PROC (BAYL UNIV MED CENT)

2022;35(6):755–758
Copyright # 2022 Baylor University Medical Center
https://doi.org/10.1080/08998280.2022.2109113

Effect of a placenta accreta spectrum multidisciplinary

team and checklist on maternal outcomes for planned
hysterectomy at time of cesarean delivery
Hadley Young, MDa, Jessica C. Ehrig, MDb, Kendall Hammonds, MPHc, and Michael P. Hofkamp, MDd
a
Department of Obstetrics and Gynecology, Baylor Scott & White Medical Center – Temple, Temple, Texas; bDivision of Maternal Fetal
Medicine, Department of Obstetrics and Gynecology, Baylor Scott & White Medical Center – Temple, Temple, Texas; cBiostatistics Core,
Baylor Scott & White Research Institute, Temple, Texas; dDepartment of Anesthesiology, Baylor Scott & White Medical Center – Temple,
Temple, Texas

ABSTRACT
Evidence suggests that multidisciplinary teams that perform cesarean hysterectomy for placenta accreta spectrum have better
maternal outcomes. The aim of this study was to assess the effects of a multidisciplinary team on outcomes for patients with
placenta accreta spectrum at our institution. We examined all planned cesarean hysterectomy procedures performed for placenta
accreta syndrome at our hospital between July 1, 2015, and June 30, 2021. Nine and 21 subjects had planned cesarean hyster-
ectomy before and after implementation of the new procedures, respectively. Overall, there was an increase in volume of cases
and depth of placental invasion but no change in the demographic characteristics of patients. Additionally, we found decreased
blood loss, decreased blood transfusions from a median of 2 units to 0 units, and decreased intensive care unit admission rates
from 22.2% to 4.8%, but these results did not reach statistical significance. The main limitation of our study was our small num-
ber of subjects. Our findings suggest that multidisciplinary placenta accreta teams improve maternal outcomes for hysterectomy
at the time of cesarean delivery.
KEYWORDS Blood transfusion; hysterectomy; patient care team; placenta accreta

P
lacenta accreta spectrum (PAS) describes varying primary aim of our study was to compare maternal outcomes
degrees of abnormal trophoblast invasion into the for patients with PAS who underwent C-HYST before and
myometrium of the uterus and beyond.1 The after initiation of our multidisciplinary PAS team.
most common risk factors for PAS include history
of cesarean delivery or uterine surgery and placenta previa.2
METHODS
In recent years the number of cases of PAS has risen drastic-
The Baylor Scott & White Research Institute institu-
ally in parallel to the overall rate of cesarean deliveries in the
tional review board waived informed consent for our study.
United States. PAS is now reported to occur in about 1 out
We used our electronic medical record system (Epic, Verona,
of every 300 pregnancies1 and has significant maternal mor-
bidity and mortality, which is usually related to hemor- WI) to search for patients who had C-HYST performed
rhage.3 Despite the significant risks associated with PAS, a from July 1, 2015, through June 30, 2021. Patients who had
recent study indicated that only about a fourth of general unplanned C-HYST at the time of cesarean delivery or a C-
obstetricians referred patients with suspected PAS to centers HYST indication other than PAS were excluded from the
of excellence.4 In July 2018, a multidisciplinary team was study. We performed a manual chart review for each patient
created at our hospital to perform hysterectomy at the time and entered demographic and clinical data into Research
of cesarean delivery (C-HYST) for patients with PAS. The Electronic Data Capture (REDCap). In July 2018, we

Corresponding author: Michael P. Hofkamp, MD, Department of Anesthesiology, Baylor Scott & White Medical Center – Temple, 2401 S. 31st Street,
Temple, TX 76508 (e-mail: [email protected])
The authors have no relevant financial conflicts of interest to disclose. This study was departmentally funded.
Received June 17, 2022; Revised July 18, 2022; Accepted July 25, 2022.

November 2022 755

Figure 1. Sample checklist for cesarean hysterectomy. CD indicates cesarean delivery; CSE, combined spinal epidural; HYST, hysterectomy; L&D, labor and
delivery; NICU, neonatal intensive care unit; OR, operating room; PDS, polydioxanone suture.

created a standardized checklist for C-HYST performed for unit admission rates from 22.2% to 4.8%, but these results
the indication of PAS (Figure 1). were not statistically significant. Demographic and clinical
We used a chi-square test to evaluate categorical variables data for the cohorts are presented in Table 1.
in bivariate associations when the expected cell count was

