WELCOME TO THE PLACENTA ACCRA
SPECUM.
YOUR PRESENCE IS TRULY
ECIATED.
I'LOOKING FORWARD TO HEARING
YOUR INSIGHTS AND
RECOMMENDATION ON TS
IMPOT TOPIC.
I WOULD LIKE TO EXTEND MY THAS
TO NICHD LEADERSHIP,
SPECIFICALLY DR.HAKHTOUR AND
DR. HAZRA IN TIR SUPPORT
CO-CHAIRS FHE SIGFICANTK THE
CONTRIBUTIONNRGIZG AND
LEADIN THISORKSHO WITH ME.
ADDITIALLY, MY THANKS GO OUT
TO THE SOCIETY PTICITING
WITH U
I WOULD ALSO LIKE TO ANOWLEDGESS
THAT ARE GOING TO BE PSENT
WI US TODAY.
NOW ANO FEW HOUSEKEEPINI WOU
LIKE TO GO OVER WITH YOU NOW.
AS YOU'RE AWARE, OUR ANDA IS
VERY PACKE SO PLEASETICK TO
YOUR ALLOCATED TIME. TIME OF 20
MINUTES.
THEY WILL NOTIF YOU 2 MINUTES
US O SCHEDULE.ME IS UP TO KEEP
PLEASEETN PROMPTLY FROM YOUR
LUNCH, THERE IS A CETIAT ORD
LOCATED ON THEIGHT SIDE OF THE
BUILDING.
YOUR BGE CONTAINS A
COLOR-DED STICKER FOR YOUR
WORKING GUP.
WE HAVRIED TO AOMDATE
ALYSE.FERENCEUT IT DOES IT IS T
WHEN IT'S TIME FOR YOUR SESSION,
PLEASE CE OVER WITH YR TENT
CARD AND REMN THERE UNTIL THE
END OF THE SESSION INCLUDING T
DISCUSSION.
TO ENSE ALL ATTENDEES CAN HEAR
YOU, PLEASE REMBER TO SPE
WELLNTO YOURICROPHONE AND
REMEMBER TO UNMUTE AFTER
VIDEO PARTICIPANTS CAN SEND YOUR
PROVIDED BOW AND WE WAKEESS
EVERY EFFORTO ADDRESS ALL
INQUIRIES.
TOMORR I G TO BE THE
FIRST -- THE SECOND DAY OF OUR
WILL BPENT IUR WORKING
AS YOU PASS SECURIT COME TO
YOUR ASSIGD WORKI GROUP
ROOM.
AFTER THAT, WE'LL RMEET IN
THIS ROOM.
NOW WITHOUT FURTHER ADO, I'M
GIVING TO MY CEF,
DR. CHAKHTOURA, OB-GYN, TO KICK
OFF THIS MEETING.
>> THANK YOU, MONICA.
I REALLY WANT TO THANK Y ALL
D WELCOME YOU TOOIN U FOR
IMPOANT WORKSHOP, AND WANT
TO THANKHE PEOPLE IN THE ROOM
D ALSOOINING U BY
VIDEOCAST.
THANKING DR. MICA LONGOS LL A
HERSELF BECAUSE I DON'T THI
THIS MEETING WOULD HE HAPPENELD
WITHOUT HER PERSISTENCE AND
SO WITHOUT FURTHERSODO, IT IS MY
PLEASURE TO INTRODUCE DR. RNOHAN
HAZRA, DIRECTOR OF INTRAMURAL
RESEAR.
HE BECAME THE DIRECTOR OF
EXTRAMURAL RESRCH COUPLE
YES AGO AND BEFORE THAT, HE
WAS THE BRANCH CHIEF OF THE
BRANCH HERIN T DIVISION OF
DRZRA RECEIVED HISH.
MEDICAL DEGREE FROM JNS
HOINS UNIRSYCHOOOF
MEDICINE AND COMPLETED HIS
PEATRIC RESIDCY A A
PEDIATC DISEASE FELLOWSHIP AT
CHILDR'S HOSPITAL IN BOSTON.
BRANCH CHIEF WHE IAS WITH THE
MATERNAL PEDIATR INFECTIOUS
DISEASE BRAN,, AND IT'S MY
PLEASURE TONVIM TO
PROVIDE OUR OPENING REMARKS FOR
THE MEETING
>> THANK YOU VERY MUC NAHIDA.WOT
HIRES A BRANCH CHIEF WASAHIDA
AND ONE OF MY FIRST HIRES AS
DIVISION DIRECR W NAHIDA AS
CHIEF OFREGNANCY PERINATOLOGY
BRCH SO IF NOTHINGLSE I'VE
DONE THOSE TWO GOOD DEEDS.
SO I WANT TO JOIN MONICAND
NAHIDA TO WELCOME ALL OF Y.
OFOURSE REALLY APPRECIE
FOLKS THAT ARE ONLINE, BUT
REALLYEALLY LIKE TO SEE THE
NUER OF PEOPLE THATRE HEREIN PSL
RECOGNIZE THAT IN PSON,
THERS GOING TO BE A LOT OF
SUBSNCE THAT HAPPE AS PART
OF THE FORMAL MEE,UT TN
ALSO EXPECTING AN EQUAL AMOUNT
OF PRODUIVITY WITH
COERSATIS THAT HAV HAPPED
DURING BREAKS AND AFTER H AS
WELL,O REALLY ARECIATE
EVERNE THERE.
THE THANKS BUT DO WANT TO BEING
A OWLEDGEONICA LONGO AND ALL
THE WOR SHE'S DE TO PUT THIS
TOGETHER.PORTANT WORKSHOP
SO DO I JT SAY NEXT SLI?
OK, THERE WE G
SO JUST TO REMIND ERYONE ABOUT
OUR INITUTE' MISSION.
DR. BIANCHI, O DECTOR, OFTEN
WILL NOTE THA WHILE HAVE
CHILD HEALTH IN OUR NE, WE
HAVE A MAJOR, MAJOR EORT IN
PREGNANCY AND REPRODUCTIVE
HEALTH, WHH IS NOT REFLECTED
IN OUR NAME, BUT CERLY
REFLECTEIN OUR MSION AND
ON.
