The Greater Impact of Placenta Accreta Spectrum (PAS) on Quality of Life

[Dr. Amy Park]
Yes, I was just going to comment on that because way back when we were lucky to get a dating ultrasound. But ultrasound has become so much more accessible, better in terms of the clarity, et cetera, and it seems like there's just so many more C-sections scar pregnancies that are getting diagnosed. I think at least the Cleveland clinics have gotten a reputation for treating these.

That just brings up another question about what you just alluded to, like who should be owning this? What specialty? Because you're MFM and Justin Lapin is MFM and you guys do complex surgery. This is badass surgery, like much respect. You could tell that the residents when you came were like, "This guy knows," because you had all the pictures. It is like really tough surgery but some places it's MIGS, a lot of places it's ORC. You have a big collaboration with radiology.

I just had this conversation with my friend who's the upcoming president of SGO, Amanda Fader, and we were just talking about should ORC be owning PAS? I think they're like “Not us,” but I think some of them are like “We should be doing it.” I don't know. I'm not sure. I'm not part of that debate stream.

[Dr. Brett Einerson]
It's close to the bladder Amy. I think UroGyn probably should be the ones to own that.

[Dr. Amy Park]
No, I'm one of those not-it people but anyway, it's interesting. It seems very local. It seems like MFM definitely is involved on some level, but you take a lot of ownership. You have a program. You're the director of this thing and you get a lot of referrals through this network that you have. Just curious about your thoughts.
[Dr. Brett Einerson]
I think the answer to who owns this is all of us. The difficult thing is that this is a pathology and a disease that exists between subspecialties and even exists between specialties. You can be the best surgeon in the world. If you don't have a good OB anesthesiologist and blood bank, you can't take good care of patients with placenta accreta spectrum.

This is, I like to say, interdisciplinary. The thing that's leached in the literature is multidisciplinary but it's really interdisciplinary care for these patients. I think that there isn't one specialty optimally situated to be the future caretaker for these patients. It's imperative on OB-GYNs to, I think, be the central rallying force around getting radiology, NICU, OB anesthesiology, pathology, and the various subspecialists together to do as good a job of taking care of these patients locally and regionally.

To some degree, MFM makes a little bit of sense because it's the one where most MFMs have at least some familiarity with their imaging and interest and investment in getting the diagnosis right. The problem of course for MFMs is that for many of us, 75% of our specialty is consultative. Many MFMs don't cover labor, delivery, much less want to perform a planned cesarean hysterectomy. In those cases for the average or meeting MFM, it's imperative to rally a team.

I think about interdisciplinary care as there needs to be a champion locally if you're going to be a center that takes care of placenta accreta spectrum. I know colleagues from general OB-GYN who do that really well. I have colleagues from GYNORC who are that team at their local institution. There's MFMs who do it clearly, there are MIS people who do that really well. I think whatever subspecialty it is, I think that there has to be active investment in understanding the imaging and the surgery, and the pathology. That in itself is an impossible task for one type of subspecialist and really requires an interdisciplinary approach.

I think gynecologists are incredible in the work that they do, but a lot of them do not come out of fellowship having seen a ton of cases. If you talk with our gynecologists, although they are the best situated to handle difficult pelvic surgery, a lot of them just haven't seen enough cases to be familiar with the pitfalls and avoid the worst outcomes during a PAS case. A lot of their training is on the fly. Once they get out of fellowship, they get called in for these difficult cases. To me, locally and regionally, it's about finding a team to put together who's going to really concentrate on getting better at this really difficult surgery. That's going to probably involve multiple subspecialists.

[Dr. Amy Park]
Can you just talk a little bit about your journey? It's just hard, like you're saying, to get the volume even if you're an MFM, you're a referral center so you're getting it but how did you get trained up? How did you assemble your team? How do you take calls? These are all very crucial elements.

[Dr. Brett Einerson]
Sure. Yes, I took interest in placenta accreta spectrum from a research perspective first and then figured out that clinically and surgically. It was a challenge that I wanted to take on. Midway through my fellowship, I started going to as many accreta cases as I could possibly go to. Even if I wasn't the fellow assigned to the cases, as one of the surgical assistants, I was there to see the surgical team operate.

It's remarkable how much I learned from just watching cases even when I wasn't there operating. You see the pitfalls, you see the approaches that work and the approaches that don't. I was able to see 25 to 30 cases during my fellowship and by the time I graduated, I had been one of the surgeons assisting on most of the cases that I had seen. I showed up to learn about the surgery, learn about the way that other people in the department were handling it. At the time it was mostly MFM delivering the baby, the gynecologist did the hysterectomy.

There were gynecologists who taught me a lot. At the end of my fellowship when I said, "I want to build this PAS program and I want to make this as good as possible for patients," I had gynecologists who already knew me, who were willing to invest in me, who were willing to walk me through cases, who were willing to be my surgical assist for the first couple of cases that I had as attending and they really helped me to do that. At the end of about 18 months, they and I agreed, "All right these are cases that Brett and a small team of non-gynecologist can handle and when things get difficult or if the disease is really bad, we'll have the gynecologist there on backup."

