Dr. Warner Huh (Host): Hello, everyone. This is Dr. Warner Huh, the Chair of Obstetrics and Gynecology at the University of Alabama Birmingham, and I'd like to welcome you to this monthly episode of Women's Health with Dr. Huh. It's June and feels like it's about 120 degrees outside, but hope you guys are all having a good summer.

 So for our listeners, you probably remember last month we talked about something known as the placenta accreta spectrum, also known as PAS. And I had doctors Haller Smith and Akila Subramaniam talk about a little bit about what this is, risk factors, how it was diagnosed. And you probably remember that I was going to do this in two parts and today's the part two of that, and we're going to talk a little bit more about how you manage and treat placenta accreta spectrum.

And with me today are two amazing experts and surgeons on this topic. The first is Dr. Michael Straughn, who is a professor in the Department of Obstetrics and Gynecology in the Division of Gynecologic-Oncology. And he's also the Chief of Medical Staff for UAB Hospital; and his partner, Dr. Charles Leath goes by Trey, who is also a Professor in the Department of OB-GYN, and the Division Director for Gynecologic-Oncology here at UAB. So Dr. Straughn and Dr. Leath, welcome to the podcast.

Dr. Michael Straughn: Thanks a lot.

Dr. Trey Leath: Thanks.

Host: Okay. So like I mentioned last time, on the last podcast, we talked about what exactly is PAS or placenta accreta spectrum, its risk factors, diagnosis, and the tests that we use to make the diagnosis. And today, I want to spend some time talking about how to treat this and manage this. And the reason I did this in two parts is because the treatment of management is something that I can pretty much assure our listeners that you don't know anything about, and it's a pretty significant deal because these are some of the biggest cases that we do in the field of OB-GYN, particularly Gynecology.

So, I was wondering if one of you could explain to our listeners in our audience today why the surgical management issue is such a big deal with PAS.

Dr. Michael Straughn: Yeah. Thanks, Warner. Happy to be on with you today with Dr. Leath. Yeah, this is a very interesting topic and one that I've had some interest in in the last few years. And I am part of the PAS team along with Dr. Leath and Dr. Smith and some of our other colleagues. But the surgical management is quite complicated because you are trying to deliver a baby via cesarean section, and then you have to deal with a placenta that is not going to be able to be removed from the uterus. And because of the significant blood supply related to the placenta and the fact that the placenta has grown into the uterus, it makes it very challenging to remove the placenta. And so, many of these cases, the plan is actually to undergo a hysterectomy after the safe delivery of the infant. And because of the anatomy and the blood supply, it can be very challenging to safely do the hysterectomy while controlling for blood loss and dealing with abnormal anatomic features related to the placenta being basically stuck in the wall of the uterus.

And so, really, the whole management begins with a Gynecologic-Oncology consultation. And so, our Maternal-Fetal Medicine colleagues do an excellent job identifying, diagnosing, and getting these patients into the system at UAB. And ultimately, we get involved when they feel like there's going to be a high risk situation where the patient is ultimately going to need a hysterectomy. And so, that's kind of where our involvement begins. We want to meet with the patient, go over all the potential issues related to getting prepared for the surgery, the things that we might do during surgery, and then even sort of the postoperative care. It's really important for the patients to understand all of that, because they're also going to be dealing with a newborn at the same time.

And so, I sort of break down the surgical treatment into a couple parts. I'd say the first part is the preoperative planning, and that's where we're going to be working with our Maternal-Fetal Medicine colleagues. They're going to be telling us when the baby needs to be delivered. They'll be taking care of things like steroids and whether we're going to deliver in Labor and Delivery or the main OR. Making sure the patient's medically stable for surgery. And again, we work together and try to make sure we have the best time and date and place planned for the delivery.

Once we get to the day of delivery, we really work well with our Anesthesia colleagues, and we have some really great anesthesiologists who are experts in this field. And so, they're doing things like preparation for blood loss, getting blood products available, making sure there's proper IVs in place, and obviously getting the patient to sleep safely. Most of these cases are performed under general anesthesia, because we need the patient maximally taken care of by Anesthesia. And that's usually best done with general anesthesia versus a spinal like you would with a normal cesarean delivery. But getting everything ready is a big part of the surgical planning.

And so once we get to the operating room, patients will get their antibiotics and get prophylaxis for blood clots. They'll have compression devices on their legs. We'll make sure we get them up in the proper positioning and stirrups. And it's pretty amazing when we do the surgery, there may be up to 20 people involved in the room, including pediatrics, Anesthesia, all the nursing support, the Maternal-Fetal Medicine team, and then the Gynecologic-Oncology team.