SO OUR MISSION IS TO LEAD
RESEARCH AND TRAINING TO
UNDERSTAND HUMAN DEVELOPNT,
IMPROVE REPROCTIVE HEAH,
ENHANCE THE LIVES OF CHILDREN
AND ADOLEEN AND OPTIZE
ABILITIES FOR ALL.
AND OUR VION IS HEALTHY
PREGNANCIES, HEALTHY CHILDREN
AND OPTIMAL LIVES.
JUST TOEMIND PEOPLE, AIN,
THAT WHILE WE DON'T HAVE
REPRODUCTI HEALTHR PREGNAN
OR MATERNAL HEALTH IN OUR
INSTUTE NAME, WE DO HAVE A
SUBSTANTIAL INVESTMENT INHESE
I MENTIONED, THEY' IN OUR
MISSN AND VISION.
TH WERE ALSO IN OUR ORIGINAL
LEGISLATION THAESTABLISHEDHE
INSTITUTE THAT PRESIDENT KENNEDY
GNED BACK IN 1962.
OF WHAT WE COVER WITH RESPECT TO
MATERNAL HEALT ADVANCING
SCIENTIFVIDENCEND
KNOWLEDGE TO PROMOTE HEALTHY
EGNANCIEAND IMPROVE
OUTC.
R EFFORTS SPAN SCROS MULTIPLE
BRANCHES, SO WHI THE MAIN
PRNANCY ANDERINOLOGYHE
SEVEN OF O 12 EXTRAMURAL SIX OR
BRANES TT ADDRESS MATERNAL
HEALTH, INCDING, OBSTEIC
PHARMACOLOGY, MERNAL
INCTIOUS DISEASE, AND A NUMBER
OF OTHERREAS AS WEL
OUR RESEARCH INVTMENTS COVER
NORMATIVE AND DISEASE PROCESSES,
CLINICAL INTERVENTIONS, OF
COURSE WE HAVE A MAJOR CLINICAL
TRIAL EFFOR AS W IN MATERNAL
HEALTH, ROUGH OUR MATNAL AND
TALEDICINE NETWO.
WE HAV A POPULATION DYNAMICS
BRANCH THAT ADDRESSES A NUMBER
OF TSE ISSUES, CLINICAL A
STITIONAL CTORANDTHER
ISSUES THAT M ILUENCE
PREGNANCY AND CHILDBIRTH.
WE BASICALLY LEAD AND/OR
CONTBU TO SEVAL NIHIDE
EFFORTS IN THIS AREA,NCLUDING
THE IMPROVE INITIATE.
SO JUST TO GO OR A LITTLE BIT
ABT WHAT THIS FUNNG IS, SO
WHAT WE'RE SHOWING HER IS THE
AMOUNT OFDING IN MATERL
HEALTH, D IN THE LOWER PART OF
VESTMENT, AND THEN THE UPPER,
ALL OF THE OTHER INSTITUTES.
SO CLEARLY, YOU CAN SEE THAT
WHILE WE AREHE LEAD, WE, IN
FACT, FUND ONLY MINORITYF
THIS TYPE OF RESEARCH, AND HENCE
THE REALLY IMPORTANT EFFTS
THAT WE DO IN CLABORATING AND
COORDINATING ACROSS THE NIH WIT
A NUMBER OF OTHER INSTITUTES
INCLUDING, FOR EXAMPLE T
NT HEALT INSTITUTE AND THE
HEART, LUNG AND BLOOD INSTITUTE
AS EXAMPLES.
AND TS JUST SHOWS UP, AIN,
BYNSTITUTE, WHERE THESE
INVESTNTS ARE.
AS I MTIONED, WLEE'RE
THE LARGEST FUNDER, IT'S STILL A
MINORITY, APPXIMATELY 35%ND
L OF THE OTHER INSTITUTES AND
THIS MATERNAL HEALTH RESEARCH,
AND ASOUAN SEEHERE AS
MENTIONED, NHL IA MAJOR
THE MINORITY AND HEALTHHD IS
DISPARITIES INSTITUTE, NIDDK IS
DIGESTIVEISEASES AND KIDNEY,
ENRONMENTAL HEALTH INSTITUTE
THE NIH OFFICE OF THE DIRECTOR,
AND THEN, AGAIN, A NUMBER OFUTE
OTHERS ASELL.
I JUST WANT TO REMIND Y ABOUT
OUR SATEGIC PLAN.
AS PART OF T0TH CTURY
CURES A, ABOUT THE FINAL PIECE
OF LEGISLATION THAT PRESINT
OBAMA SIGNED IN NOVEMBER OF
2016, THAT REQUID EACH
FOR CHD, WE HAD ACTUALLY N
NE ONE SINCE THE LAST CENTURY.
THIS WAS REALLY A MAJ
EFFORT LED BY OUR DIRECTOR,
DR. BIANCHI, AND OVER T COUE
OF ABOUT TWO YEARS, WE ENGAGED
WITH NUMEROUS, NUMEROUS
H ASELL AS EERL, INTERNAL TO
OBABLY SOMEF YOU WERE
AND BASICALLY WITH AN ITERATIVE
PROCESS, TOOK OVER 200
SCIENTIFIC THEMESND FOCUSED
THEM DOWN TO THESE FIVE.
THI STRATEGIC PLAN WAS
LAUNCHED IN THE FALL OF 29,
JUST BOR THE PANDEMI AND WE
E NOW IN THE PROSS OF
REFRESHING THAT STRATEGIC PN,
SO WE'RE ENGAGING I A NUMBER OF
LISTENING SESSIONS AGAIN THAT
SOME OF YOU M B INVOLVED
TH, AND THERE WILL ALSO BE A
REQUESTOR INFORMATION THA
WE'LL MAKE SURHAT FOLKS GET
THAT LINK SO YOU'RE ABLE T
PROVIDE INPUT.
