Hospital padrino: a collaborative strategy model to tackle maternal mortality: a mixed methods study in a middle-income region.

Background: Reducing maternal mortality ratio (MMR) remains a paramount goal for low- and middle-income countries (LMICs), especially after COVID-19's devastating impact on maternal health indicators. We describe our experience implementing the Hospital Padrino Strategy (HPS), a collaborative model between a high-complexity hospital (Fundación Valle del Lili) and 43 medium- and low-complexity hospitals in one Colombian department (an administrative and territorial division) from 2021 to 2022, to sustain the trend towards reducing MMR. The study aimed to assess the effects of implementing HPS on both hospital performance and maternal health indicators in Valle del Cauca department (VCD). Methods: A mixed-methods study was conducted, comprising two phases. In the first phase, we investigated a cohort of hospitals through prospective follow-up to assess the outcomes of HPS implementation on hospital performance and maternal health indicators in VCD. In the second phase, qualitative data were collected through focus groups with 131 health workers from 33 hospitals to explore the implications of the HPS implementation on healthcare personnel. All data were obtained from records within the HPS implementation and from the Health Secretary of VCD. Findings: Evidence shows that in the context of HPS, 51 workshops involved 980 healthcare workers, covering the entire territory. Substantial improvements were observed in hospital conditions and healthcare personnel's technical competencies when providing obstetric care. Seven hundred eighty-five pregnant women with obstetric or perinatal emergencies received care through telehealth systems, with a progressive increase in technology adoption. Nine percent required Intensive Care Unit (ICU) admission, and none died. The MMR decreased from 78.8 in 2021 to 12.0 cases per 100,000 live births by 2022. Improvements in indicators and conducted training sessions instilled confidence and empowerment among the healthcare teams in the sponsored hospitals, as evidenced in focus groups derived from a sample of 131 healthcare workers from 33 hospitals. Interpretation: Implementing the Hospital Padrino Strategy led to a significant MMR reduction, and consolidated a model of social healthcare innovation replicable in LMICs. Funding: The Hospital Padrino Strategy was funded by the Fundación Valle del Lili and the Health Secretary of Valle del Cauca. Furthermore, this study received funding from a general grant for research from Tecnoquimicas S.A.

Short-term effect of intravitreal dexamethasone implant in refractory diabetic macular edema.

PURPOSE: To evaluate the short-term effects (hours-days) of intravitreal dexamethasone implant (IDI) in eyes with diabetic macular edema (DME) refractory to anti-vascular endothelial growth factor (VEGF) injections. METHODS: This was a prospective, single-arm, interventional clinical series. Eyes with DME and 3-9 injections of ranibizumab without a good response were included. Patients underwent a single IDI. Best-corrected visual acuity (BCVA) measurement, complete ophthalmic evaluation, and spectral-domain optical coherence tomography (SD-OCT) were performed at baseline, 2 h, 3 h, 24 h, 7 days, and 1 month. The main outcomes were change in central retinal thickness (CRT) on SD-OCT and BCVA. RESULTS: Fifteen eyes of 15 patients were included. Mean CRT decreased after treatment from 515.87 µm ± 220.00 µm at baseline to 489.60 µm ± 176.53 µm after 2 h (p = 0.126), and 450.13 µm ± 163.43 at 24 h (p = 0.006). Change in BCVA was from 0.85 ± 0.44 logMAR baseline to 0.58 ± 0.37 log MAR at 1 month (p = 0.003). CONCLUSIONS: Eyes treated with IDI showed significant decrease in CRT detectable 1 day after injection. In some patients, the effect could be observed 3 h post-implantation. TRIAL REGISTRATION: Clinicaltrials.gov NCT05736081 . Registered 20 February 2023, Retrospectively registered.

Knowledge, attitudes, and perceptions of health care providers regarding the recommendation and use of long-acting reversible contraceptive devices for adolescent patients.