Ultimately, the surgery starts out with making usually a vertical skin incision. So, we have adequate room to work inside the abdomen and the OB team will assess where the placenta is and avoid that area. So, it's usually an incision, sort of in the upper part of the uterus. They get the baby out safely. And then, the majority of the time, the placenta truly is stuck inside the uterus. And so, we're not going to try to pull it out or manually remove it. We're actually going to sew the placenta up inside the uterus so that it will help control bleeding. And then, at that point, the baby is safely delivered. The OB team has done their job. They have closed the uterus. And at this point, we've made the decision to move forward with the hysterectomy.

The challenges of doing one of these cases is that the uterus is still quite large. It has a placenta inside of it, and the blood supply is 10 times what you would normally find in a regular hysterectomy. And so, that's why through the years, gynecologic-oncologists have been involved in doing these cases because we do have the experience and expertise dealing with things that require, control of bleeding. And so, at UAB, our team continues to sort of operate in the usual fashion. We still use metal clamps, suturing devices. There's been other things that have been brought up in the recent years, different electrocautery devices that can help assist with the hysterectomy or stapling devices. But at UAB, we still use our primary techniques that we've used for 25 years, which is to control blood vessels, clamp them, and then ultimately remove the uterus with the placenta in situ. We do try to let the patient keep their ovaries, because we want them to continue to have estrogen production from their ovaries. So, the usual plan is to remove the cervix, the placenta, and the uterus. And when you do that, then you have controlled the bleeding and removed the placenta.

The main issue that I think we run into is that many of these cases, the placenta has invaded either into the bladder or close to the bladder. So, we have to get the bladder safely detached from the uterus. And so, there are times where we enter the bladder and do some work inside the bladder, remove part of the bladder. And again, we have that expertise from doing other gynecologic surgery, cancer cases, et cetera. But usually, at the end, Anesthesia's done a great job with blood product replacement. As we're losing blood, they'll transfuse the patient and keep the patient stable. And then, hopefully, these patients do well during all of this. Occasionally, they'll have to go to the intensive care unit for monitoring for a day or two.

But ultimately, in our experience, I think most of these patients, we've been able to get out of the hospital safely within three to five days with their healthy baby. Obviously, it's a big deal for patients to have to decide to understand that a hysterectomy will mean no further childbearing options. But certainly, doing a hysterectomy in these cases, we feel like, is oftentimes the safest way to manage this complicated situation. So, thanks.

Host: Yeah. Yeah. So, there's a lot to kind of repack there, but what I'm hearing from you and just kind of wanted to make sure our audience understands is that this is a big surgery. You mentioned earlier that the blood loss can be significant, so it's not uncommon for these patients to receive blood products, including red blood cells for anemia. But the other thing obviously is that there's sometimes more to just the hysterectomy surgery, but we resect portions of the bladder because the placenta actually invades into the wall of the bladder, what we call a percreta, is the technical term. But these are pretty big surgeries. And because you're dealing with such a well-perfused uterus, it's not surprising that the blood loss is so high. And so, it requires true multidisciplinary care at its peak actually, to make sure that we have the best outcomes for these patients. And oftentimes, I think you would agree that the surgeries are life-saving for some of these women, right?

Dr. Michael Straughn: So, yeah. No, I agree with you. Just one more comment. At other institutions, they do involve urologists, trauma surgeons, interventional physicians that can do techniques related to the aorta or the major vessels. And so, there's different ways to put together your team to help with that. But as long as you have expertise, like you said, with bladder surgery, bleeding, pelvic surgery, we've been pretty successful here at UAB with the GYN Oncology team sort of taking care of the surgery. And rarely do we need other consultants to help us.

Host: Okay. Well, thank you. I appreciate that. It's a really thorough answer to that question. So Dr. Leath, let me ask you this question. So, I think for a lot of our pregnant patients, it's like, "Okay, it's great. You're pregnant. You're going to deliver," and then they're told that you will likely need a hysterectomy at the end of your pregnancy. So, that's a bit tough to swallow. Can you just comment, and I think Dr. Straughn touched upon this, why is the hysterectomy often necessary to manage placenta accreta spectrum? And is there a role for potentially delaying the hysterectomy? Is there a way for someone to leave the placenta in and maybe come back weeks later and do a hysterectomy when things are a little bit more controlled?

Dr. Trey Leath: Yeah. Warner, that's a great question. Again, thank you for having Michael and myself here to talk about this topic. I think Michael alluded to this, as GYN-oncologists, as you know, we do have unique training, and pelvic surgery and oncologic training. And I think some of that training really directly allows us to make these intraoperative decisions. And one of the decisions that often is made, and again, the MFMs are high-risk pregnancy experts are usually able to give us a pretty good sense based on preoperative imaging of the likelihood of significant attachment, as well as the involvement of other work such as the bladder like Dr. Staughn spoke upon.

