title: Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach.
abstract: OBJECTIVE
  The purpose of this study was to test the hypothesis that a standardized multidisciplinary treatment approach in patients with morbidly adherent placenta, which includes accreta, increta, and percreta, is associated with less maternal morbidity than when such an approach is not used (nonmultidisciplinary approach).
  
  
  METHODS
  A retrospective cohort study was conducted with patients from 3 tertiary care hospitals from July 2000 to September 2013. Patients with histologically confirmed placenta accreta, increta, and percreta were included in this study. A formal program that used a standardized multidisciplinary management approach was introduced in 2011. Before 2011, patients were treated on a case-by-case basis by individual physicians without a specific protocol (nonmultidisciplinary group). Estimated blood loss, transfusion of packed red blood cells, intraoperative complications (eg, vascular, bladder, ureteral, and bowel injury), neonatal outcome, and maternal postoperative length of hospital stay were compared between the 2 groups.
  
  
  RESULTS
  Of 90 patients with placenta accreta, 57 women (63%) were in the multidisciplinary group, and 33 women (37%) were in the nonmultidisciplinary group. The multidisciplinary group had more cases with percreta (P = .008) but experienced less estimated blood loss (P = .025), with a trend to fewer blood transfusions (P = .06), and were less likely to be delivered emergently (P = .001) compared with the nonmultidisciplinary group. Despite an approach of indicated preterm delivery at 34-35 weeks of gestation, neonatal outcomes were similar between the 2 groups.
  
  
  CONCLUSIONS
  The institution of a standardized approach for patients with morbidly adherent placentation by a specific multidisciplinary team was associated with improved maternal outcomes, particularly in cases with more aggressive placental invasion (increta or percreta), compared with a historic nonmultidisciplinary approach. Our standardized approach was associated with fewer emergency deliveries.
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX. Electronic address: alirezashamshirsaz@yahoo.com.
authors.forename: Alireza A
authors.initials: AA
authors.lastname: Shamshirsaz
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Karin A
authors.initials: KA
authors.lastname: Fox
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Bahram
authors.initials: B
authors.lastname: Salmanian
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Concepcion R
authors.initials: CR
authors.lastname: Diaz-Arrastia
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Wesley
authors.initials: W
authors.lastname: Lee
authors.affiliation: Department of Anesthesiology and Obstetric and Gynecologic Anesthesiology, Texas Children's Hospital, Houston, TX.
authors.forename: B Wycke
authors.initials: BW
authors.lastname: Baker
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Jerasimos
authors.initials: J
authors.lastname: Ballas
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Qian
authors.initials: Q
authors.lastname: Chen
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Teelkien R
authors.initials: TR
authors.lastname: Van Veen
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Pouya
authors.initials: P
authors.lastname: Javadian
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Haleh
authors.initials: H
authors.lastname: Sangi-Haghpeykar
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Zacharias
authors.affiliation: Department of Neonatology, Texas Children's Hospital, Houston, TX.
authors.forename: Stephen
authors.initials: S
authors.lastname: Welty
authors.affiliation: Department of Radiology, Texas Children's Hospital, Houston, TX.
authors.forename: Christopher I
authors.initials: CI
authors.lastname: Cassady
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Amirhossein
authors.initials: A
authors.lastname: Moaddab
authors.affiliation: Department of Pathology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Edwina J
authors.initials: EJ
authors.lastname: Popek
authors.affiliation: Department of Pathology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Shiu-ki Rocky
authors.initials: SK
authors.lastname: Hui
authors.affiliation: Department of Pathology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Jun
authors.initials: J
authors.lastname: Teruya
authors.affiliation: Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX.
authors.forename: Venkata
authors.initials: V
authors.lastname: Bandi
authors.affiliation: Department of Urology, Baylor College of Medicine, Houston, TX.
authors.forename: Michael
authors.initials: M
authors.lastname: Coburn
authors.affiliation: Operating Room, Texas Children's Hospital, Houston, TX.
authors.forename: Thomas
authors.initials: T
authors.lastname: Cunningham
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Stephanie R
authors.initials: SR
authors.lastname: Martin
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Belfort
mesh_terms: D000328:Adult; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D002585:Cesarean Section / Q000379:methods*; D002985:Clinical Protocols; D015331:Cohort Studies; D017707:Erythrocyte Transfusion / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D007902:Length of Stay / Q000706:statistics & numerical data; D008875:Middle Aged; D010921:Placenta Accreta / Q000601:surgery*; D018457:Placenta, Retained / Q000601:surgery*; D011247:Pregnancy; D012189:Retrospective Studies; D055815:Young Adult
keywords: invasive placenta; maternal complication; placenta accreta; placenta increta; placenta percreta; standard treatment