Podcast Transcript: Placenta Accreta Spectrum (PAS)

[Dr. Mark Hoffman]
It feels like you're watching a fuse on a bomb because you aren't sure what you're looking at but yet waiting longer, as you just told us, dramatically increases the risk to the patient. One of my big questions was how do we counsel our patients? Because sometimes you see a low-lying placenta, a niche and it grows up into the uterus, sometimes it turns out into what we're talking about here today. When do we intervene? When do we take that opportunity at seven, eight weeks to do something knowing that maybe it won't be an accreta?

[Dr. Brett Einerson]
To me, there's a ton of work to be done here. There's some interesting developing criteria for location of the early pregnancy in the start to direct us, but all of that stuff still needs to be validated. We are really oftentimes stuck in the gray, but for the cases that are less gray, for black and white cesarean scar pregnancies that are deep within the scar at less than 10 weeks, my recommendation for patients, because it's so deep in and because the diagnosis is clear, my recommendation to those patients is pregnancy termination. A fair number of my patients don't take that recommendation.

My experience has been, with six or seven cases now over the last five years, that all of those turn into terrible what we used to call percreta or FIGO 3, all of them turn into difficult cases. Some of them result in very, very early deliveries, even pre-viable deliveries. I have had patients who don't proceed with a recommendation, then go on to have a pre-viable delivery, and at that time, 18 weeks, they lose their uterus because there's not good treatment options.

My recommendation for obvious growth into the scar, low implantation, obvious cesarean scar pregnancy in the first trimester is termination of pregnancy by whatever local standard there is. Those standards differ. Sometimes it's injection, here it's suction D&C under ultrasound guidance with laparoscopic backup. That's been super successful for us. To me, that's one case where the risk of proceeding with pregnancy is considerable. The likelihood of taking home a baby that will be live-born and survive is lower and the likelihood of losing your uterus with expected management is close to 80% to 100%.

In the gray zones, it's much harder to counsel patients. If it's on the scar instead of in the niche pregnancy, cesarean scar ectopic at 10 weeks, or if you don't make the diagnosis until 15 weeks, it's very difficult to know what to do. I've had a lot of patients who come to me bleeding at 15 weeks, who look back at their images, they had cesarean scar ectopic, now they've got full blown, bad accreta and they're already bleeding.

I've counseled patients in that time period to have gravid hysterectomy because they're bleeding so much. I've had a few patients make it to viability or beyond in that group, but knowing an individual's outcome is beyond our abilities at this point. If there's not enough cases in the literature, there's not a good enough risk paradigm set up yet to be able to counsel patients well, aside from the obvious cases early on.

[Dr. Amy Park]
That's super fascinating because this whole dialogue about cesarean scar ectopic seems to be, like I said, just so much newer. This was not a discussion when I was a resident. Like I said, so many surgical videos, so much discussion, so much-- there is a gray zone and you've seen this develop over your experience. I'm so appreciative.

[Dr. Mark Hoffman]
And MIGS people and MFMs have to talk to each other now, which is a little uncomfortable at times. It's not great, but we do it. It's what we do for our patients.

[Dr. Amy Park]
Let me ask you about just what have you established in terms of best practices? I know that's an evolving area, but what's the optimal timing of delivery? Are you giving everyone steroids? Do you put them in the main OR instead of L&D, do you position them some way? Do you have a massive transfusion protocol ready? How are you managing all this stuff? Do you have IR and backup? How are you managing these patients?

[Dr. Brett Einerson]
Thanks for asking that. We have a protocol that we put together a couple years ago. It's iterative, it's updated every year basically to try to adapt to the evolving best practices. Our general approach is that we think our best practice based on the current literature and our experience is first of all to, like I said before, to have a pretty healthy skepticism that we are going to know about every case, and as such to overprepare even when we're not sure of the diagnosis and even when we think the diagnosis is more mild.

I can tell you that within our system in the last 10 years, I wasn't here for the whole 10 years, but looking back at some of our worst cases, they were cases of unclear diagnosis. "We're not sure that this patient has placenta accreta. Let's try to pull on the placenta," or, "This looks like a milder case. Why don't we try for uterine conservation or pulling on the placenta?" Those are some of the actual worst cases.

I think optimal care really starts with a low threshold to over prepare. Meaning, having them done at a time when you can have surgical backup, having enough blood available in the room, having the team ready and not just relying on your response to unexpected cases but to over prepare even in cases that are a little bit borderline. That's a philosophical point.

We see these patients throughout pregnancy, we get an ultrasound about every month to take a look at the placenta. In our experience, the placenta doesn't continue to grow into organs. It's established by 20 to 24 weeks how severe it's going to be. Then depending on the individual's characteristics, we start having them see our anesthesiology team to prepare for that. Having them see the pelvic surgeons who are going to be involved in their care. Getting familiar with our labor and delivery triage in case they have a bleeding event. We introduce people to all of the team members who are going to be involved in their care.

For patients who have bleeding during pregnancy, we have a pretty low threshold to admit though, because our experience is that one bleeding event often leads to an unexpected delivery. We have a pretty low threshold to monitor people beyond what we would otherwise monitor people for preview with bleeding. I've had patients, unfortunately, who spent most of their pregnancy in the hospital. Delivery timing, our approach with that is to usually follow the guideline that's put forward by ACOG, which is 34 and 0 to 35 and 6. Although I will say that even the ACOG guideline says that the optimal delivery time is unclear.

