo: placenta previa e historia de miomectomía o cesárea en embarazo previo. En caso de haber signos sugestivos de EAP por ecografía, las pacientes deben ser remitidas de manera inmediata, sin tener una edad gestacional mínima, a hospitales reconocidos como centros de referencia. Las modalidades virtuales de comunicación y atención en salud pueden facilitar la interacción entre las instituciones de atención primaria y los centros de referencia para EAP. Se debe evaluar el beneficio y riesgo de las modalidades de telemedicina. Recomendación 2. Es necesario que se definan hospitales de referencia para EAP en cada región de Colombia, asegurando el cubrimiento de la totalidad del territorio nacional. Es aconsejable concentrar el flujo de pacientes afectadas por esta condición en unos pocos hospitales, donde haya equipos de cirujanos con entrenamiento específico en EAP, disponibilidad de recursos especializados y un esfuerzo institucional por mejorar la calidad de atención, en busca de tener mejores resultados en la salud de las gestantes con esta condición. Para lograr ese objetivo los participantes recomiendan que los entes reguladores de la prestación de servicios de salud a nivel nacional, regional o local vigilen el proceso de remisión de estas pacientes, facilitando rutas administrativas en caso de que no exista contrato previo entre el asegurador y el hospital o la clínica seleccionada (IPS). Recomendación 3. En los centros de referencia para pacientes con EAP se invita a la creación de equipos que incorporen un grupo fijo de especialistas (obstetras, urólogos, cirujanos generales, radiólogos intervencionistas) encargados de atender todos los casos de EAP. Es recomendable que esos grupos interdisciplinarios utilicen el modelo de "paquete de intervención" como guía para la preparación de los centros de referencia para EAP. Este modelo consta de las siguientes actividades: preparación de los servicios, prevención e identificación de la enfermedad, respuesta ante la presentación de la enfermedad, aprendizaje luego de cada evento. La telemedicina facilita el tratamiento de EAP y debe ser tenida en cuenta por los grupos interdisciplinarios que atienden esta enfermedad. Recomendación 4. Los residentes de Obstetricia deben recibir instrucción en maniobras útiles para la prevención y el tratamiento del sangrado intraoperatorio masivo por placenta previa y EAP, tales como: la compresión manual de la aorta, el torniquete uterino, el empaquetamiento pélvico, el bypass retrovesical y la maniobra de Ward. Los conceptos básicos de diagnóstico y tratamiento de EAP deben incluirse en los programas de especialización en Ginecología y Obstetricia en Colombia. En los centros de referencia del EAP se deben ofrecer programas de entrenamiento a los profesionales interesados en mejorar sus competencias en EAP de manera presencial y virtual. Además, deben ofrecer soporte asistencial remoto (telemedicina) permanente a los demás hospitales en su región, en relación con pacientes con esa enfermedad. Recomendación 5. La finalización de la gestación en pacientes con sospecha de EAP y placenta previa, por imágenes diagnósticas, sin evidencia de sangrado vaginal activo, debe llevarse a cabo entre las semanas 34 y 36 6/7. El tratamiento quirúrgico debe incluir intervenciones secuenciales que pueden variar según las características de la lesión, la situación clínica de la paciente y los recursos disponibles. Las opciones quirúrgicas (histerectomía total y subtotal, manejo quirúrgico conservador en un paso y manejo expectante) deben incluirse en un protocolo conocido por todo el equipo interdisciplinario. En escenarios sin diagnóstico anteparto, es decir, ante un hallazgo intraoperatorio de EAP (evidencia de abultamiento violáceo o neovascularización de la cara anterior del útero), y con participación de personal no entrenado, se plantean tres situaciones: Primera opción: en ausencia de indicación de nacimiento inmediato o sangrado vaginal, se recomienda diferir la cesárea (cerrar la laparotomía antes de incidir el