[Dr. Mark Hoffman]
That's such a great point for learners, for trainees. I think Elliot Richard said the same thing. Most of it's just showing up. A lot of it is in getting into the OR and watching other people operate, watching how they get set up, watching the team, how they interact with the other people in the room, watching how they physically do the techniques. To become an expert in something, just sometimes watching as opposed to when you're actually in there doing it and you're really focused on a small narrow window of a procedure, watching something can let you see a bit more of the whole thing. It's a great, great lesson there, a great story in how you went from becoming just someone who wanted to watch a bunch to becoming honestly the expert in this. That's a great story.

[Dr. Brett Einerson]
I gave a talk a couple of years ago and said, this is the most pressing current issue that's not being addressed in placenta accreta care. We've been so laser-focused and rightfully so, on keeping moms from dying, keeping cases from getting to the point of massive blood loss that we have not done as good of a job as a field, in my opinion, of addressing the anticipation of anxiety associated with PAS and then post-delivery care for the psychological fallout and long-term outcomes that are really pretty bad associated with this.

I actually did a study at the end of my fellowship with a medical student named Brian Grover that just asked patients how they were doing at 6 months, 12 months, 24 months, 36 months, out all the way, some to 5 years. We asked them how they were doing from a psychological and health standpoint. Compared to people who were having a third or fourth C-section but didn't have accreta, patients with placenta accreta spectrum who underwent hysterectomy had two to five times the risk of pelvic pain, difficulty with sex, anxiety, and depression, postpartum grief and loss, decreased quality of life on quality of life surveys.

It's incredibly important for us to acknowledge that the morbidity does not end if we avoid the ICU or discharge that person home from the hospital. The morbidity continues on well beyond that. There are other studies out there by Toll that suggest that PTSD-like symptoms are incredibly common in patients that fits with my experience. There are logistical postpartum problems with coordinating, with sending a person back to Montana where their gynecologist doesn't really know what's happened and having them get postpartum care. It's an incredible challenge and an incredibly underappreciated challenge, I think, taking care of these patients long term.

[Dr. Amy Park]
I agree. The PTSD in UroGyn about fourth-degree tears, anal sphincteroplasty, all that stuff. There's like a lasting sequelae. Interestingly, there used to be this person who was quite active. It used to be called Mothers with Fourth-Degree Tears, but now it's called something differently to be more inclusive. She just struck a chord with how many people out there were suffering from PTSD after this traumatic delivery event.

Losing your uterus and having a preterm delivery and living somewhere away from your family for a couple of months, it's a lot of stuff going on. That is incredible. I can see that as being a huge need to study because it's not really well understood. At least you're making the inroads into it. I wonder if it's also a little cultural, like are there international studies looking at this too?

[Dr. Brett Einerson]
Honestly, the best studies on patient experience related to placenta accreta spectrum are from Ireland. A person who I've gotten to know pretty well, Helena Bartels, has done a ton of work on this in Northern Ireland to try to assess the patient experience and long-term outcomes associated with placenta accreta spectrum. The things that their patients say in their quality of studies are the same things that our patients are saying in Utah. If we had a larger sample, I feel confident that patients in rural Kentucky and patients in Cleveland, and patients in suburban Los Angeles would be saying a lot of the same things.

My challenge to people who are taking care of placenta accreta spectrum is that if you don't think this is a problem, then ask your patients, check in with them 12 months from now. I guarantee that even if you've been the best doctor that you can possibly meet, even if you've reduced morbidity to the maximum extent, your patients were still terrified by this problem.

I had a patient who talked about writing letters to her kids because she was worried that she wouldn't make it through surgery. I had no idea that she was going through that. I was confident that we were doing the best possible care that we could do for her. I was totally blind to the fact that she was so psychologically distraught that she was worried about just coming out the other side. We've completely changed the way we address the psychological needs of our patients because we were so moved by our patients and what they told us, they were appreciative of their care and they also felt like they needed so much more help psychologically and emotionally.

[Dr. Mark Hoffman]
It's a testament to you as not just a physician, but also as a person to look at your patients as people because you clearly have a great deal of talent and brains and logistical and administrative abilities to put a program like this together, but you can forget. There's so many things you just-- well if it just goes well, then everything else is someone else's problem, but taking the extra steps and to think about it in those terms is something we all don't do as well.

I won't speak for others, but I know that there's times when I've been very grateful to have had some patients who were willing to share their experience with me, that you went the step further and asked the questions to others so we could have some data so we could have a conversation so we could understand how to change practice and which sounds like you've done in Utah.

Kudos to you and your patients are extremely lucky to have you and we're all lucky to have now the opportunity to hear from you and understand more about not just the diagnosis and management, but the whole, you say spectrum. I think I've just now expanded my definition of the accreta spectrum. It's all the way through the postpartum and to the social and emotional side of it too. Great work.