Internationally, there are a lot of people who are pushing for a later delivery, 36 to 37 weeks in well-selected patients. In some patients, they have been very stable, they don't have a lot of uterine activity. They live very close to the hospital. Maybe they don't have a placenta previa. They're highly motivated to deliver later. We will aim for 36 to 37 in those patients. We individualize it and if it's a sure case and there's anything that the patients are having in terms of uterine contractions, bleeding at all, we typically aim for that 34 to 35 and 6-week window.

[Dr. Mark Hoffman]
Just hearing you talk, the number of cases you've done, the nuance between each case and how individualized you're able to be with each case, case by case. Like you said, if you're doing a couple of these a year, if you're doing a handful a year, there's no way, and without an abundance of literature, this is where experience can matter maybe as much as in any place in medicine and what we do in obstetrics in general.

Not as much research as we'd like, but in this area, just hearing you talk and how you'd be able to counsel patients, "Oh, well I've been doing this for years. I've seen this many--" Well, I'm going to listen to whatever you say as a patient as opposed to like, "Well we're just going to see how it goes." I'm just getting a window into the value and the power of having a center like yours.

[Dr. Amy Park]
Do you give everyone steroids based on your experience, or obviously if they have a bleeding event or uterine contractility or what have you?

[Dr. Brett Einerson]
I try to save the steroids up until the time that delivery seems fairly imminent. Certainly if somebody comes in at 28 weeks and has a liter blood clot or we’re wondering whether or not they're going to get delivered, they get steroids. Most cases, we hold off until a week or two before delivery. Since we're aiming for that 34 to 35-week time period, it's right at that cusp of traditional antenatal steroids and ALPS. We are typically administering steroids around that 33-week time period if all is going well in their pregnancy.

Mark, I think to add on to what you were saying or to throw in my 2 cents on that, I think for other types of serious health problems, and I think this is a serious health problem, it's evident that you get a second opinion. It's evident to patients and to doctors that you go to the place that does more of them. My dad got cancer living in rural Minnesota when I was a first year fellow. At the risk of offending the University of Minnesota, another healthcare system is like when you get cancer in Minnesota, you go to Mayo. I'm not saying Mayo has something hyper special there, but patients know you have a serious diagnosis to do it to the place that has the name for taking good care of patients.

[Dr. Mark Hoffman]
I'm in Kentucky and I've spent time working in rural Eastern Kentucky. We had a rural eastern Kentucky doc on the show because I think the work that they do is invaluable and not to do anything but to give them credit. That being said, when you're dealing with things like this that are incredibly rare and in your case potentially incredibly catastrophic, volume matters.

In terms of proximity, are you having folks move to Salt Lake City? What can you do to get social support? Because one of the big things I've learned working with the population of patients that live remotely and live rurally, access is-- you can know the right answer, you can check the right box, but if they're 120 miles down country roads away, it doesn't matter that you know the right answer. What measures are you guys taking in Utah to solve some of those social determinants of health, the proximity issues?

[Dr. Brett Einerson]
Yes, so thank you for that. The best study on how unpredictable delivery can be for patients is, I think, comes from Baylor where they show that about 35% to 45% of patients, depending on the year, delivered before their expected delivery time, placenta accreta spectrum and many of them weeks and weeks beforehand. It's a particular challenge for those of us taking care of accreta to not only be ready 24/7 but also to not take substantially worse care of our patients who live four or five hours from the hospital.

That's inequitable. If we don't have systems set up to help those patients financially, then we're being inequitable with our care. It shouldn't be the happenstance that if you live in my area code that you get much better care than if you live in rural Idaho. What I will typically do when we make the diagnosis, oftentimes in the middle of the pregnancy, is to have a conversation or communication with the home doctor and give them the expectations for what things I want to see the patient for and do co-management up until about 30 weeks. Then sometime between 30 and 32 weeks, I ask patients who live more than 45 minutes from the hospital to make arrangements to come to live in Salt Lake City.

For some patients that means a family member. There's a lot of large families in Utah, but for many patients, that's taking up residents at Ronald McDonald House. We, unlike a lot of other centers that I've heard from, actually have really amazing support for pregnant people at Ronald McDonald's Center.

[Dr. Mark Hoffman]
I was going to ask because I don't think of the Ronald McDonald House as being a place where people stay who are still pregnant. Talk about what makes that special or how that came to be.

[Dr. Brett Einerson]
I think it existed prior to my coming onto the scene in Utah. It wasn't something that I had to set up personally. I think it was a realization on the Ronald McDonald House that so many patients, whether it was due to a complicated fetus or complicated mom, were going to end up in their hands anyways. We're not as landlocked in Salt Lake as we were in Chicago where I know that Ronald McDonald had maybe a little bit stricter criteria for who could be there. We have, I think just out of good relationships and good luck, had the good fortune of Ronald McDonald being able to house these patients with placenta accreta spectrum or other anticipated fetal and maternal prematurity-related needs.

Its prematurity is the key that unlocked our ability to have patients around Ronald McDonald, and as long as they have another adult with them, they're able to stay there. For patients who don't, and a lot of them don't, our hospital has arranged for basically sliding scale type housing at one of the very local hotels or will set them up in an apartment depending on their unique needs. For patients who prefer something different, I've had patients who do other things like stay in their RV at an RV park and it's 20 minutes from the hospital. RV life is big in Utah.