útero) hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura. Segunda opción: ante indicación de nacimiento inmediato (por ejemplo, estado fetal no tranquilizador), pero sin sangrado vaginal o indicación de manejo inmediato de EAP, se sugiere realizar manejo en dos tiempos: se realiza la cesárea evitando incidir la placenta, seguida de histerorrafia y cierre de abdomen, hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura. Tercera opción: en presencia de sangrado vaginal que hace imposible diferir el manejo definitivo de EAP, es necesario extraer el feto por el fondo del útero, realizar la histerorrafia y reevaluar. En ocasiones, el nacimiento del feto disminuye el flujo placentario y el sangrado vaginal se reduce o desaparece, lo que hace posible diferir el manejo definitivo de EAP. Si el sangrado significativo persiste, es necesario continuar con la histerectomía haciendo uso de los recursos disponibles: compresión manual de la aorta, llamado inmediato a los cirujanos con mejor entrenamiento disponible, soporte de grupos expertos de otros hospitales a través de telemedicina. Si una paciente con factores de riesgo para EAP (por ejemplo, miomectomía o cesárea previa) presenta retención de placenta posterior al parto vaginal, es recomendable confirmar la posibilidad de dicho diagnóstico (por ejemplo, realizando una ecografía) antes de intentar la extracción manual de la placenta. Conclusiones: esperamos que este primer consenso colombiano de EAP sirva como base para discusiones adicionales y trabajos colaborativos que mejoren los resultados clínicos de las mujeres afectadas por esta enfermedad. Evaluar la aplicabilidad y efectividad de las recomendaciones emitidas requerirá investigaciones adicionales.

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ABSTRACT Objective Placenta accreta spectrum (PAS) is a cause of massive obstetric hemorrhage and maternal mortality. The application of family-centered delivery techniques (FCDTs) during surgery to treat this disease is infrequent. We evaluate the implementation of FCDTs during PAS surgeries. Methods This was a prospective, descriptive study that included PAS patients undergoing surgical management over a 12-month period. The patients were divided according to whether FCDTs were applied (group 1) or not (group 2), and the clinical outcomes were measured. In addition, hospital anesthesiologists were surveyed to evaluate their opinions regarding the implementation of FCDTs during the surgical management of PAS. Results Thirteen patients with PAS were included. The implementation of FCDTs during birth was possible in 53.8% of the patients. The presence of a companion during surgery and skin-to-skin contact did not hinder interdisciplinary management in any case. Conclusion Implementation of FCDTs during PAS care is possible in selected patients at centers with experience in managing this disease.

Resumo Objetivo O espectro da placenta acreta (do inglês placenta accreta spectrum - PAS) é causa de hemorragia obstétrica maciça e mortalidade materna. A aplicação de técnicas de parto centrado na família (do inglês family-centered delivery techniques - FCDTs) durante a cirurgia para tratar esta doença é pouco frequente. Avaliamos a implementação das FCDTs durante as cirurgias do PAS. Métodos Estudo prospectivo e descritivo que incluiu pacientes com PAS submetidos a tratamento cirúrgico durante um período de 12 meses. Os pacientes foram divididos de acordo com a aplicação de FCDTs (grupo 1) ou não (grupo 2), e os resultados clínicos foram medidos. Além disso, anestesiologistas hospitalares foram entrevistados para avaliar suas opiniões sobre a implementação das FCDTs durante o manejo cirúrgico do PAS. Resultados Foram incluídos 13 pacientes com PAS. A implementação de FCDTs durante o parto foi possível em 53,8% das pacientes. A presença do acompanhante durante a cirurgia e o contato pele a pele não prejudicou o manejo interdisciplinar em nenhum caso. Conclusão A implementação de FCDTs durante o atendimento do PAS é possível em pacientes selecionados em centros com experiência no manejo dessa doença.