EXPECTING A MAJOR REVAMPING OF
IT, BU REALLY WHAT WE'RE
CALLING IT IS A STRATEGIC PN
REFRESH.
OUR CURRENT STREGIC PLAN THAT
AS I SD WAS LAUNCHED I 2019,
THESE ARE OUR FE SCIENTIFIC
THES AND HIGHLIGHTEDRE IN
RED,F COSE, IS THE ONE TT
AI TOHI GROUP AND THIS
WORKSH, WHICH IS SETTING THE
PREGNANCIES AND LIFELONG
WENESS.
AND I THINK A KEY THEME HERE IS
NOJUSTHE HEALTH OF A
EGNANC BUT HOW IMPORTANT THE
PREGNANCY IS IN THE LIF OF AN
INDIVIDUAL IN TMS O-- BOTH
AS A STRESS TEST F FUT
HAINGER F OTHER IS AS
WE
SO REALLYORTANT THEME IS NOT
JUST THE PREGNANCY, BUT REALLY
THE HEAL AND WELLNESS OF THE
PREGNANTERSON BEFORE AND AFT
PREGNC
SO OF URSELL OF YOUNOW
EVEN BETTER THA I DO AS AN
INFECTIOUS DISEA DOCTOR WHAT A
ISIS WE' FACIN IN MERNAL
MORBIDITY AND MORTALITYN THIS
COUNTRY, ANDHIS GRAPH HERE IS
SHOWINE CSES OF
PREGNANCTED DEATHS IN THE
HEU.ROM 2017 T 2020, AND AS
YOU CAN SEE, HORAGE HERE IS
LISTED AS A MAJORONTRIBUTOR,
AND REALLY THE FOURTH LEADING
USE OF MBIDITYND
MORTALITY.
AND I THINK WE ALSO ALL OR YOU
ALL KNOW AGAIN BETTER THAN IO,
I THINK THIS WHOLE ISSUE AROUNDA
MATERNITY CARE DEZ ERT AS WELL.
DES AS WELL.
SO BASICAL WHILE THERE ARE
URBAN CENTERS, ESPECIALLY ON THE
COAST WHE WE HAVE A LOT OF
AVAIBILITY OF CE, THERE ARE
MANYMA AREAS INHIS COURY
THAT REALL LACK APPPRIATE
MATERNITY CARE.
SO THEN WHAT ARE WE DOING WITH
ALTH INFSTRUCTURE?N MATERL
SO AS MENTIONED WE LEAD THIS
NIH-WIDE EFFORT CALLED THE
IMPROV INITIIVE.
IMPROVE STANDS FOR IMPLEMENTING
A MATERNALEALTH AND PREGNAN
OUTCOMES VISION FOR EVERYONE.
THIS WASCTUALLY LAUNCHED IN
APPROPRIATED DOLLARS, A IT WAS
ONLY AFTER019HA CONGRESS
ACTUALLY SFICALLY GNT
DOLLARS FOR THIS EFFORT, BUT
WE ACTUALLY HAD DEDATEDEN BEFORE
FUNDING FOR IT.
CURRENTLY THE FUNNG FT
IS -- NAHIDA CORRECT ME IF'M
WRONG, BUT ABOUT $43 MILLI A
YEAR AGAIN THAT WE AT NICHD A
LEADING BUT A NUMBER OF OTHER
INSTITUTES ARE INVVED.
IT'S SORTF MULTIFACETED
PRRAM.
REDUCINGRENTABLE CAUSE OFUSH, ON
MATERNAL DEATHS ANDMPROVING
HEAL FOMEN BEFORE, DING
AND AFTER DELIVERY.
AGAIN, KEY T OUR SCIENTIFIC
RESEARCH THEME ABOUT THAT IT'S
T JUST ABOUT HLTH DURING
HEALTHEFORE AND AFTTANCE ABOUT
PREGNANCY ASL.
D OF COURSE GIVEN
THIS COUNTRY, THERE'S A SPECIAL
EMPHASIS ON HEALTH DISPARIES
AND POPULATIONS THAT ARE
DISPROPORTIONATELY AFFECTED.
AS I MENTIONED, THIS IS A
MULTACETED PGRAM UNDER
IMPLENTAON PROGRAM OR CALLED
THE CIHERE'S THE MATERNAL
ALTH RESEARCH CENTERS OF
CELLENCE THAT WERJUST
RECENTLY AWARDED AND WE'RE
ANTIPATINGNOTHER ROUND OF
EXCELLENCE.OSEENTERS O
AGAIN, IMPORTANT FOR THIS IS NOT
JUST BASICEARCH BUT
IMEMENTATION, SO W HAV
EFRTS IN THOSERT ARE AS WEL
WE'RE ALSOF COURSE -- VER
IMPORTANT TT THIS RESEARCH IS
PARTNERED WITH COMMUNI, AND SO
CONNECTING T COMNITY FOR A
MATERNAL HEALTH CHALLENGE, AND
THIS CHALLENGEIS MECNISMS A
UNUE MECHANISM AT THE NIH
THAT'SOT A GRA OR
CONTRACT, BUT REALLY ALLOWS FOR
ORGANIZATIONS THAT USUALLY DON
COMPETE FORIHUNDING, AN
ABILITY TO ACTUALLY ENGAGE WITH
NIH AND SEEK FUNDINGS WELL.
D THERE'SLSO ANOTHER
REALLY T T ENCOURAGENG TO
RADX, WHICH WAS A PROGRAM STOOD
UP BY THE BIOMEDICAL ENGINEERING
INSTITUTE DURING COVID, AND
THEY'RE NOW TING THAT
INFRTRUCTURE AND RESRCE AND
REALXPANDING IT BEYOND COV
R INNOVIVE TECHNOLOGS.