OBJECTIVE: To describe the knowledge, attitudes, and perceptions of healthcare providers in a region in southwestern Colombia regarding the recommendation and use of long-acting reversible contraceptive (LARC) methods for adolescents. STUDY DESIGN: This was a cross-sectional study. An online exploratory survey was designed to assess healthcare providers' knowledge, attitudes, and perceptions of Valle del Cauca hospitals. For the development of this the questionnaire, a literature search and validation of the instrument's appearance were conducted. RESULTS: The survey was completed by 115 people. Knowledge: 62.6% and 33% of the participants did not consider themselves capable of correctly placing an intrauterine device (IUD) or a subdermal implant, respectively. However, 73.9% of the participants had adequate theoretical knowledge. Attitudes: 64.3% of the participants considered that adolescents can acquire contraceptive methods without limitations. Short-acting reversible methods were the least recommended. Perceptions: For IUDs, 40.8% and 16.5% of the participants imposed a minimum age and minimum parity requirement for their use, respectively. Side effects were the main reason for not recommending in health institutions with a lower level of complexity. CONCLUSION: Healthcare providers had positive attitudes and adequate theoretical knowledge concerning to the effectiveness of LARCs. The main areas for improvement were practical knowledge about the insertion and proper use of the devices, indications for referral to gynaecologists for the insertion procedure, and concerns about side effects.

Our research explores healthcare providers' knowledge, attitudes, and perceptions regarding long-acting reversible contraceptives for adolescents. While attitudes were positive, practical knowledge gaps on device, placement and referral indications emerged. Read the full findings to uncover more about LARCs in adolescent healthcare.

Impacts of childbirth on anxiety, disability, and depression: Results from a Brazilian cohort.

Conditions such as violence, drug abuse, sexual satisfaction, anxiety, depression, and disability interfere with a healthy pregnancy and can also account for maternal morbidity. The instrument WOICE was built by WHO to measure it. We applied WOICE in a prospective cohort of 125 pregnant women, using a before-after approach, during the third trimester of pregnancy, and after 42 until 90 days of childbirth. 60% had anxiety during pregnancy, decreasing to 48.8% after delivery (p = 0.07), and depression scores decreased from 7.56 to 5.80 (p = 0.014). Disability affected 62.4% and 56, respectively. 9.6% used drugs during pregnancy, reducing to 4.0% after delivery (RR 0.69, IC 0.49 - 0.69).

Effect of the postpartum hemorrhage intervention package implementation in a fourth-level hospital in Latin America.

OBJECTIVE: To evaluate the effectiveness of the implementation of intervention packages for postpartum hemorrhage (PPH) management in pregnant women hospitalized in a High Obstetric Complexity Unit in a Latin American country. METHODS: Retrospective cohort study including pregnant women with PPH attended between January 2011 to December 2019. Three periods of time were defined according to management strategies We performed univariate and multivariate robust Poisson regression logistic models for each of the outcomes derived from each period. RESULTS: We included 602 patients. There was a reduction in period 3 of the incidence of massive PPH (16% versus 12% P < 0.001, relative risk [RR] 0.61, 95% confidence interval [CI] 0.44-0.85; P = 0.003), major surgery (24%, 13%, 11%, P = 0.002, RR 0.54, 95% CI 0.33-0.883; P = 0.014), and admission to the intensive care unit (ICU) (14%, 7%, 6.1%, P = 0.0, RR 0.40, 95% CI 0.17-0.96 P = 0.00). CONCLUSION: The implementation of PPH intervention packages in a hospital in a middle-income country from Latin America, led to a significant decrease in the incidence of massive bleeding, the rate of major surgery, and the ICU stay of pregnant women affected by this condition.

Clinical Experience of Using Telemedicine for the Management of Patients Using Continuous Subcutaneous Insulin Infusion in a Highly Complex Latin American Hospital.

INTRODUCTION: Continuous subcutaneous insulin infusion (CSII) has emerged as a potential solution for diabetes management during the pandemic, as it reduces the need for in-person visits and allows for remote monitoring of patients. Telemedicine has also become increasingly important in the management of diabetes during the pandemic, as it allows healthcare providers to provide remote consultations and support. Here, we discuss the implications of this approach for diabetes management beyond the pandemic, including the potential for increased access to care and improved patient outcomes. METHODS: We performed a longitudinal observational study between 1 March 2020 and 31 December 2020 to evaluate glycemic parameters in diabetic patients with CSII in a telehealth service. Glycemic parameters were time in range (TIR), time above range, time below range, mean daily glucose, glucose management indicator (GMI), and glycemic variability control. RESULTS: A total of 36 patients were included in the study, with 29 having type 1 diabetes and 6 having type 2 diabetes. The study found that the proportion of patients achieving target glucose variability and GMI remained unchanged during follow-up. However, in patients with type 2 diabetes, the time in target range increased from 70% to 80%, and the time in hyperglycemia decreased from 2% to 0%. CONCLUSIONS: The results of this study suggest that telemedicine is a strategy for maintaining glycemic control in patients using CSII. However, the lack of access to the internet and adequate telemonitoring devices make it difficult to use on a large scale in emerging countries like ours.