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RESUMEN Introducción: el espectro de acretismo placentario (EAP) es una condición asociada a sangrado masivo posparto y mortalidad materna. Las guías de manejo publicadas en países de altos ingresos recomiendan la participación de grupos interdisciplinarios en hospitales con recursos suficientes para realizar procedimientos complejos. Sin embargo, algunas de las recomendaciones de estas guías resultan difíciles de aplicar en países de bajos y medianos ingresos. Objetivos: este consenso busca formular recomendaciones generales para el tratamiento del EAP en Colombia. Materiales y métodos: en el consenso participaron 23 panelistas, quienes respondieron 31 preguntas sobre el tratamiento de EAP. Los panelistas fueron seleccionados con base en la participación en dos encuestas realizadas para determinar la capacidad resolutiva de hospitales en el país y la región. Se utilizó la metodología Delphi modificada, incorporando dos rondas sucesivas de discusión. Para emitir las recomendaciones el grupo tomó en cuenta la opinión de los participantes, que lograron un consenso mayor al 80 %, así como las barreras y los facilitadores para su implementación. Resultados: el consenso formuló cinco recomendaciones integrando las respuestas de los panelistas. Recomendación 1. Las instituciones de atención primaria deben realizar búsqueda activa de EAP en pacientes con factores de riesgo: placenta previa e historia de miomectomía o cesárea en embarazo previo. En caso de haber signos sugestivos de EAP por ecografía, las pacientes deben ser remitidas de manera inmediata, sin tener una edad gestacional mínima, a hospitales reconocidos como centros de referencia. Las modalidades virtuales de comunicación y atención en salud pueden facilitar la interacción entre las instituciones de atención primaria y los centros de referencia para EAP. Se debe evaluar el beneficio y riesgo de las modalidades de telemedicina. Recomendación 2. Es necesario que se definan hospitales de referencia para EAP en cada región de Colombia, asegurando el cubrimiento de la totalidad del territorio nacional. Es aconsejable concentrar el flujo de pacientes afectadas por esta condición en unos pocos hospitales, donde haya equipos de cirujanos con entrenamiento específico en EAP, disponibilidad de recursos especializados y un esfuerzo institucional por mejorar la calidad de atención, en busca de tener mejores resultados en la salud de las gestantes con esta condición. Para lograr ese objetivo los participantes recomiendan que los entes reguladores de la prestación de servicios de salud a nivel nacional, regional o local vigilen el proceso de remisión de estas pacientes, facilitando rutas administrativas en caso de que no exista contrato previo entre el asegurador y el hospital o la clínica seleccionada (IPS). Recomendación 3. En los centros de referencia para pacientes con EAP se invita a la creación de equipos que incorporen un grupo fijo de especialistas (obstetras, urólogos, cirujanos generales, radiólogos intervencionistas) encargados de atender todos los casos de EAP. Es recomendable que esos grupos interdisciplinarios utilicen el modelo de "paquete de intervención" como guía para la preparación de los centros de referencia para EAP. Este modelo consta de las siguientes actividades: preparación de los servicios, prevención e identificación de la enfermedad, respuesta ante la presentación de la enfermedad, aprendizaje luego de cada evento. La telemedicina facilita el tratamiento de EAP y debe ser tenida en cuenta por los grupos interdisciplinarios que atienden esta enfermedad. Recomendación 4. Los residentes de Obstetricia deben recibir instrucción en maniobras útiles para la prevención y el tratamiento del sangrado intraoperatorio masivo por placenta previa y EAP, tales como: la compresión manual de la aorta, el torniquete uterino, el empaquetamiento pélvico, el bypass retrovesical y la maniobra de Ward. Los conceptos básicos de diagnóstico y tratamiento de EAP deben incluirse en los programas de especialización en Ginecología y Obstetricia en Colombia. En los centros de referencia del EAP se deben ofrecer programas de entrenamiento a los profesionales interesados en mejorar sus competencias en EAP de manera presencial y virtual. Además, deben ofrecer soporte asistencial remoto (telemedicina) permanente a los demás hospitales en su región, en relación con pacientes con esa enfermedad. Recomendación 5. La finalización de la gestación en pacientes con sospecha de EAP y placenta previa, por imágenes diagnósticas, sin evidencia de sangrado vaginal activo, debe llevarse a cabo entre las semanas 34 y 36 6/7. El tratamiento quirúrgico debe incluir intervenciones secuenciales que pueden variar según las características de la lesión, la situación clínica de la paciente y los recursos disponibles. Las opciones quirúrgicas (histerectomía total y subtotal, manejo quirúrgico conservador en un paso y manejo expectante) deben incluirse en un protocolo conocido por todo el equipo interdisciplinario. En escenarios sin diagnóstico anteparto, es decir, ante un