ONE OF T FIRST NON-COVID
CHALLENGESHAT THEY'RE DOING IS
WELL.ATERNAL HLTH CHALLENGE AS
AGAIN,HIS IS TO TRY TO
ENURAGE TECHNOLOGIES TO
AND MORTALITYRISIS.IDITY
THE MATERNAL HEALTH RESEA,MP
THE ITIAL SET OFWARDS FORADE
ESE CENTERS WIT $24 MILLI
YEAR AND WRE ANTICIPATING
FURTHER AWARDSHIS YEAR.
I MTIONED THE RADXECH FOR
MATERNAL HEALTH CHAENGE
THEREE'RE INVESNG UP TO
$8 MILLION THROU SEVERAL
PHASES OF INNATIO, THEN
NNECTATHON, WE ALSO REALIZE IN
THIS AGEF BIG DATA AND
ELECTRONIC HEALTH RECORD WHAT A
LUABLE RESE THO BIG DATARESOURCW
DIFFICULT IT CAN SOMETIMES BE TO
PRNANCY, DURING PREGNANCY,
STREGNANCY AND OFT AGA
IMPORTANTLY WH THE OFFSPHRING
SPRING AS WELL, SO AGA UNDER
NADA'S LEADERSHIP, WE HE THE
CONNECTAON TO IB OVATE AROUND
HOW WE CAN ACTUALLY CONNECT
INDIVIDUALS ACROSS MULTIPLE
ECONIC SYSTEMS TOE ABLE TO
BETTER TCK, AGAIN, NOT JUST
TH HEALTH OF T PREGNANCY BUT
HEALTH BEFOR AND AFT
MENTIONED ALREADY OF COURSE WE
HAVE MAJORLICAL TRIAL
EFFORTS I THESE AREAS WITH T
MATERNAL FAL MEDICE NRK.
AIN FOR INDIVUALS THAT ARE
INTERESTED IN CLINIC TRIALS,
WE HE TOTALLY REVAMPED OUR
CLINICAL TRIAL INFRASTRUCTURE B
BASICALLY OPENG IT UP TO
OUTSID INVTIGATORS, AND SO
WHILE, AGAIN, CERTAINLY WITHIN
PROPOSE TRIE ARE ALSOARE ABLE TO
ENURING INVESTIGATS THAT
ARE NOT PART OFHE NETWORK TO
PROPOSE TRIALS AS WL, AND WE
HAVE A PROGRAM ANNOUNCEN THAT
HIGHLIGHTS THAT AND WE CAN SHARE
OF COURSEERY, VERY ALIGNED
WITH MUCH OF WHAT WE DO, WE HAVE
THE NEONATAL RESEARCH NETWORK
AL, REALLY TRYI TO ENCOURAGE
GREATER RGS ACROSS TSE
TWO NETWORKS.
I KNOW I'M PROBABLY RUNNING
OF TE BUT WANT TO JUS END
WI THIS SLIDE TO REALLY THINKABS
FOR YOU ALLO ADDRESS OVERHE
NEXT DAY AND HALF.AGAIN, AS A FE
HAVE -- SOMETIMES I FEEL LIKE WE
MY DISION, WE HAVE OF MONEY.
$1.2 BILLION A YEAR, BUT OF
COURSE WHEN YOU THINK ABOUT T
BROAD IO OF NICHD,SE
DOLLAR END UP GETTING SPREAD
ACROSS MANY, MANY DIFFERENT
VERY STREGIC IN HOW WE DEPLOBE
THOSE RESOS ANDE REALLY
RELY ON WORKSHOPS LIKE T TO
REALLYELP US FOC THE BES
WAY POSSIBLE.
SO I THINK SE OF THE QUESTIONS
FOR YOU ALL TOR ARE WHAT
REURCES AND IRASTRUCTURE ARE
NEEDED T ENHAN AND ADVANCE
PLENTACCTA SPERUM
SCREENING DIAGNOSIS AND
MANAGEMENT, WHRE THE ECK
SENIOR INVESTIGATORS GAPS AND
SOLVING, HOW CAN WE MOTIVATE
RESEAR TOTILIZE RESOUES
CURRENTLY AT THE DSAL MORE
EFFECTIVELY, LOOKING TO EMPLOY
NEW RESOURCES BUT HOW CAN WE
EMPLOY EXISTING RESOURCES TO
ADDRESS THISSSUE AND HOW CAN
WE AT NICHD ENHANCE PARTNERSHIP
WITH INTERESTED STAKEHOLDERS TO
ACEVE MUTUAL OBJECTIVES.
WITH THAT, IIL AGAIN REALLY
WANTO LCOM EVERYONE HERE,
FOR ALL O THEORKT TAKES TOO
PUT TOGETHER WORKSHO LIKE
THIS, AND REALLY LOOK FORWARD TO
HEARING ABOUT WHATOMES OUT OF
THIS NEXT DAY AND HALF.
THANK YOU.
WE HAV TO FIX A LITTLE BIT
OF THE SEEN BEFE WE PROCEED
BECAUSE IN THE RM, THE SCREEN
DOESN'T LOOK AS IT SHOULD.
THANK YOU.
>> HELLO, EVERYONE.
WEE J THRILLED THAT YOU
CAME HERE IN PERSON, AND THOSE
WA TO REVIE THE GOA OF E, WE
WORKSHOP.
AME IS BRETT EINERSON,
UNIVERSITY OF UTAH.