Telemedicine consultation for emergency patients' attention: a clinical experience from a high complex university hospital from Latin America.

INTRODUCTION: As a result of the new coronavirus pandemic, a highly complex academic hospital in Latin America implemented a telemedicine service for the care of obstetric, pediatric, and adult patients. In 2020, regional emergency services collapsed due to the increase in demand for care, generating the need to open expansion services and seek strategies to provide timely care to consulting patients. OBJECTIVE: We retrospectively describe the clinical experience of patients who consulted the emergency department via telemedicine across a videoconference tool using digital platforms. METHODS: A descriptive study with retrospective data collection was conducted to describe the implementation of the teleconsultation care model for patients. We constructed the clinical process indicators to evaluate the model. RESULTS: A total of 4652 teleconsultations were registered. Telemedicine consultation was above 50% in the country and department and above 90% in Cali city. The average waiting time for care was estimated to be 1:59:52 h. A total of 275 patients were transferred to the emergency room after consultation. The principal reasons for consultation in the institutional telemedicine program were respiratory and gastrointestinal symptoms. Teleconsultations related to SARS-COV 2 infections reported 3775 patients (3127 with unidentified virus and 648 with the identified virus). CONCLUSIONS: Telemedicine is a tool that provides support and guidance to patients who consult emergency departments, reducing barriers to access health care and decreasing emergency department collapse.

Reevaluating the protective effect of smoking on preeclampsia risk through the lens of bias.

Preeclampsia is a hypertensive disorder that is usually diagnosed after 20 weeks' gestation. Despite the deleterious effect of smoking on cardiovascular disease, it has been frequently reported that smoking has a protective effect on preeclampsia risk and biological explanations have been proposed. However, in this manuscript, we present multiple sources of bias that could explain this association. First, key concepts in epidemiology are reviewed: confounder, collider, and mediator. Then, we describe how eligibility criteria, losses of women potentially at risk, misclassification, or performing incorrect adjustments can create bias. We provide examples to show that strategies to control for confounders may fail when they are applied to variables that are not confounders. Finally, we outline potential approaches to manage this controversial effect. We conclude that there is probably no single epidemiological explanation for this counterintuitive association.

Pregnancy-specific responses to COVID-19 revealed by high-throughput proteomics of human plasma.

BACKGROUND: Pregnant women are at greater risk of adverse outcomes, including mortality, as well as obstetrical complications resulting from COVID-19. However, pregnancy-specific changes that underlie such worsened outcomes remain unclear. METHODS: Plasma samples were collected from pregnant women and non-pregnant individuals (male and female) with (n = 72 pregnant, 52 non-pregnant) and without (n = 29 pregnant, 41 non-pregnant) COVID-19. COVID-19 patients were grouped as asymptomatic, mild, moderate, severe, or critically ill according to NIH classifications. Proteomic profiling of 7,288 analytes corresponding to 6,596 unique protein targets was performed using the SOMAmer platform. RESULTS: Herein, we profile the plasma proteome of pregnant and non-pregnant COVID-19 patients and controls and show alterations that display a dose-response relationship with disease severity; yet, such proteomic perturbations are dampened during pregnancy. In both pregnant and non-pregnant state, the proteome response induced by COVID-19 shows enrichment of mediators implicated in cytokine storm, endothelial dysfunction, and angiogenesis. Shared and pregnancy-specific proteomic changes are identified: pregnant women display a tailored response that may protect the conceptus from heightened inflammation, while non-pregnant individuals display a stronger response to repel infection. Furthermore, the plasma proteome can accurately identify COVID-19 patients, even when asymptomatic or with mild symptoms. CONCLUSION: This study represents the most comprehensive characterization of the plasma proteome of pregnant and non-pregnant COVID-19 patients. Our findings emphasize the distinct immune modulation between the non-pregnant and pregnant states, providing insight into the pathogenesis of COVID-19 as well as a potential explanation for the more severe outcomes observed in pregnant women.

Pregnant COVID-19 patients are at increased risk of experiencing complications and severe outcomes compared to the general population. However, the reasons for this heightened risk are still unclear. We measured the proteins present in the blood of pregnant and non-pregnant patients with COVID-19 and compared these to healthy individuals. We found that some COVID-19-associated proteins were present at lower levels in pregnant women, which could help to protect the fetus from harmful inflammation, the body's natural response to infection. While some proteins affected by COVID-19 are shared between pregnant and non-pregnant patients, others were distinctly affected only in pregnant women, providing a potential explanation for the more severe outcomes in this group.