hallazgo intraoperatorio de EAP (evidencia de abultamiento violáceo o neovascularización de la cara anterior del útero), y con participación de personal no entrenado, se plantean tres situaciones: Primera opción: en ausencia de indicación de nacimiento inmediato o sangrado vaginal, se recomienda diferir la cesárea (cerrar la laparotomía antes de incidir el útero) hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura. Segunda opción: ante indicación de nacimiento inmediato (por ejemplo, estado fetal no tranquilizador), pero sin sangrado vaginal o indicación de manejo inmediato de EAP, se sugiere realizar manejo en dos tiempos: se realiza la cesárea evitando incidir la placenta, seguida de histerorrafia y cierre de abdomen, hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura. Tercera opción: en presencia de sangrado vaginal que hace imposible diferir el manejo definitivo de EAP, es necesario extraer el feto por el fondo del útero, realizar la histerorrafia y reevaluar. En ocasiones, el nacimiento del feto disminuye el flujo placentario y el sangrado vaginal se reduce o desaparece, lo que hace posible diferir el manejo definitivo de EAP. Si el sangrado significativo persiste, es necesario continuar con la histerectomía haciendo uso de los recursos disponibles: compresión manual de la aorta, llamado inmediato a los cirujanos con mejor entrenamiento disponible, soporte de grupos expertos de otros hospitales a través de telemedicina. Si una paciente con factores de riesgo para EAP (por ejemplo, miomectomía o cesárea previa) presenta retención de placenta posterior al parto vaginal, es recomendable confirmar la posibilidad de dicho diagnóstico (por ejemplo, realizando una ecografía) antes de intentar la extracción manual de la placenta. Conclusiones: esperamos que este primer consenso colombiano de EAP sirva como base para discusiones adicionales y trabajos colaborativos que mejoren los resultados clínicos de las mujeres afectadas por esta enfermedad. Evaluar la aplicabilidad y efectividad de las recomendaciones emitidas requerirá investigaciones adicionales.

ABSTRACT Introduction: Placenta accreta spectrum (PAS) is a condition associated with massive postpartum bleeding and maternal mortality. Management guidelines published in high income countries recommend the participation of interdisciplinary teams in hospitals with sufficient resources for performing complex procedures. However, some of the recommendations contained in those guidelines are difficult to implement in low and medium income countries. Objectives: The aim of this consensus is to draft general recommendations for the treatment of PAS in Colombia Materials and Methods: Twenty-three panelists took part in the consensus with their answers to 31 questions related to the treatment of PAS. The panelists were selected based on participation in two surveys designed to determine the resolution capabilities of national and regional hospitals. The modified Delphi methodology was used, introducing two successive discussion rounds. The opinions of the participants, with a consensus of more than 80 %, as well as implementation barriers and facilitators, were taken into consideration in order to issue the recommendations. Results: The consensus drafted five recommendations, integrating the answers of the panelists. Recommendation 1. Primary care institutions must undertake active search of PAS in patients with risk factors: placenta praevia and history of myomectomy or previous cesarean section. In case of ultrasound signs suggesting PAS, patients must be immediately referred, without a minimum gestational age, to hospitals recognized as referral centers. Online communication and care modalities may facilitate the interaction between primary care institutions and referral centers for PAS. The risks and benefits of telemedicine modalities must be weighed. Recommendation 2. Referral hospitals for PAS need to be defined in each region of Colombia, ensuring coverage throughout the national territory. It is advisable to concentrate the flow of patients affected by this condition in a few hospitals with surgical teams specifically trained in PAS, availability of specialized resources, and institutional efforts at improving quality of care with the aim of achieving better health outcomes in pregnant women with this condition. To achieve this goal, participants recommend that healthcare regulatory agencies at a national and regional level should oversee the process of referral for these patients, expediting administrative pathways in those cases in which there is no prior agreement between the insurer and the selected hospital or clinic. Recommendation 3. Referral centers for patients with PAS are urged to build teams consisting of a fixed group of specialists (obstetricians, urologists, general surgeons, interventional radiologists) entrusted with the care of all PAS cases. It is advisable for these interdisciplinary teams to use the "intervention bundle" model as a guidance for building PAS referral centers. This model comprises the following activities: service preparedness, disease prevention