I CHRISTIUZ YANG JIECHI
FROM MASSA.H ENCOURAGED ALL OF S
TO NOT INCLUDE THIS FIRSTULT
IN THEIRRESENTATIONS TOD,
BUT I THI AT LEAST ONCE TAY
WE HAVE TO ACKNOWLEDGE THAT
REASON WE'RE ALL IN THIS ROOM IS
THAT PCENTA ACCRETA IS A
SERIOU DISEASE TT TAKES
SERIOU STRATEGS AND
MANAMENT AND THATE A KNOW
THAT FOR MANY OF US I THIS
ROOM, THIS HASN A LIFELONG
PASSION PROJECT, SO THIS IS A
PLACE WHERE WE ARE HEFUL THAT
WE'LL HAV THE OPPORTUNITY TO
GET TOGETHER TO TALKBOUT NOT
PRACTICE BUT TO TNK ABOUT HOW
WE MOVE THE STATEF THEHE SCIENCE
AND WHAT I KNOW FROM
CONVERSATIS WITH S MY OF
GHT NOWHERE WE HAVE AE
THENE BEST PRACTICE A
THERE ARE INSTITUTIONSHAT HE
DIFFERENT STRATEGIESORT
WORKS FOR THEM, AND THAT PEOPLE
ARE SORT OF INDIVIDUALIZING
WHERE THEY ARE WITHHAT WORKS
FOR THEM AND WE REALLY NEED TO
MOVE FROM THAT PHASE INTO A NEW
PRACTICES A NEW APPROACHEST
THAT WE CAN DO REAL SCICE ON,
REAL RESEARCH, SO THE
OPPORTUNITY OF THIS WORKSHOP IS
FOR US T REALLY GET TOGETHEA
PANEL OF ABSOLUT EXPERTS, AND
WHEN WE WERE APPROACHED TO THINE
PEOP THAT WERE GOING TO
IN PLACENTA ACCRE SPECTRUM FOR
US TO TACE, I WAS REALLY
AMING OPPORTUNITY BRING THE
LEADERS IN THE COURY, NATNAL
HOW WE SHAPE THE FUTUR OFBOUT
SPECTRUM.FOR PLACENTA ACCRETA
SOHANK YOU ALLOR AEPTING
BRETTND I, IT WAS A REALLYSE FOR
TING MOMENT TO THINK WHO ARE
E LEADE IN THE WORLD
THINNGBOUT THIS A HOW D
WE MOVE THE STATE OF THE SCIENCE
FORWARD.
SO THE GOALF THE WORKSHOP FOR
THE NEXT DAY AND A HALF ARE FOR
INSIGHTS, THINK ABO CONSENSUS
ON WHAT ARE T TOPIC THAT NEED
SOLUTE ADDRESS, WHERE ARE
GAPS, AT ARE THE THING T TT
WE DON'T KNOW OR WE'RE SORT OF
MAKING UP AS WE'RE WORKING
THROUGH CAREF PATIENTS, AND HO
HIGHLIGHT AT ARE OUR
OPPORTUNITIES.
THIS ISEALLY INTENDED TO BE A
CLICAL EXPERIENCE, SO
CLINICLY-FOCUSED WORKSHOP, A
I THINK THAT TT'S VERYPIC
BSTETRICS, WE'RE MOVING TO
THE CNICAL AS W MAYBE DON'T
MPLELY UNDERSTAN THE
SCIENCE, BUT WE'RE SLL WORKING
THROUGH THAT.
SO THINKING THROUGH HOW WE
MANAGE THE PATIENTTHAT A IN
FRONT OF US WELL.
THEN TO ENHANCE UNDERSTANDING
FOR ENTSND UNDERSTAND
WHERE CAN WE BETTER INFORM OUR
CLICAL RESEARCH EFFTS.
>> YOU MAY NICE THAT NOTVERY
SILEERSON OR SPECIALTY THAT
TAKES PA IN PLACENTA ACCRETA
ECTRUM IS PRESENT AT THE
THAT ISOMETHING ACKNOWL
KNOWLEDGE.
BUT ALSO A WE THOUGHT ABOUT HOWN
ACCOLISHING THE GOALS OF
MOVINGLICAL RESEARCH
FORWARD, WE HAD TOAKE SOME
DECISIONS ABOUT WHO AND WHO
COULDN'T BE HERE, BUT THAT DOES
NOT MN THATE DON'T
APPRECIATE T FACT THAT OTHER
PEOPLE ARENVOLVED IN THEARE
OF PIENTS AND THEESEARCH
INVOLVED IN PLACTA ACCRETA
ECTRUM.
SO HOW A WE GOING TO BEING A
PUISH OUR GOALS?
ON DAY O, WRE GOING T HAVE
FOCUSED PRESENTATIONS FROM
BJECMATTER EXPTS BROKEN
ROUGHLY INTO FOUR BAS TOPICAL
AREAS.
THERE IS SOME OVERLAP BETWEEN
AREAS SO WE'VE INSTRUCTED OUR
MOD RMORATORS TO KIND OF HELP KP
GROUPS.IT UP BASED ON TSE FR DAY
AND DAYWO, WE'REOING TO
ENE WORKING GROUPS TO
RESEARCH TARGETS FOR THE FURE
AND THEN REPORT BACKAN TOHE
GROUP WITH CONNSUS ON THOSE
TOPIC PRIORITIES.
EVENTUALLY, THAT WILL MAKE ITS
Y IO WHITE PAPER, OF
PEFULLY S ON RESEARCH AND
WE'RE REALLY THALYFUL TOHOSE
WHO AGREED T BE MODATORS.
DR. CAHILL IS GOING TO LEAD OUR
GROUP ONE ON PASPIDEMIOGY
SCREENING AND DIAGNOSIS.
DR. FO IS GOING TO WK
THUGPREOPETIVE MAGEMENT
AND PPARING FOR SURGERY.
. WRIT ANDR. SDE ARE
GOIN TO MODERATEUR SESSION ON
OPERATIVE MANAGEMENT OF P
DR. CARU IS GOING TO WK U
THROUGH FOCUSED O PREVENTIVE
AND PATNT-CENTERED APPROHES
TOLACENTA ACCRA SPECTRUM.
SO WE'RE VERY THANKFUL FOR THEM
>> WE CERTAINLY ARE ALS GOING
TO BE JOINING THESE WKING
OUPS AND THIING THROUGH
DIFFERENT STTEGIES GOING
FORWD AND AO THIS IS GOING
TO BE THE ITIAL CONTENT OF O
DR. CAHI MERATING.IT
U'LL NOTICE THAT WE ARE NOT
GOING TO B DOING A L OF
INTRODUCTIONS WE MOVE ON
TIGHT.E THE TIMELESRE QUITE
SO THIS IS OUR OPPORTUNITY FOR
US TO SORT OF THI THROUGH THE
ENDA.
