Thread by @OBsleepmerchant

@FarberMichaela’s 2nd lecture at #OAA3dc2022 - placenta accreta spectrum. A few disclosures. An extensive/ complete objective list. #OBAnes

Why is it important? Entire families’ lives are changed. So many traumatic, physical and psychological impacts. Now several societies for PAS. #OAA3dc2022

@FarberMichaela continues PAS by stressing that terminology is key! FIGO classification = how deep does it invade.Risk factors for PAS primarily related to previous cesarean & placenta previa. Antenatal assessment US/ MRI. NB normal does NOT exclude PAS, prepare!
#OAA3dc2022

Placental lacunae an important finding on US. Delay in PPH diagnosis = increased severity. Serosa-bladder interface vessels = predictor of major hemorrhage (POCUS @rosie_hogg ). Where the placenta is makes all the difference.
#OAA3dc2022

Minimizing blood loss through novel techniques. Intentional retention of placenta may be an option - desirable for women wishing to retain fertility. Another place for REBOA/ manual compression of aorta - minimizes blood loss. Multivessel embolization deceases EBL. #OAA3dc2022

On that minimal bleeding cesarean section, see video below #OAA3dc2022

https://twitter.com/TheMillennialMD/status/1591281167890001921

Routine use not recommended BUT should be available? In PAS knowing QBL is king! However, treat the patient not the number - clinical picture should guide escalation of care.
#OAA3dc2022

PAS tools - massive transfusion protocol. POC FIBTEM/ ROTEM to guide coagulation management - however may not change transfusion patterns (habit? As alluded to by Prof Rachel Collis). Centre specific protocols are advantageous.
#OAA3dc2022

Simulation is NB. Realism NB - @FarberMichaela subscribes to the universal rule: “no coffee, no gassy” (@GongGasGirl would approve). Key objectives in PAS Mx. Suspected PAS patients should be escalated to specialty, but unexpected WILL occur - @MySMFM checklist useful
#OAA3dc2022

Actions to take in massive hemorrhage - trendelenberg/ raise legs, aortic compression. Rescue maneuvers: uterine tourniquet, REBOA, manual aortic compression.

GA vs RA - pro’s & con’s. Several knowledge gaps exist. Neuraxial for PAS: 95% RA —> 62% hysterectomy, 12% conversion to GA. In hysterectomy group 1 in 5 converted to GA.

Of neuraxial group only 38% had no IV sedation - ? GA without airway. Of GA: 3 difficult intubations (one awake fibre optic) all in cases converted from RA. Average duration 2.6 hours - plan RA around that. How to avoid conversion to GA? - use primary GA #OAA3dc2022

That’s a lot of people on the OR - manage communication carefully, POCUS, patient focussed, tailored care. Knowledge gaps exist for PAS Mx. Succinct conclusion slide from @FarberMichaela
#OAA3dc2022

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