5 and used a Fisher’s exact test when expected cell counts DISCUSSION
were 4. We used an unpaired t test to evaluate continuous We found a nonstatistically significant decrease in the
variables in bivariate associations that had a normal distribu- number of packed red blood cells transfused in the peri-
tion and used a Mann-Whitney U test to evaluate continu- operative period, estimated blood loss, and rate of admission
ous variables in bivariate associations that did not have a to the intensive care unit in patients who had C-HYST for
normal distribution. We used the Kolmogorov-Smirnoff test PAS after we created a multidisciplinary PAS team that used
to determine if a sample deviated from the normal distribu- a standardized checklist.
tion. Statistical significance was determined a priori to have a The main limitation of our study was that only 9 and 21
P value of 0.05 or less. patients had planned C-HYST before and after implementa-
tion of our multidisciplinary PAS team, respectively. Even in
RESULTS a tertiary care referral center, C-HYST is a relatively uncom-
Nine and 21 subjects had planned C-HYST before and mon procedure and statistical significance is difficult to dem-
after implementation of the new procedures, respectively. onstrate in single-center studies. Another limitation of our
Checklist use by the multidisciplinary team resulted in study was that we transitioned from estimated blood loss to
decreased blood loss, decreased blood transfusions from a quantitative blood loss for cesarean deliveries in 2018.
median of 2 units to 0 units, and decreased intensive care Quantitative blood loss has been shown to more accurately

756 Baylor University Medical Center Proceedings Volume 35, Number 6

 Table 1. Demographic and clinical data
Preimplementation Postimplementation P
Variable (N 5 9) (N 5 21) value

Age (years): median (IQR) 35 (26–39) 33 (30–35) 0.40

Height (cm): mean (SD) 161.9 (5.8) 163.0 (8.6) 0.75
Weight (kg): mean (SD) 93.5 (19.7) 90.5 (17.3) 0.68
2
Body mass index (kg/m ): mean (SD) 35.6 (6.9) 34.2 (6.4) 0.55
Gravidity: median (IQR) 5 (4–6) 5 (4–6) 0.57
Parity: median (IQR) 3 (2–4) 3 (2–4) 0.94
Gestational weeks at delivery: mean (SD) 34.2 (2.2) 33.6 (1.9) 0.48
Prior cesarean delivery 8 (88.9%) 21 (100%) 0.30
Preoperative hemoglobin (g/dL): mean (SD) 10.1 (0.6) 10.5 (1.5) 0.48
Preoperative diagnosis 0.30
Accreta 7 (78%) 15 (71%)
Percreta 1 (11%) 6 (29%)
Complete placenta previa 1 (11%) 0
Postoperative diagnosis
Accreta 5 (56%) 9 (43%)
Percreta 3 (33%) 8 (38%)
Increta 1 (11%) 3 (14%)
No evidence of abnormal placentation 0 1 (5%)
Urgency 0.67
Elective 6 (67%) 16 (76%)
Urgent 3 (33%) 5 (24%)
Initial anesthetic technique 1
Regional 9 (100%) 20 (95%)
General anesthesia 0 1 (5%)
General anesthesia as final anesthetic technique 8 (89%) 18 (86%) 1
Subject remained intubated at end of procedure 2 (22%) 1 (5%) 0.21
Intensive care unit admission 2 (22%) 1 (5%) 0.21
Accreta surgeon present for procedure 7 (78%) 21 (100%) 0.08
Incision to wound closure (min): mean (SD) 183.4 (88.9) 184.2 (81.6) 0.98
Incision to uterine incision (min): mean (SD) 19.1 (17.3) 13.2 (8.8) 0.22
Uterine incision to delivery (min): mean (SD) 1 (1–3) 1 (1–2) 0.44
Delivery to conversion to general anesthesia (min): mean (SD) 26.7 (27.5)a 6.4 (2.9)b <0.01*
Delivery to wound closure (min): mean (SD) 162.2 (81.7) 169.5 (83.7) 0.83
Blood loss N/A
Estimated blood loss (mL): mean (SD) 2139 (2364)c 1580 (401)d
Quantitative blood loss (mL): mean (SD) N/A 1777 (1391)e
Total transfused units of PRBC: median (IQR) 2 (0–5) 0 (0–2) 0.15
Units of PRBC transfused intraoperatively: median (IQR) 0 (0–2) 0 (0–1) 0.54
Units of PRBC transfused postoperatively: median (IQR) 1 (0–2) 0 (0–1) 0.11
Total units of FFP transfused: median (IQR) 0 (0–2) 0 (0–0) 0.10
Postoperative hospital days: median (IQR) 3 (3–4) 3 (3–4) 0.86
a
N ¼ 7; N ¼ 17, N ¼ 9; N ¼ 3; N ¼ 21.
b c d e

FFP indicates fresh frozen plasma; IQR, interquartile range; PRBC, packed red blood cells; SD, standard deviation.