Clinical outcomes in patients with solid tumors living in rural and urban areas followed via telemedicine: experience in a highly complex latin american hospital.

BACKGROUND: Difficulties in cancer services access increase the burden of disease and mortality in rural areas, and telehealth can be a useful tool to address these inequalities. OBJECTIVE: We aimed to describe the outcomes of patients in rural and urban areas with solid tumors managed by oncologists through telemedicine. METHODS: We conducted a retrospective cohort study of patients with solid tumors from March to December 2020. A total of 1270 subjects with solid tumors were included, 704 living in urban areas and 566 in rural areas. RESULTS: The most frequent tumors were breast (51.8%) and prostate (12.4%). The trend of telemedicine care was similar for both populations; in-person care was more frequent in the urban population. There were no differences in referral to the emergency room, need for hospitalization, and mortality for both groups. CONCLUSION: Telemedicine is a care modality that reduces barriers in the care of patients with solid tumors, evidencing similar outcomes regardless of living in rural or urban areas.

Maternal and perinatal outcomes in mixed antenatal care modality implementing telemedicine in the southwestern region of Colombia during the COVID-19 pandemic.

INTRODUCTION: Contingency measures due to the COVID-19 pandemic limited access to routine prenatal care for pregnant women, increasing the risk of pregnancy complications due to poor prenatal follow-up, especially in those patients at high obstetric risk. This prompted the implementation and adaptation of telemedicine. OBJECTIVE: We aim to evaluate the maternal and perinatal outcomes of patients who received prenatal care in-person and by telemedicine. METHODS: We conducted a retrospective observational cohort study of pregnant women who received exclusive in-person and alternate (telemedicine and in-person) care from March to December 20,202, determining each group's maternal and neonatal outcomes. RESULTS: A total of 1078 patients were included, 156 in the mixed group and 922 in the in-person group. The patients in the mixed group had a higher number of prenatal controls (8 (6-9) vs 6 (4-8) p < 0.001), with an earlier gestational age at onset (7.1 (6-8.5) vs 9.3 (6.6-20.3), p < 0.001), however, they required a longer hospital stay (26 (16,67%) vs 86 (9,33%), p = 0.002) compared to those attended in-person; there were no significant differences in the development of obstetric emergencies, maternal death or neonatal complications. DISCUSSION: Incorporating telemedicine mixed with in-person care could be considered as an alternative for antenatal follow-up of pregnant women in low- and middle-income countries with barriers to timely and quality health care access.

Telemedicine for the management of diabetic patients in a high-complexity Latin American hospital.

BACKGROUND: Noncommunicable diseases such as diabetes mellitus (DM) have gained attention worldwide. Latin America experienced a rise in rates of DM. During the COVID-19 pandemic, a telemedicine program was implemented in a quaternary care academic complex in Latin America to continue the follow-up of patients with diabetes. OBJECTIVE: The aim of this study is to describe the clinical experience of DM patient management through telemedicine and the HbA1c behavior of patients followed-up through this modality. MATERIALS AND METHODS: We conducted a retrospective cohort study including all patients with type 1 or 2 diabetes who were treated via telemedicine from March to December 2020. A Wilcoxon statistical test was used to compare the changes in glycosylated hemoglobin between the first teleconsultation and after 6 months of telemedicine follow-up. RESULTS: A total of 663 patients were included, 17.65% (117) of whom had type 1 diabetes and 82.35% (546) of whom had type 2 diabetes. Patients with both types of diabetes, presented with stable HbA1c values regardless of the length of follow-up. CONCLUSION: The use of telemedicine can be a helpful tool for both patients and health care providers to support the continuity of care to maintain acceptable control levels within glycemic control goals.

Effect of a model based on education and teleassistance for the management of obstetric emergencies in 10 rural populations from Colombia.

