Transfusion requirements with hybrid management of placenta accreta
spectrum incorporating delayed hysterectomy: a retrospective study
Abstract
Objective: To compare the number of units of red blood cells (RBCs)
transfused in patients with placenta accreta spectrum (PAS) treated with
or without a multidisciplinary algorithm including placental uterine
arterial embolisation (P-UAE) and a selective use of delayed
hysterectomy. Design: Retrospective review Setting: Tertiary care
hospital, United States, 2001-2018 Population: Women with
histologically-confirmed PAS delivered after 24 weeks gestation Methods:
Comparison of transfusion outcomes among PAS cases managed with versus
without a multidisciplinary algorithm. To improve the equity of
comparison, analyses were made separately among scheduled and
unscheduled cases. Subjects were assigned to one of four cohorts:
scheduled/per-algorithm, scheduled/off-algorithm,
unscheduled/per-algorithm, or unscheduled/off-algorithm. P values were
adjusted for multiple testing. Main outcome measures: RBCs transfused
and estimated blood loss (EBL). Secondary outcomes included
peri-operative complications and intensive-care unit admissions.
Results: 87 subjects were identified: 36 treated per-algorithm (30
scheduled, 6 unscheduled), 51 off-algorithm (24 scheduled, 27
unscheduled). Among scheduled deliveries, 9 (30.0%) subjects treated
per-algorithm received RBCs, compared to 20 (83.3%) subjects treated
off-algorithm (p<0.01), with a median (interquartile
range[IQR]) of 3.0 (2.0, 4.0) and 6.0 (2.5, 7.5) units transfused
(p=0.13), respectively. Among unscheduled deliveries, 5 (83.3%)
subjects treated per-algorithm were transfused RBCs compared to 25
(92.6%) off-algorithm (p=0.47), with a median (IQR) of 4.0 (2.0, 6.0)
and 8.0 (3.0, 10.0) units transfused (p=0.47), respectively.
Peri-operative complications were similar between cohorts. Conclusions:
A multidisciplinary algorithm including P-UAE and selective use of
delayed hysterectomy is associated with a lower rate of blood
transfusion in scheduled but not unscheduled cases.