First experience with the use of placenta topographic staging and conservative surgery in Lithuania

Introduction:Placenta accreta spectrum (PAS) is one of the most problematic conditions in pregnancy caused by growing rates of cesarean deliveries. It has a high risk for life-threatening bleeding during delivery and mortality. The best options for PAS management include antenatal ultrasound detection, surgical planning in a hospital with the necessary resources to prevent and treat severe bleeding, and surgery execution by a multidisciplinary team (MDT) trained in different surgical options. Previous reports show that tele-education and teleconsultation during surgery promote the competencies of surgical teams and facilitate the performance of one-step conservative surgery (OSCS) in selected PAS cases. We report the results of four PAS cases managed with teleconsultation for the first time and the successful implementation of OSCS in a university clinic in Lithuania. Cases: All patients had placenta previa and a history of two or three previous CS. They were referred to our tertiary hospital (Hospital of the Lithuanian University of Health Sciences (LUHS) Kaunas Clinics, Lithuania) for suspected PAS. Only one of them had repetitive antenatal bleeding. After confirmation of the diagnosis by detailed ultrasound evaluation, all patients were taken for planned CS at 36-37 weeks. A protocolised ultrasound evaluation was performed, including transabdominal and transvaginal views following previous recommendations for tele-ultrasound in PAS, with the storage of short de-identified videos that were shared with the PAS MDT in America (Fundacion Valle de Lili, Cali, Colombia) together with a three-plane drawing summarising the findings. The clinical details of each patient, as well as outcomes, are in Table 1. All the surgeries started with regional anaesthesia and converted to general anaesthesia after the bleeding started in two cases. A wide Pfannenstiel skin incision was done, and then bladder dissection from the anterior uterine wall was performed to evaluate the intraoperative topography stage of PAS. During surgery, PAS was confirmed in all cases, with two low anterior lesions (type 3 of the topographic classification) and two high anterior lesions (type 1 of the topographic classification), achieving OSCS execution with the help of a uterine tourniquet. The operating time varied between 81 and 155 minutes (mean 111). The intraoperative bleeding was objectively quantified by weighing the blood-soaked surgical clothing and quantifying the content of the suction devices, which varied between 1300 and 3000 ml. The mean of days of postoperative stay was 7.5 ( 5 - 11) days. Conclusions: conservative surgery is an accurate practice for patients with a placenta accreta spectrum. It is a secure procedure after selecting the patient through ultrasound and surgical staging, applying topographic classification. Telemedicine can promote the incorporation of these surgeries in hospitals that previously used hysterectomy as the only management alternative.