and identification, response to the occurrence of the disease, and debriefing after every event. Telemedicine facilitates PAS treatment and should be taken into consideration by interdisciplinary teams caring for this disease. Recommendation 4. Obstetrics residents must be instructed in the performance of maneuvers that are useful for the prevention and treatment of massive intraoperative bleeding due to placenta praevia and PAS, including manual aortic compression, uterine tourniquet, pelvic packing, retrovesical bypass, and Ward maneuver. Specialization Obstetrics and Gynecology programs in Colombia must include the basic concepts of the diagnosis and treatment of PAS. Referral centers for PAS must offer online and in-person training programs for professionals interested in improving their competencies in PAS. Moreover, they must offer permanent remote support (telemedicine) to other hospitals in their region for patients with this condition. Recommendation 5. Patients suspected of having PAS and placenta praevia based on imaging, with no evidence of active vaginal bleeding, must be delivered between weeks 34 and 36 6/7. Surgical treatment must include sequential interventions that may vary depending on the characteristics of the lesion, the clinical condition of the patient and the availability of resources. The surgical options (total and subtotal hysterectomy, one-stage conservative surgical management and watchful waiting) must be included in a protocol known by the entire interdisciplinary team. In situations in which an antepartum diagnosis is lacking, that is to say, in the face of intraoperative finding of PAS (evidence of purple bulging or neovascularization of the anterior aspect of the uterus), and the participation of untrained personnel, three options are considered: Option 1: In the absence of indication of immediate delivery or of vaginal delivery, the recommendation is to postpone the cesarean section (close the laparotomy before incising the uterus) until the recommended resources for safe surgery are secured. Option 2: If there is an indication for immediate delivery (e.g., non-reassuring fetal status) but there is absence of vaginal bleeding or indication for immediate PAS management, a two-stage management is suggested: cesarean section avoiding placental incision, followed by uterine repair and abdominal closure, until the availability of the recommended resources for safe surgery is ascertained. Option 3: In the event of vaginal bleeding that prevents definitive PAS management, the fetus must be delivered through the uterine fundus, followed by uterine repair and reassessment of the situation. Sometimes, fetal delivery diminishes placental flow and vaginal bleeding is reduced or disappears, enabling the possibility to postpone definitive management of PAS. In case of persistent significant bleeding, hysterectomy should be performed, using all available resources: manual aortic compression, immediate call to the surgeons with the best available training, telemedicine support from expert teams in other hospitals. If a patient with risk factors for PAS (e.g., myomectomy or previous cesarean section) has a retained placenta after vaginal delivery, it is advisable to confirm the possibility of such diagnosis (by means of ultrasound, for example) before proceeding to manual extraction of the placenta. Conclusions: It is our hope that this first Colombian consensus on PAS will serve as a basis for additional discussions and collaborations that can result in improved clinical outcomes for women affected by this condition. Additional research will be required in order to evaluate the applicability and effectiveness of these recommendations.

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RESUMO

Abstract Objective The immediate referral of patients with risk factors for placenta accreta spectrum (PAS) to specialized centers is recommended, thus favoring an early diagnosis and an interdisciplinary management. However, diagnostic errors are frequent, even in referral centers (RCs). We sought to evaluate the performance of the prenatal diagnosis for PAS in a Latin American hospital. Methods A retrospective descriptive study including patients referred due to the suspicion of PAS was conducted. Data from the prenatal imaging studies were compared with the final diagnoses (intraoperative and/or histological). Results A total of 162 patients were included in the present study. The median gestational age at the time of the first PAS suspicious ultrasound was 29 weeks, but patients arrived at the PAS RC at 34 weeks. The frequency of false-positive results at referring hospitals was 68.5%. Sixty-nine patients underwent surgery based on the suspicion of PAS at 35 weeks, and there was a 28.9% false-positive rate at the RC. In 93 patients, the diagnosis of PAS was ruled out at the RC, with a 2.1% false-negative frequency. Conclusion The prenatal diagnosis of PAS is better at the RC. However, even in these centers, false-positive results are common; therefore, the intraoperative confirmation of the diagnosis of PAS is essential.