KNOW EVERYBODY HAS THE
OPPORTUNY TO GRA THE AGENDA
WHEN TY WALKED IN, PLEASE D
BECAUSAS W SAID BEFORE, A
DOG IN THIS CONFERENCE IS
OVIDING OPPORTUNITIESOR FM
PEOPLE TO GET TOGHER AND CHAT,
SO DR. LYELL, DR. AHAR FOR
>> SSIONWO, PREPARING FOR
PAS SURGERY MODERATED BY
DR. FOX, STARTING WITH
DR. HERRERA.
MODIFICATI TOHE SCHULE.GHT
DR. FARBER ISOT ABLE TO MAKE
ASED ON AN EMERGENCY, SO DR. CA,
LAENT, AND THEN WE'REAT THE
THRILLED TO HAVE DR. ROBTS
PART OF SESSION T. THE TRD
SESSION THREE, OPERATIVE
NAGEMENTF PAS WIL BE
MODETED BYR. I SDE AND
DRWRIGHT.
. SENTILHES, DR. HOBN,
DR. SIBAI WILL SAKING
DURING THI SESSION.
SSI FR, PREVENTIVE
AND PATIENT-CENTERED APPROACHES
AGAIN MODERATED BY DR. CARI
WILL INCLUDE THE PATIENT PERER
PERSPECTIVE, DR.HAINR,
SILVER AND BARTELS.
HANK YOU FOR AGRING TO
COME ANDIVE TALKS.
VING PREVIEWED THE SLIDES,
THEY'RE FANTASTIC, WE'RENOR
A REALLY AMAZING DAY.
I INK THIS IT'S GOING TO BE VER
DIFFICULT FOR EH O THESE
SPEAKERS TO STICK WITHIN THE
ALLOTTED 2 MINUTES, S WHICH
APOLOGIZE IN ADVANCE IF ABODY
IS C OWP, THERE'S SO MUCH
ING CONTT HE BUT GOOD
FEUNTS ARE FUTURE TO CONNUE
OUR ONGOINGISCUSSIONS TOMROW.
ONE OF THE MOST IMPORTANT THINGS
MONICA SAID WAS TT PLACENTAACCRM
SPORT.
I THINK WE ALL CAN ACKNOWLEDGE
THAT AND THAT IT IS SETHI
AT TES A L OF DFERENT
AKEHOLRS, SO WE REALLY WANT
TO THANK ALL OF THE DIFFERENT
SOCIETIES WHO AGREED TO HAVE
THEIR MEMBERS COME A JOIN.
THIS IS A REALLY IMPORTANT PIECE
OF THIS, NO SINGLE SOCIETY OWNS
PLACENTA ACCRETA SCTRUM.
IF ANYTHING, IT'S MOREMPORTANT
FOR ALL OF US TO COME TOGETHER
ABOUT WHAT ARE OUR VISIONS AND
THE WAYSHAT WEANAGE, AND TO
THIN THRGHHAT TOGETHER.
SO THANK YOU TO EACH OF THE
STEHOLDERS W AGRD TO
ONSOR SOME OF THE SPEAKERS
TOY.
>> ANDE KNOW THAT WE HAVE TO
RE TRA SHUFNLT WE ALSO WANTORE D
TO POINT OUT A SPECIAL THANKS TO
NAONALCCRETA FION AS
WELL, A GRO OF PATIENT
VOCATES REALLY PUSHING THAT
AREAORWARD AND ARE MING SE
THAT PATIENTS ASELL AS
PHYSICIA KW ABOUT THI
PROBLEM.DLOMPLEX ANDEADLY
THAN
.
SO TT'S THE END OF OUR
OVERVIEW FOR THEAY.
FOR THE FIRST TALK AND AGA,YELL
DR. CAHILL WILL BEERATING
IS FIRSTESSION.
>> GREAT.
ANK YOU SO MUCH.
I'M JUST WAINGOR MY VIEDZ TO SLS
TO COME
M DEIDRE LYELL, SNFORD,
RENT BECAME THE CO-CHAI AND
CO-PI OF -- AND IT IS DELIGHT T
HERE.
SO FIRST I HAVE DISCLOSURES
NON-RELATED PLACENTA ACCRETA
SPTRUM WHICH I'M GOING TO
REFER TO AS PAS.
WHEN I SAY PAS, I'M RERRING TO
PLACENTA ACCRETA -- BUT I'M HERE
ON BEHALFF THE PANAMERICAN
SOCIETY FOR PLACENTACCRETA
SPECTRUM.
THIS IS OUR BOA OFIRECTORS.
I F WANT TO TELL THETORY
OF HOW WELL CAME TOGETHER
BECAE I THINK IT'S REALL
REFLECTIVE OF THE HISTORY OF
ACCRETAND ACCRETA REARCH.
ABOUT 15 YEARS AGO FOR SOME,
AND LOT OF USERE THOSE WHOLOT
WERE RUNNI OUR ACCRETA
PROGRAMS WHICH MANY KIND OF
AT MY OWN INSTION I FELTWNND
LIKE IT WAS AN AREA THATDED
STREAMLINING AND SO A LOTF US
SORT OFAME DE FACCCRE
PEOPLE.
AND WE GET TOGETHER OFTEN IN THE
HALLWAY AT LUNCH AND-HEREVER
WEOULD FIND A SPACE A JT
TALK ABOUT HOW ARE WE HDLING
THIS, ARE WE HOSTI IR IN THEIR
CASES, WHO'S DOI WHAT, WHEN
ARE YOU DELIVERING.
THERE WAS ATLEIT LESS
GUIDANCEHAN THERE IS NOW, BUT
FROM THIS, WE -- AND I THINK A
LOT OF THISAME ABOUT BECAUSE
ACCRETA USED TO BE A VERY
COMMON THING, A W KNOW IT'
BECOME MUCH MORE CMON.