But ultimately, intraoperatively, we have to look at the uterus. We have to look at the placenta, I think as hopefully many of our listeners know normally the placenta would detach, it would deliver. The incision in the uterus itself would be closed, and the patient then would end her operation, and she would be able to have another child in the future if that was part of her reproductive plans. Unfortunately, with this condition, we know that the placenta itself does not detach. It is abnormally attached and that can be just very superficially. It can be growing into the muscle wall or all the way through the muscle wall, which is certainly very challenging and can be associated with multiple life-threatening, developments in the operating room.

And so, we are always excited when we're-- for lack of a better word-- wrong about the abnormal attachment, which does happen from time to time, and the placenta delivers the patient's not having any abnormal bleeding, and we can leave the uterus. That being said, in our experience here at UAB, the vast majority of cases, when we are concerned about a PAS case, with that abnormal attachment, a hysterectomy is going to be necessary, and we'll ultimately perform that in the operating room.

As you noted, there have been other centers, and again, Dr. Staughn noted this as well. Every team is a little bit different. Prior to coming back to UAB, I was in San Antonio, Texas, and we had Urology and Interventional Radiology involved a little bit more in our team and did more embolization procedures in selective patients. But again, here we tend to, if we're able to safely perform the hysterectomy, perform that rather than leaving the placenta behind.

I think really several of the reasons for doing that are, number one, it avoids a subsequent surgery. The second thing is there have been some reports that for patients who have a retained placenta, that there is a risk of a potential life-threatening infection. And again, and Michael alluded to this, it's always important to remember that these operations are being performed after the delivery of a newborn. And so, certainly, if we can be cognizant of that and allow a woman to recover as quick as possible in a safe as fashion as possible, that's also important.

I think overall the data that is available in the medical literature would suggest that there's not necessarily a superior approach. Although, again, I think most centers would tend to favor primary hysterectomy unless for some reason there did not appear to be a way to safely do that. Certainly, there may be some cases, especially with more extensive spread of the placenta into multiple different organs. But thankfully, that is very, very rare.

Host: And I guess further on that topic, and there's been some publications on this, but are there ways for us to manage PAS without resorting to a hysterectomy? Like in other words, are there options short of doing a hysterectomy that might be considered to be successful? And I thought maybe one of you could just take that on and address that.

Dr. Trey Leath: Yeah. So, I think there are published small series from other institutions, describing what I would say would be sort of conservative management of a PAS case. Again, we haven't really done that here at UAB, but I know other centers do, and I've talked to some of those physicians and read their articles. There is this Idea that in a minor case or a low-risk PAS that you could manually sort of remove the placenta and then try to locally resect sort of the roots or the attachment there. And then, come in and suture the area where the placenta had been attached. And so, that would be sort of called local resection and repair of that area. I think that's reasonable. If the placenta is loosely adherent and ultimately comes out, suturing the bed of the placenta I think is reasonable. We just don't see that very often here. We're usually dealing with more severe cases.

Another sort of strategy that we've talked a little bit about is what's called interval hysterectomy. So at the day of the C-section, you deliver the infant, and again, you leave the placenta inside the uterus and you suture it up and send them to the recovery area with the placenta inside. And then, the idea of that is that over the next six weeks or so, the blood supply is going to decrease to the uterus. The uterus is going to shrink up, the placenta's going to shrink up. And then, the thought is that six weeks later, you could do an operation that might be easier, result in less blood loss, potentially even do that hysterectomy laparoscopically or robotically. And what you're trying to do is decrease the complications from doing a hysterectomy right after a C-section. Most of the reports show that patients will stay in the hospital for a week or so getting antibiotics, and then go home with close followup with ultrasound and, again, waiting for the uterus and placenta to shrink up and then to come in and ultimately do that surgery six weeks after delivery. Ultimately, you're losing your uterus either way, whether it's on the day of the C-section or six weeks later. But that is a strategy of what you call interval hysterectomy or delayed hysterectomy.

Host: Yeah. To kind of add on to that, and Dr. Leath mentioned this earlier, my understanding is by leaving the placenta in there is that increased risk of infection. And I think, based on just our understanding and talking to other experts nationally, I think we're a little fearful of that risk. Mainly because the patients that we serve in the state, many of them live hours away from UAB Hospital. I can't say that every single hospital in the state of Alabama has the capacity to take on a super sick patient that might need an emergent hysterectomy.

So at the end of the day, I think it's a risk-benefit ratio. I think we're trying to do the right thing for the patient. I don't think any of us are just thrilled about doing a hysterectomy in this type of patient, but we also don't want them to have even a worse outcome. Like you said, Dr. Leath, in light of the fact that they are a new mother taking care of a newborn, it's a less than optimal situation. I think people are looking at it, but I think what we struggle is whether that really fits in the paradigm of clinical care here at UAB in Birmingham, Alabama. I'm assuming you agree with that, but I'm going to ask you that point blank whether you agree or disagree with that.