Introduction: Pregnant women and health providers in rural areas of low-income and middle-income countries face multiple problems concerning high-quality obstetric care. This study was performed to identify changes in maternal and perinatal indicators after implementing a model based on education and telecare between a high-complexity hospital in 10 low-complexity hospitals in a southwestern region of Colombia. Methods: A quasiexperimental study with a historic control group and without a pretest was conducted between 2017 and 2019 to make comparisons before and after obstetric emergency care through the use of teleassistance from 10 primary care centers to the referral center (Fundación Valle del Lili, FVL). Results: A total of 470 patients were treated before teleassistance implementation and 154 patients were treated after teleassistance implementation. After program implementation, the maternal clinical indicators showed a 65% reduction in the number of obstetric patients who were referred with obstetric emergencies. The severity of maternal disease that was measured at the time of admission to level IV through the Modified Early Obstetric Warning System score was observed to decrease. Conclusion: The implementation of a model based on education and teleassistance between low-complexity hospitals and tertiary care centers generated changes in indicators that reflect greater access to rural areas, lower morbidity at the time of admission, and a decrease in the total number of emergency events.

Experience with Obese Patients Followed via Telemedicine in a Latin American Tertiary Care Medical Center.

BACKGROUND: Obesity is a major public health concern worldwide. Latin America has experienced rapid growth in obesity incidence during the last few decades. Driven by confinement measures, a telemedicine program was implemented in March 2020 to give continuity to obese patients' care through a weight loss program led by the endocrinology department in a tertiary care medical center in Latin America. OBJECTIVE: This study aimed to describe the clinical experience of using digital health for monitoring and attention of obese patients and description of weight change outcomes of these patients followed via telemedicine during March 2020-December 2020. METHODS: A retrospective cohort study was conducted including 202 patients. A Skillings-Mack test was performed to conduct a subgroup analysis of the medians of the weight over the follow-up period, and a mixed multiple linear regression model was performed to estimate the expected average change in weight over time Results: We observed good adherence to the program, represented by a weight loss of -4.1 kg at three months of follow-up, which was maintained even during the sixth month of follow-up. CONCLUSIONS: Digital Health strategies such as telemedicine can be a helpful tool for both patients and health care providers to support the continuity of care and showing satisfactory results in the management of obese patients.

Pregnancy-specific responses to COVID-19 are revealed by high-throughput proteomics of human plasma.

Pregnant women are at greater risk of adverse outcomes, including mortality, as well as obstetrical complications resulting from COVID-19. However, pregnancy-specific changes that underlie such worsened outcomes remain unclear. Herein, we profiled the plasma proteome of pregnant and non-pregnant COVID-19 patients and controls and showed alterations that display a dose-response relationship with disease severity; yet, such proteomic perturbations are dampened during pregnancy. In both pregnant and non-pregnant state, the proteome response induced by COVID-19 showed enrichment of mediators implicated in cytokine storm, endothelial dysfunction, and angiogenesis. Shared and pregnancy-specific proteomic changes were identified: pregnant women display a tailored response that may protect the conceptus from heightened inflammation, while non-pregnant individuals display a stronger response to repel infection. Furthermore, the plasma proteome can accurately identify COVID-19 patients, even when asymptomatic or with mild symptoms. This study represents the most comprehensive characterization of the plasma proteome of pregnant and non-pregnant COVID-19 patients.

Experience of a telehealth and education program with maternal and perinatal outcomes in a low-resource region in Colombia.

INTRODUCTION: Maternal morbidity and mortality rates associated with perinatal care remain a significant public health concern. Rural populations from low and middle-income countries have multiple barriers to access that contribute to a lack of adherence to prenatal care, and high rates of maternal mortality and morbidity. An intervention model based on telehealth and education was implemented between a tertiary high complex care hospital and a second-level hospital from a limited source region. OBJECTIVES: We sought to identify an association in maternal and perinatal care quality indicators after implementing a model based on telehealth and education for patients with obstetric emergencies between two hospitals in a southwestern region of Colombia. METHODS: We conducted an ecological study between 2017 and 2019 to compare before and after obstetric emergency care through telemedicine from a secondary care center (Hospital Francisco de Paula Santander-HFPS) to the referral center (Fundación Valle del Lili-FVL). The intervention included verification visits to determine the installed capacity of care, a concerted improvement plan, and on-site educational training modules in obstetric and perinatal care. RESULTS: There were 102 and 148 patients treated before and after telemedicine implementation respectively. Clinical indicators after model implementation showed a reduction in perinatal mortality of 29%. In addition, a reduction in the need for transfusion of blood products due to postpartum hemorrhage was observed as well as the rate of eclampsia. CONCLUSIONS: Implementing a model based on telehealth and education between secondary and tertiary care centers allowed the strengthening of the security of care in obstetric emergencies and had a positive effect on perinatal mortality.