ENTUALLY USULY BOB SILVER
HE HAD AN ACCRE MANUAL OF
ATIONS THAT MANY OF US
STARTED USING SHAT WE COULD
START TO DO RESEARCH TOGETHER AS
SND THIS INCLUDEDHE WE
VE PIENTS COME IN THAT WE
URINE, WE STORE TSE AT THE
TI OF DELIVER WE'LL HAVE
MYITTAL SAMPLES, PLACENTAL
SAMPLES, SO NOW WE'VE GOT A
PRETOOD SIZE DATAANK AND
TISSUE BANK AND I TNK THAT'S
IT JUST A THRILL TO SEE NIH
IMPORTANT PROBLEM BECAU W ALL
WANTO DO BETTER FOR OUR
THIS IS A OBVIOUS DEVASTATING
OBLEM
SO ONE A LITTLE BIT O LEVEL
SETTING, I UNDERSTAN WE DON'T
WANT TO DO TOO MH, I THINK
ST PEOPL HAVE SOME BASIC
UNRSTANDING OF ACCRETA.
I WAS ASKED TO DO SOMETHING THAT
THAT'S DINING PAS EPIDEMIOLOG
EPEMIOLOGY, SEVERITY,
DETECTIONND SURVEILLANCE.
WHAT I'MOING T GET AT I
TRYI TO DO THATS SOME OF THE
DERTH OF EITHE DATA OR DERTH OF
CONSISTENCIN THE DA TO
KN OUR TRUE NUMBERSABLE THAT WE
I WANTO DESCRIBE THE
CHALLEES AND UNDERSTANDING HOW
PAS CONTRIBUTES TO SMM, SEVERE
MARNAL MORDITY, ANDSE
TREN OR TIME, THAT'S WHAT I
S ASKED TO DO.
IT'S A TOUGH QUESTION TO ANSWER.
AND WE'LL TALK ABOUTHY.
ALLENGESHAT ARE IERENTO
USING THINGS LIKE ADMINISTRATE
DA, BECAUSE WE D'T HAVE
CONSISTENCY IN HOW PEOPLE DEFINE
PAS ANDHERE ARE A LOT
UNMEASURED DRIVERS OF
VAABILITY THAT WE'LL TALK
ABT.
BU I THINK WEAN ALLGREE
THAT PLACENTA ACCRETA SPECTRUM
IS INCREASING, AND AAJOR
RA HAS INCREASED. THE CESAREAN
AND ESTATES IN THE 1960s,
WH THE CESAREANATE WAS
AROUND 5%, WE SOMEWHEREROUND
1 IN 40,000.
IT'S HD TO ARGUE HOBUST
THAT ESTIMATES, BUT W CAN
REALLY CLEARLY S THE RISE, THE
BLACK LINE TO THE 1980s, WHEN
IT BECAME AUC MOR COMN
PROBLEM A THAT CESAREAN
DEVERY RATE ROSE.
IT'S DEBATLE WHAT T TRUE
INCIDENCE ISODAY,ND I'M
COUPLE MINUTES, BUT IT'SN A
INTERESTING TOOTEHAT WE HAVE
THIS HUGE RISE IN CAREAN
DELIVERY RATES AND THIS BIG
INCRSE IN ACCRETA O WHAT WE
THINK T ESTIMATEDUM IS,
AND YET WITH NOT AS MOR AN
INCREASEN CAREAN DELIVERY
I THINKT'S IMPTANT TOPRETTYMAJO.
ACLEDG WHY, AND SOME OF
THAT IS THE EVIL TWIN O
CESAREAN, WHICH I EENTILY
IN WORK T BOB DID REALLY
ELEGANTLY AND OERS HAVE SHOWN,
WE KNO THAT WHENOUAVE
PREVIA AND A PRIORESAREAN
LIVERY, THATVE IS A MAJOR
PRIOR CESAREAN, THAT'S A MAJOR
DRIVER OFCCRETA.WE KNOW THAT BHA
INCREASING PREVIOUSLY BEEN
INCREASING.
I NT T ACKNOWLGE THAT
PREVIA NEEDS TO BE HIGHLHTED
WHEN WE APPROACH THI WORK.
WE KNOW PREVIA RISK FACTORS
IT'S HDER TO FIND DATA ON THE
TRUE INCIDENCE OF ACCRETA -- I'M
SORRY, PREVIA AND WHE IT'S
BEEN AND WHERE IT ISOW, BUT
ACCRETA -- BECAUSE WE'RE GETTI
RE PREVIA.
SO AGEPRIORREA AND THEN
PRIORESAREAN DELIVERY I
THERE ARE OERSOO BUT THO
SO LET'S TK ABOHAT TO WE
PAS? ABOUT THE PREVALEE OF
I THINK A LOT OF WT'S
CHALLENGING IN TRYING TO DEFINE
THAT I IUSTRATED BY ERIC
JAUNIAUX.
IN THISORK HE DEFINED PREVI
BY -- OR DEFINED PVALENCE BY
THEUMBER OFAS CASES TT
WERE FOUND INHE GENERAL
POPULATION FORHE TOTAL NBER
OF PREGNANCIES, BIRS AND
DEVERIES IN TH POPULATION.
AND ESTIMATING -- THE ESTIMATED
PA PRESENCEF .01 T 1.1%.
AT IS A HUG RAN.
YOU KNOW, WE WANT T BE PCISE
IN DATA, WE LEO BE PRECISE
IN OUR ESTIMATES, BUT THAT IS
QUITE AANGE FROM THESE
STUDS.
HE EIMATED A POOLED PREVALENCE
OF 0.17%, AND NOTED AOUE OF
THINGS THAT I THINKRE REALLY
IMPORTAN WHEN WE'RE THINKG
ABOUT GAPS IN THIS AREA.
A THIRD OF SDIES HAD
NO DESCRIPTION OF WHAT CLINICAL
CRITERIAERESED FOR DIAGNOSI
DIAGNOSIS.
