Emergency peripartum hysterectomy and management of placenta accreta in a regional hospital in Australia

Abstract

Objectives: Worldwide, there is a rising incidence of placenta accreta (PA) and post partum haemorrhage (PPH). The absence of a failsafe technique to diagnose PA, or for predicting which women may require an emergency peripartum hysterectomy (EPH) complicates planning the management of these patients in both tertiary and regional centres. The aim of this study was to review the recent incidence, management and outcomes of PA and EPH in an Australian regional hospital, and to determine if women with a suspected antenatal diagnosis of placenta accreta could be managed safely in this setting. Method: A retrospective chart review of all patients diagnosed as having a morbidly adherent placenta or who underwent EPH at Nambour General Hospital between 2008 and 2013 was performed to review the antenatal history, diagnosis, indications for and surgical procedures performed, the outcomes and complications of care, and neonatal outcomes. A database was collated using Microsoft Excel™ and descriptive statistics performed using SPSS™. Results: There were 32 cases of clinically and histologically diagnosed PA (0.2/100 deliveries). 3 cases of PA were diagnosed antenatally (9%). 4 patients underwent EPH, 2 for PA, 2 for intractable PPH. 21% of cases were elective caesarean sections. 65% of patients had previous uterine surgery. Average estimated blood loss (EBL) was 1840mL (range 200-7300mL). 40% of patients received a blood transfusion, 25% required large volume transfusion (>4units PRBC), 6% were admitted to intensive care (ICU). Results have shown similar rates of EBL and transfusion, with low complication, ICU admission and reoperation rates compared with that previously reported from tertiary centres. Conclusions: Given the inaccuracy of diagnosing PA antenatally, the reluctance of women to travel long distances to a tertiary centre, where they may have to wait several weeks before delivery, and the absence of gynaecological oncologists in a regional hospital setting, it is essential for such hospitals to have a realistic management plan in place for dealing with these women, and for generalist Obstetrician- Gynaecologists working in regional hospitals to have adequate surgical training to enable them to perform EPH if required.<br />