November 2022 Effect of a placenta accreta spectrum multidisciplinary team and checklist 757
predict postpartum hemorrhage.5 A final limitation of our study are generalizable to institutions that perform planned
study was that we had higher volume and increased complex- C-HYST procedures on patients with PAS.
ity of PAS cases after implantation of our multidisciplinary
PAS team. Over half of the cases performed before the multi-
ORCID
disciplinary team were diagnosed as accreta in the postoperative Michael P. Hofkamp http://orcid.org/0000-0002-5749-2849
period, while more than half the cases after implementation
were postoperatively diagnosed as increta or percreta.
Several studies have found maternal benefit when multi-
disciplinary teams care for patients with PAS.6–9 In July 1. Silver RM. Abnormal placentation: placenta previa, vasa previa, and
2018, a maternal fetal medicine (MFM) physician at our placenta accreta. Obstet Gynecol. 2015;126(3):654–668. doi:10.1097/
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2. Society of Gynecologic Oncology American College of Obstetricians
team for C-HYST. The checklist was similar to other PAS
and Gynecologists and the Society for Maternal–Fetal Medicine,
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linary team included members from MFM, anesthesiology, 3. Nieto-Calvache AJ, Palacios-Jaraquemada JM, Osanan G, et al; Latin
neonatology, urology, and a surgeon experienced in PAS. It American Group for the Study of Placenta Accreta Spectrum. Lack of
also included antenatal management at our institution with experience is a main cause of maternal death in placenta accreta spec-
trum patients. Acta Obstet Gynecol Scand. 2021;100(8):1445–1453.
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Prior to implementation of a multidisciplinary team, ajog.2014.11.018.
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detection of postpartum hemorrhage and accuracy of postpartum
days. Yasin and colleagues found a much higher mean post-
hemorrhage rates: a retrospective cohort study. Cureus. 2021;13(2):
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with increta and percreta patients staying significantly longer of excellence with multidisciplinary teams in the management of
than accreta patients. abnormal invasive placenta. Clin Obstet Gynecol. 2018;61(4):841–850.
The increased volume of PAS cases at our institution doi:10.1097/GRF.0000000000000393.
7. Al-Khan A, Gupta V, Illsley NP, et al. Maternal and fetal outcomes
may in part be due to the increasing rates of PAS.12 Our
in placenta accreta after institution of team-managed care. Reprod Sci.
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tem in 2021 during the last 2 months of the study period. 8. Sylvester-Armstrong K, Reeder C, Patrick K, et al. Improved manage-
This significantly increased the volume and acuity of MFM ment of placenta accreta spectrum disorders: experience from a single
transfers that our institution received. The maternal fetal institution. J Perinat Med. 2021;50:286–293. doi:10.1515/jpm-2021-
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9. Gillespie C, Sangi-Haghpeykar H, Munnur U, Suresh MS, Miller H,
patients with PAS in our surrounding area. Hawkins SM. The effectiveness of a multidisciplinary, team-based
In 2021, the Texas state legislature passed a bill signed by approach to cesarean hysterectomy in modern obstetric practice. Int J
the governor that requires hospitals with a level IV maternal Gynaecol Obstet. 2017;137(1):57–62. doi:10.1002/ijgo.12093.
designation to have a multidisciplinary PAS team that partic- 10. Tussey C, Olson C. Creating a multidisciplinary placenta accreta pro-
ipates in continuous education and quality improvement.13 gram. Nurs Womens Health. 2018;22(5):372–386. doi:10.1016/j.nwh.
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Our hospital carries a level IV maternal designation, and our
11. Yasin N, Slade L, Atkinson E, Kennedy-Andrews S, Scroggs S, Grivell
multidisciplinary PAS team was designed to meet those R. The multidisciplinary management of placenta accreta spectrum
requirements. (PAS) within a single tertiary centre: A ten-year experience. Aust N Z
We found that the implementation of a multidisciplinary J Obstet Gynaecol. 2019;59(4):550–554. doi:10.1111/ajo.12932.
team and standardized checklist to perform C-HYST proce- 12. Liu X, Wang Y, Wu Y, et al. What we know about placenta accreta
dures in patients with PAS was associated with improved spectrum (PAS). Eur J Obstet Gynecol Reprod Biol. 2021;259:81–89.
doi:10.1016/j.ejogrb.2021.02.001.
maternal outcomes, although they did not reach statistical
13. An act relating to the designation of centers of excellence for the man-
significance. Future large-scale studies are needed to examine agement and treatment of placenta accreta spectrum disorder [Texas
the effect of multidisciplinary care teams and checklists on H.B.A. No. A1164]. 2021. https://capitol.texas.gov/tlodocs/87R/bill-
patients who undergo C-HYST for PAS. The results of this text/pdf/HB01164F.pdf#navpanes=0.

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