Dr. Trey Leath: That's a great point, Warner. Again, I think what we see at UAB is we really have a regional practice and that we have patients that come from many hours away, two, three, four, or five hours. I think, as you know, we have patients sometimes traveling from other states. And for somebody that is located 10 minutes away and has maybe a concern or an issue, they're able to be evaluated pretty timely. But some of our patients come from different geographic regions where resources perhaps are a little bit limited. And although in the operating room, we do have a large degree of control, should significant bleeding begin at home or a significant concern for infection occur at home, it may be more challenging to get that patient both evaluated and then potentially transferred to an appropriate center where the life-saving surgery could be performed in an appropriate and timely fashion.

Host: Yep, totally agree. So, one of the things I think is probably the most transformative aspect of placenta accreta spectrum is this team concept that I think Dr. Straughn mentioned at the very beginning of this podcast. And 10, 15 years ago, we really didn't have a team. Now, we do have an established team, but I would love for you all to talk about why the teen concept is so transformative, particularly for this particular disease process. And Dr. Staughn talked about a little bit about the components of that team, but just why we think it's so important for care with people with this particular disorder.

Dr. Trey Leath: Yeah. Warner, again, another great question. I think like many things that we do in professional settings, it's all about communication and making sure that every individual that's involved in a very complex machinery is aware of what's going on around them. So, our experience with the placenta accreta spectrum or the PAS is that if we can identify individuals that have experience and interest in managing these more challenging cases, we think that that's one thing that allows us to have optimal outcomes. And the reason for that is several fold. And again, Dr. Straughn alluded to some of this from a gynecologic cancer standpoint or a gynecologic cancer surgery standpoint, although thankfully these women do not have cancer.

But I think it really starts with diagnosis, making sure that we're identifying individuals appropriately that may be at risk for this condition. Again, that can be challenging. There's not a blood test that we do. Radiology is very sensitive for predicting or finding this. We occasionally, again, will find cases inadvertently that come in, and I think that points out really another second important component, is that although we generally know which cases are going to be managed by the team, there are going to be emergencies that arise. So, patients that have never been seen at this institution before, that may be coming in for a consultation or perhaps as a transfer, and it's quickly determined that they have an abnormal placentation or an abnormal attachment of the placenta and may go to the operating room as early as that day, perhaps even within minutes to hours.

In that situation, we've found that the ability to immediately contact us on the PAS surgical team. We know what everyone else is doing, who's available. If Michael's available, he might be the first one to go. If Dr. Smith is available, she may be the first one to go. If I'm available, Dr. Boitano or Toboni, again, we have the ability to quickly communicate among ourselves. And that based again on our experience and expertise are quickly able to evaluate the patient, determine the appropriate interventions, and again, likely, allow that to result in ideal outcomes for both the mom and then obviously her newborn as well. That's really only going to occur in a center that is going to support the type of open communication that we have here. And again, the willingness and the ability to know that these cases often will bring everything else that we're doing to a hard stop because of the urgent nature of them. You know, this is not a case that we can do tomorrow or do later today. It often is truly an emergency. And by having that communication and the ability to communicate pretty rapidly, we're able to provide, I believe, optimal care.

Host: Yeah. And the reason I asked this question, and you gave a brilliant answer to this, I really do feel that this is, for the general public, one of the most important things to understand is that if you're a patient who's pregnant and they think that you have placenta accreta spectrum, I would strongly advise you to talk to your provider, your obstetrician about being seen at a tertiary medical center just because of the resources of care that are required to manage this successfully are pretty high. And I think that sometimes those resources can be limited in this state. And again, just food for thought.

I really appreciate the responses from both of you. Again, the reason I wanted to talk about this in two separate parts is because, one, the prevalence of this is actually going up. And we all know that maternal mortality and morbidity is on the rise in the United States, and that includes the state of Alabama. But this is a really big deal and I just wanted our general audience to have at least a kind of an initial understanding and appreciation of why this is an important medical topic to understand.

In fact, coincidentally, when I did the first podcast, one of the major journals that we all read called the Green Journals, Obstetrics and Gynecology, put out a supplement on this exact topic to kind of highlight how important this is. And we still have a long way to go. But I'm actually particularly grateful to you, Dr. Leath, Dr. Straughn, Dr. Subramaniam and Haller Smith for creating care, a really good care pathway and team in terms of optimizing outcomes for these patients. It's been transformative. I can't say that enough to be honest with you. So, thank you to all of you.

So again, in closing, I'd like to thank Dr. Straughn and Dr. Leath for sharing their thoughts on placenta accreta spectrum and how this is surgically managed after our first podcast on this last month. And as always, please rate this podcast and we welcome any comments, particularly on topics that you're interested in. For more information on Women's Health Services that UAB provides, please check out uabmedicine.org. And until next time, thank you. Have a great day. I hope you're all having a great summer, and we'll see you next month. Take care. Peace out.