Uterine conservative-resective surgery for selected placenta accreta spectrum cases: Surgical-vascular control methods.

INTRODUCTION: The incidence of placenta accreta spectrum (PAS) has increased, but the optimal management and the optimal way to achieve vascular control are still controversial. This study aims to compare maternal outcomes between different methods of vascular control in surgical PAS management. MATERIAL AND METHODS: A retrospective cohort study on consecutive cases diagnosed with PAS between 2013 and 2020 in single tertiary hospital. The final diagnosis of PAS was made following preoperative ultrasound and confirmation during surgery. Management of PAS using cesarean hysterectomy with internal iliac artery ligation (IIAL) was compared with two types of vascular control in uterine conservative-resective surgery (IIAL vs identification-ligation of the upper vesical, upper vaginal, and uterine arteries). RESULTS: Over an 8-year period, 234 pregnant women were diagnosed with PAS meeting the inclusion criteria. Uterine conservative-resective surgery (200 cases) was associated with lower mean blood loss compared with cesarean hysterectomy with IIAL (34 cases) in all PAS cases (1379 ± 769 mL vs 3168 ± 1916 mL; p < 0.001). In sub-analysis of the two uterine conservative-resective surgery subgroups, the group with identification-ligation of the upper vesical, upper vaginal, and uterine arteries had a significantly lower blood loss compared with uterine conservative-resective surgery with IIAL (1307 ± 743 mL vs 1701 ± 813 mL; p = 0.005). Women in the hysterectomy with IIAL group had more massive transfusion (35.3% vs 2.5%; p < 0.001; odds ratio [OR] 21.3, 95% confidence interval [CI] 6.9-66), major blood loss (>1500 mL) (70.6% vs 34%, p < 0.001; OR 4.7; 95% CI 2.1-10.3), catastrophic blood loss (>2500 mL) (64.7% vs 12.5%;p < 0.001; OR 12.8, 95% CI 5.7-29.1), other complications (32% vs 12.4%; p = 0.007; OR 3.4, 95% CI 1.5-7.7), and intensive care unit admission (32.4% vs 1.5%; p < 0.001; OR 31.4, 95% CI 8.2-120.7) compared with the uterine conservative-resective surgery groups. The identification-ligation of the upper vesical, upper vaginal and uterine arteries had a significant lower risk for major blood loss (30.5% vs 50%; p = 0.041; OR 0.44, 95% CI = 0.2-0.9) compared with IIAL for vascular control of uterine conservative-resective surgery. CONCLUSIONS: Cesarean hysterectomy is not the default treatment for PAS, PAS with invasion above the vesical trigone are suitable for uterine conservative-resective surgery with upper vesical, upper vaginal and uterine artery vascular control.

Knowledge and confidence levels improvement among obstetrics residents regarding caesarean section training using video-mannequins combination.

Background: Cesarean section rates are increasing worldwide. Obstetrics and gynecology residents are required to be experts in this surgery to provide safe procedures. Because of the COVID-19 pandemic situation, an alternative teaching strategy is needed to achieve adequate cesarean section skills. The purpose of this study was to identify the effect of video, mannequins, and the combination of video mannequins on residents' knowledge and confidence regarding cesarean section. Method: A quasi-experimental study with pre-test and post-test designs was done. Based on stratified random sampling, 33 obstetrics and gynecology residents involved as study participant. Three groups were formed and received different interventions, learning using videos, mannequins, and a combination of video-mannequins. Two kinds of questionnaires were used to examine residents' knowledge and their confidence levels. The collected data were analyzed statistically. Results: Video (0.42(CI95%-0.11-0.9)), mannequin simulation (0.60(CI95%-0.04-1.25)), and the combination of video-mannequin (1.3(CI95%0.73-1.93)) significantly increased resident's knowledge regarding caesarean section skill. Study participant showed increased scores regarding confidence in their caesarean section skills according to all learning subjects (p < 0.05) but a difference in confidence level occurred in level C- 7th semester residents (p < 0.05). Conclusion: The combination of videos and mannequin simulations is the best method for increasing knowledge of cesarean sections, compared to single video and mannequin simulations. The confidence level has been shown to increase in all subject studies but the effectiveness at each level of resident needs to be investigated further.

Management of placenta accreta spectrum disorders in COVID 19 patients.

INTRODUCTION: The COVID-19 pandemic has made it difficult to respond to demands in maternal health around the world. Placenta accreta spectrum (PAS) is one of the most severe obstetric conditions and usually requires the use of multiple health resources We describe the clinical results of the management of PAS patients during the COVID-19 pandemic and analyze how the pandemic may affect the functioning of a PAS team. METHODOLOGY: This was a descriptive, retrospective study including all patients treated for PAS in two low- to middle-income country reference hospitals between January 2020 and March 2021. The clinical results of patients with SARS-CoV-2 infection during PAS surgery (Group 1) were compared with those of PAS patients without SARS-CoV-2 infection (Group 2). RESULTS: One hundred forty-five patients undergoing surgery for PAS were included. Group 1 patients (11 cases) showed a longer operative time (250 min, IQR 200-300) and a higher frequency of intra- or postoperative complications (54.5%) than group 2 patients (180 min [IQR 125-240], and 17.9%). CONCLUSION: Placenta accreta spectrum patients undergoing surgery during acute SARS-CoV-2 infection have a higher frequency of postoperative complications. PAS teams must prepare to modify their management protocols to minimize risks for patients and healthcare personnel.