326 Placenta accreta spectrum treatment with intraoperative multivessel embolization to improve surgical outcomes: the PASTIME protocol

Abstract

To assess the implementation of a novel protocol for treating placenta accreta (PAS) spectrum, combining cesarean delivery with immediate vascular embolization and subsequent hysterectomy in a single procedure using a hybrid operative suite. A matched pre-post implementation study of PAS cases managed before (2010-2017) and after implementation of the PASTIME protocol (2018-2020) at a tertiary medical center. PASTIME cases were matched to pre-PASTIME controls in a 1:2 ratio on PAS severity and surgical urgency. The primary outcome was intraoperative blood loss (EBL). Secondary outcomes included transfusion rate, surgical time, intra and post-operative complications, Intensive care unit (ICU) and total length of stay, maternal mortality, and neonatal outcomes. Thirteen PASTIME cases and 26 matched controls were included. No significant demographic differences were noted between groups. EBL was significantly lower in the PASTIME group (750 vs 1750 mL, p = 0.01). Transfusion (38.5% vs 61.5%, p = 0.20) and massive transfusion (0% vs. 19.2%, p = 0.15) trends were improved in the PASTIME group. Surgical times were similar between groups, whereas an average of 58.2 minutes was required for embolization in the PASTIME group. ICU and postpartum LOS, non-transfusion related intra and post-operative complications were similar between groups. Three maternal deaths were observed in the control group while none occurred in the PASTIME group. Gestational age and birth weights were similar, while low 5-min APGAR was more common in the PASTIME group (76.9% vs 38.5%, p = 0.04). A multidisciplinary pathway including a single-surgery protocol with multivessel uterine embolization significantly decreases maternal blood loss with no increase in surgical complications. This PASTIME protocol provides a definitive surgical method that warrants consideration by centers specializing in PAS treatment.View Large Image Figure ViewerDownload Hi-res image Download (PPT)