Resumo Objetivo Recomenda-se o encaminhamento imediato de pacientes com fatores de risco para espectro placentário acreta (PAS, na sigla em inglês) para centros especializados, favorecendo assim o diagnóstico precoce e o manejo interdisciplinar. No entanto, erros diagnósticos são frequentes, mesmo em centros de referência (CRs). Buscou-se avaliar o desempenho do diagnóstico pré-natal para PAS em um hospital latino-americano. Métodos Um estudo descritivo retrospectivo incluindo pacientes encaminhados por suspeita de SAP foi realizado. Os dados dos exames de imagem do pré-natal foram comparados com os diagnósticos finais (intraoperatórios e/ou histológicos). Resultados Foram incluídos 162 pacientes no presente estudo. A idade gestacional mediana no momento da primeira ultrassonografia suspeita de PAS foi de 29 semanas, mas as pacientes chegaram ao CR de PAS com 34 semanas. A frequência de resultados falso-positivos nos hospitais de referência foi de 68,5%. Sessenta e nove pacientes foram operadas com base na suspeita de PAS com 35 semanas e houve 28,9% de falso-positivos no CR. Em 93 pacientes, o diagnóstico de PAS foi descartado no CR, com frequência de falso-negativos de 2,1%. Conclusão O diagnóstico pré-natal de PAS é melhor no CR. Entretanto, mesmo nestes centros, resultados falso-positivos são comuns; portanto, a confirmação intraoperatória do diagnóstico de SAP é essencial.

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RESUMO

Placenta accreta spectrum disorders are characterized by abnormal adhesion of the placenta that can be subdivided into three categories according to degree of invasion: placenta accreta (passing through the decidua basalis and adhering to the myometrium); placenta increta (penetrating the myometrium); and placenta percreta (invading the uterine serosa or adjacent tissues or organs). The incidence of placenta accreta has increased significantly in recent decades, mainly because of an increase in the rates of cesarean section, which is its main risk factor. Accurate prenatal identification makes it possible to institute the ideal treatment with a multidisciplinary team, significantly minimizing maternal morbidity and mortality. The examinations of choice are ultrasound and magnetic resonance imaging (MRI). When the ultrasound evaluation is inconclusive, as well as when the patient has risk factors for the condition or the placenta is in a posterior location, MRI is indicated. In cases of placental invasion of the adjacent pelvic organs, MRI is also preferable because it provides a broader field of view, which improves surgical planning. Numerous features of placenta accreta spectrum disorders are discernible on MRI, including dark intraplacental bands, uterine bulging, and heterogeneous placenta. Knowledge of these findings and the combination of two or more of them increase confidence in the diagnosis.

Acretismo placentário é uma condição caracterizada pela implantação anormal da placenta, que pode ser subdividida em três espectros de acordo com o seu grau de invasão: placenta acreta (ultrapassa a decídua basal e adere ao miométrio), placenta increta (penetra o miométrio) e placenta percreta (invasão da serosa uterina ou de tecidos/órgãos adjacentes). A incidência de acretismo placentário aumentou significativamente nas últimas décadas, principalmente em função da elevação das taxas de cesarianas, sendo este o seu principal fator de risco. A sua identificação pré-natal precisa permite um tratamento ideal com equipe multidisciplinar, minimizando significativamente a morbimortalidade materna. Os exames de escolha são a ultrassonografia e a ressonância magnética (RM), sendo a RM um método complementar indicado quando a avaliação ultrassonográfica é duvidosa, para pacientes com fatores de risco para acretismo placentário ou quando a placenta tem localização posterior. A RM é preferível também para avaliar invasão de órgãos adjacentes, oferecendo um campo de visão mais amplo, o que melhora o planejamento cirúrgico. Diversas características na RM são descritas no acretismo placentário, incluindo bandas hipointensas em T2 intraplacentárias, protuberância uterina anormal e heterogeneidade placentária. O conhecimento desses achados e a combinação de mais de um critério aumentam a confiabilidade do diagnóstico.