Experienced Specialists Team Up for Complex Surgical Obstetrics

For pregnant patients who have a placenta accreta spectrum disorder (PAS) or a history of abdominal surgeries, labor and delivery can be more complicated and include increased risk of hemorrhage, transfusion, the need for intensive care, or other morbidities. In the best scenario, a team of specialists familiar with the case has developed surgical strategies for optimizing outcomes. That scenario requires planning, however, as well as a setting where caregivers have the resources to put their experience to work.

Cleveland Clinic’s new Center for Complex Surgical Obstetrics does just that.

“Some obstetric patients have unique surgical needs,” says Justin Lappen, MD. “They may have had multiple surgeries in the past, or they may have specific obstetric issues going on that require complicated surgical delivery and planning. This program mobilizes an interdisciplinary surgical team to meet patient needs and to coordinate planning their care well in advance of delivery.”

Dr. Lappen and Mariam AlHilli, MD, worked with colleagues in Cleveland Clinic’s Ob/Gyn & Women’s Health Institute as well as other specialists to develop a framework for the center. From the start, they knew it must focus not only on patients with PAS — a condition in which the placenta implants into the wall of the uterus — but also include those with complex surgical histories.

“The diagnosis of placenta accreta and other placental pathology can present a challenge to patients and obstetrics providers,” says Dr. AlHilli. “At Cleveland Clinic, we are fortunate to have a subspecialized team of surgeons who perform complex pelvic surgery — gynecologic oncologist and urologists. We developed the center to bridge the gap between surgery and obstetrical care and provide comprehensive multidisciplinary care to our patients. This has been shown to improve patient outcomes and their experience.”

A host of previous intra-abdominal surgeries can make planning a C-section, if it’s needed, more challenging.

“A patient with an inflammatory bowel disease may have an extensive surgical history or may have an ostomy,” Dr. Lappen says. “If someone has had their bladder or ureter reconstructed, thoughtful delivery planning that integrates considerations related to their prior surgery is critical to achieving a safe delivery.”

Other hospitals may have programs for management of placenta accreta, but most do not include complex surgical obstetrics, says Dr. Lappen.

“We probably see 20 to 25 PAS patients a year in an institution that cares for approximately 13,000 deliveries annually,” he says. “This condition is neither rare nor common, which makes having a dedicated, experienced team that can be mobilized critical to improving outcomes. We also have a number of patients who have complex surgical histories, and I think that populations will grow in time. While this program won’t apply to the majority of our patients, it’s a critical resource for a small subset of patients who truly require a high level of planning and care coordination.”

Placenta accrete spectrum (PAS)

Most cases of PAS show up in someone who has had a C-section, and now has a placenta previa.

“The more C-sections a patient has had, the higher the likelihood that they will have PAS, particularly in the setting of a placenta previa, where the placenta covers the cervix. However, PAS can happen anywhere in the uterus where there has been a prior surgery, including at the site of a prior myomectomy (fibroid resection), septum resection, or dilation and curettage,” says Dr. Lappen.

While conservative management or uterine preservation can be possible, cesarean hysterectomy is generally recommended when there is high suspicion for PAS.

A typical patient of the program likely would be diagnosed with placenta accreta in mid-pregnancy.

“She would have a designated nurse coordinator who follows her throughout pregnancy and assists in scheduling with a team of providers, including neonatology/ pediatrics, maternal fetal medicine specialists and gynecologic oncology to discuss surgical plans and expectations following delivery,” says Dr. AlHilli.

“The date and timing of surgery would be coordinated with neonatology, anesthesiology and surgery to ensure all medical needs are provided,” she adds. “The patient would then continue to follow up with her obstetric and surgical teams postoperatively.

The team

The team that plans these deliveries also includes neonatologists because patients may have planned preterm deliveries between 34 and 37 weeks. Gynecologic oncologist serve as the surgical experts. Obstetric anesthesiologists build an anesthesia approach for high-risk surgery. The team also coordinates with the blood bank, urologists and interventional radiologists.

“Delivery planning is really important, because the literature has shown that when you have coordinated care, patients do better,” says Dr. Lappen. “Patients have lower risks of morbidity, lower risks of mortality, and lower risks of complications like blood transfusion or intraoperative organ injury. That makes a big difference in patient outcomes.”

What it takes to build a center for complex OB surgery

Certain conditions and personnel are necessary to create a center for complex OB surgery. Those include:

• A comprehensive blood bank with large volumes of blood products and capacity for massive transfusions.
• Experienced obstetric teams.
• Surgical subspecialty support, including pelvic surgical expertise (gynecologic oncology), neonatology, interventional radiology, additional surgical expertise (such as urology, trauma or vascular surgery).
• An anesthesia team comfortable with these cases, especially OB anesthesia.

In addition to those program elements, a dedicated care coordinator facilitates the coordination required to bring a large clinical team together.

“Certainly patients can present with emergencies, such as bleeding, and need to have urgent or emergent delivery,” says Dr. Lappen. “But usually we have lead time, which means that we can identify these patients based on either history or risk factors as well as their imaging long before delivery needs to happen. Having a coordinator helps facilitate antenatal delivery planning and also helps patients to navigate a complex and often anxiety-provoking situation.”

Spreading the word

With Cleveland Clinic’s program now in place, an important goal is to increase awareness of the service, especially for patients with complex surgical histories.

“We in maternal-fetal medicine are generally the ones who identify and diagnose PAS because we perform most obstetric imaging. But patients who may have complex surgical histories without PAS may not have been referred to MFM,” says Dr. Lappen. “With this program, we have a mechanism to evaluate any patients with a complex surgical history or risk factor identified, whether that’s really large fibroids, inflammatory bowel disease, bladder reconstructions or trauma history.”

The team also hopes to be recognized as a center of excellence in complex obstetrical cases in Ohio, says Dr. AlHilli. “We strive to continually optimize the quality of care we provide and patient outcomes through research initiatives and continuous improvement projects.”