Resource use decrease after implementation of care bundles for treatment of postpartum hemorrhage.

OBJECTIVE: To evaluate whether the implementation of care bundles has an impact on resource utilization in the care of patients with postpartum hemorrhage (PPH). METHODS: Retrospective, cross-sectional, observational study of 404 patients with stage II or greater PPH. Periods 2011-2014 and 2015-2017, before and after the introduction of care bundles, were compared. Billing reports were analyzed, and all services provided to treat these events were extracted. Use of resources within the two periods was computed. RESULTS: The amount billed per episode decreased 18.66% from the first to the second period. Most PPH cases used fewer resources after introduction of care bundles. The greatest reduction was in the use of medications, with a decrease of charges by 56.3%. Diagnostic procedure charges decreased by 47.6% and consultation charges decreased by (37.7%). CONCLUSIONS: The use of PPH care bundles may be associated with lower resource use and fewer interventions.

Teleconsultation for outpatient care of patients during the Covid-19 pandemic at a University Hospital in Colombia.

BACKGROUND: During the COVID 19 pandemic, direct-to-consumer telehealth (DTC) services allowed patients real-time virtual access to healthcare providers, especially those with an established relationship. In Colombia, this care modality was implemented between 2019 and 2020, under national considerations, it was implemented for outpatient care in a highly complex university hospital in Cali, Colombia. METHODS: A descriptive study with prospective information collection was used to describe the implementation of the outpatient teleconsultation care model for patients. We constructed the clinical and process indicators with which we evaluated the model. FINDINGS: A total of 56,560 patients from our institution were treated by virtual outpatient consultation during the first nine months of the health emergency declared by COVID 19 in Colombia. The strategy made it possible to achieve coverage more significant than 100% in Cali and the departments of Colombia. Attention by teleconsultation was 19% of the total ambulatory care. The effectiveness in carrying out scheduled teleconsultations had an overall result of 91.5%. The accessibility results demonstrated the need to strengthen connectivity and accessibility to payments and strengthen technology adoption in the institution, health personnel, and patients. INTERPRETATION: Implementing an outpatient teleconsultation model allowed the continuity of the management with comprehensive coverage nationwide from a highly complex hospital in southwestern Colombia. The indicators' analysis should help strengthen the policies of access to telemedicine, especially with the consequences of the pandemic in low- and middle-income countries. Latin American evidence is necessary to establish the safety profile of telemedicine and the costs associated with the provision.

A multidisciplinary approach and implementation of a specialized hemorrhage control team improves outcomes for placenta accreta spectrum.

INTRODUCTION: The main complication of placenta accreta spectrum (PAS) is massive bleeding. Endoarterial occlusion techniques have been incorporated into the management of this pathology. Our aim was to examine the endovascular practice patterns among PAS patients treated during a 9-year period in a low-middle income country in which an interdisciplinary group's technical skills were improved with the creation of a PAS team. METHODOLOGY: A retrospective cohort study including all PAS patients treated from December 2011 to November 2020 was performed. We compared the clinical results obtained according to the type of endovascular device used (group 1, internal iliac artery occlusion balloons; group 2, resuscitative endovascular balloons of the aorta; group 3, no arterial balloons due to low risk of bleeding) and according to the year in which they were attended (reflects the PAS team level of experience). A fourth group of comparisons included the woman diagnosed during a cesarean delivery and treated in a nonprotocolized way. RESULTS: A total of 113 patients were included. The amount of blood loss decreased annually, with a median of 2,500 mL in 2014 (when endovascular occlusion balloons were used in all patients) and 1,394 mL in 2020 (when only 38.5% of the patients required arterial balloons). Group 3 patients (n = 16) had the lowest bleeding volume (1,245 mL) and operative time (173 minutes) of the entire population studied. Group 2 patients (n = 46) had a bleeding volume (mean, 1,700 mL) and transfusions frequency (34.8%) slightly lower than group 1 patients (n = 30) (mean of 2,000 mL and 50%, respectively). They also had lower hysterectomy frequency (63% vs. 76.7% in group 1) and surgical time (205 minutes vs. 275 in group 1) despite a similar frequency of confirmed PAS and S2 compromise. CONCLUSION: Endovascular techniques used for bleeding control in PAS patients are less necessary as interdisciplinary groups improve their surgical and teamwork skills. LEVEL OF EVIDENCE: Therapeutic care management, level III.