Improved maternal outcome in placenta accreta spectrum disorders: a single-institute observational cohort study

To describe the evolution and outcomes of protocol-orientated multidisciplinary quality improvement for clinically confirmed placenta accreta spectrum (PAS) disorders mainly receiving uterine preservation.

This single-institute, retrospective cohort study compared clinical outcomes of patients within three periods of 2013-2016 (initial period), 2017-2019 (transition period), and 2020-2023 (current period) during January 1st, 2013, to December 31st ,2023. The quality improvement elements were introduced mainly in the transition period, including optimization of peripartum care, prenatal diagnosis, surgical plan and preparation of autologous blood products. The primary outcomes included early composite maternal morbidity and uterine preservation rate. Meanwhile, secondary outcomes were late composite maternal morbidity, estimated blood loss and allogenic blood transfusion.

This study enrolled 474 consecutive patients, involving 153 patients in initial period, 202 patients in transition period and 119 patients in current period. There was a large proportion of patients (97.5%) receiving surgery for uterine preservation in current period than in initial period (81.0%) and transition period (93.6%) (P < 0.001). Early maternal morbidity gradually decreased from 23.5% in initial period to 17.8% and 11.8% in transition period and current period (P = 0.044). The major contributors included reduced transfusion of 4 or more red blood cells (22.9% vs. 16.3% vs. 10.9%; P = 0.032) and early reoperation (5.2% vs. 1.5% vs. 0.8%; P = 0.034). There was also increase of 400 ml in intraoperative blood loss and overall blood loss (P = 0.003 and P = 0.034, respectively), which might relate with less application of invasive hemostatic procedures, including preoperative balloon occlusion and intrauterine tamponade. However, no significant difference in allogenic blood transfusion was revealed due to raising in preoperative hemoglobin level (107 g/L vs. 110 g/L vs. 113 g/L; P = 0.001) and establishing various forms of autologous blood preparation.

The implementation of quality improvement elements may result in lower composite maternal morbidity with more uterine preservation, coupled with less application of MRI and invasive intraoperative hemostatic procedures. Our findings suggest that institutional quality improvement may reduce morbidity and improve uterine preservation.