I THINK IT'S IMPORTANT FOR THOSE
WHO MAYBE DON'T TAKE CEF
THESE PATIENTS TO NOTE THA NOT
EVERYONE GOES O TOAVE A
CESARE HTERECTOM OR EVEN A
HYSTERECTO.
SO THERE ARE PEOE WHERE THE
PLACENTA MHT JUST NOT DETACH
AND RHAPS SOMEBODYAKES A
AND REMOVES THE PLACENTA IN SOME
THE. LER WHERE THE UTERUS IS
E -- NO STUDIES DCRIBED WHAT
THE CLINICAL FINDINGS WERE IN
TERMS OF THE VASCULARITY THA
ULD SUGGEST PLACENTA ACCRETA
AND THIS ISMPORTANT BECAUSE AS
RESEARCHERS AND LEADERSN THIS
FIELD, WE ALSO NEED T BE
LPING PROVIDERS AND SURGEONS
KNOW WHAT ARE THE DIAGNOSTIC
SIGNS THAT O MIGHT SEE THAT
D SUEST PAS TO AID
PLACENTAL DELIVER
ACCRETA, YOU DON'T WANT TO
LIVER THELACENTA, YOU'RE
GOING TO TRIER A MASSIVE
HEHAGE, AND THAT' SOME OF
THOST DANGEROUS POINTS IN
THESE DELIVER
THINK ALL OF US ARE AWARE THAT
THERE'S PRETTY LARGE POTENTIAL
MATERNAL MORBIDITY.
THIS IA VERYUICK SUMMARY.
WE SEE ACUTE LIFE THREATEIN
HERRHAGE.
MOST PEOPL WHO HAVECCRETAO
TO GETLOOD TRANSFUSIONS,
SOMETIMETHAT MSIVE
A LOT OF THE COMICATIONS ARE
E CONSEQNCE O THATASSIVE
BLOOD TRANSFUSION THAT CAN
PEOPLE CAN BEDY.
POSTOPATIVEL
WE KNOW THE PENTIAL RENAL OR
CAIACAMAGE, T BOL
DISEASE, TRANSFUSION ASSIATE
SUOUING ORGANRGICAL DAMAG TO
USUALLY THELAER, ALSO
HYSTERECTOMY.
BUT THERE'S LOT OF INFECTIOUS
MORBIDITY AS WELL.
EMBOLISM IS N SOOMN.U
PSYCH LOGIC HARM.O ACKNOWLED
I THKN A LOT OF US WHO TAKE
CARE OF THESE PATIENTS, WE DO
SPEND A LOTF TIME NOW IN
ADDRESSING THIS PIECE OF IT AND
SOMEING THAT WE'LL STICK WILLTIH
PEOPLE F A LONG TE DURIN
THE PREGNAN AND TOUGHOUT
THEIR T LIVES.
E RISK OF DEAS QUOTED AT 6 TO 7.
WONDING IF THAT'S THE TRUERT OF
RISK, AND TRE'S SO MY
DIFFERENT DRIRS, BUT I TAKE
CARE OF A LOT OF PEOPLE IN
CLINIC A TY COME IN AND MAY
ACCRETA, THEY'RE PREGNT AGAIN,
THEY SEE THIS NUMBER AND THAT'
WHER THEY CAN'T GET PAS THAT.
AND I TNK THAT WE CAN DO A
BETTER JOB IN SORT OF DIVIDING
OUT WHAT THE TRUE RISKS ARE
END HOW WE SHOULD COUNSEL
PELE.
BUT LET'S LOOK AT TOHAT DEGREE
THEN DOESAS CONTRIBUT TO SMM,
ANJAUNIAUX IN THIS STUDYRELY COE
ESTIMATE OF THE PREVALEE AND
OUTCES, THASUR SMM, OF
PLENTA ACCTA SPECTRUM IS
VARYING CLINICAL CRITEAAUSE
THAT USED TO DINE IT AT
BIRTH,O LSFEOPLE IN
ACCRETA? DO THEY TRULY HAVE
AND THE LACK OF DETAILED
PATHOLOGIC EXAM IN MOST OF O
COHORT STUDIES.
IHINK ONE GAP HERE IS THAT WE
CLRLY NEED CONSTENT
DEFINITIONS, PARTICULARLY IF
AVAILABLE, A CONSISTENT AND
DETAILED PATHOLOGIC EXAMS FOR
WHAT WE'RE CALLING ACCRETA.
ADMINISTVE DATA, HE
ACKNOWLEDGES, CAN BE VERY USEFU
FOR W-PREVALENCE CONDION
BUT I'M GOING TO TALK A LITTLE
THE CHALLENGES AND THE RISKS OF
.SG THAT, RELYING TOO MH ON
SO ONE GAP ALSO ITHE DATA IS
WE'LL HAVE STUDYS THAT TALK
ABOUT PAS AND ALL THE RISKS,
BUT WHO ARE THEATIENTS THAT
HAVE PAS AND IT'S IMPORTANTO
REALIZEHAT NOT ALL P CREATES
THE SAME SMM.
WE KNOW T PCENTAREVIA ASI MENTIR
OF SEVE MATERNAL MORBITY.
IF YOU THINK ABOUT IT, LOOK AT
E PICTUN THE UPPER RIGHT,
THAT'S A UTERUS AND THA LOWER
PART IS -- OR THE LOWERART OF
MY SCREEN IS -- YOU CAN SEE THE
VASCULAR AREA.THAT'S THE
PREVIA JUST MEANS YOU'V G
ACTA IN T LEVEL OF THE
EP UTERINE VASLATURE.
THAT IS LIKYO A MUCH MORE
MORB CONDITION THAN IF
SOMEBO HAS, SAY, A FUNDAL
PLENTA,ND I THINK THIS GROUP
REALLYHOWED IT.T.
THEY UTILIZED THEATIONAL
INPAENT SAMPLE DATABASE.
AGAIN, THERE'S SOME CONCERN
ABOUT THE RELIABILITY OF THE
PATIENTS WH PAS AND PREVIA,
AN PATNT WITH PAS WITHOUT
EVIA.
THEY HAD SOME PRETTY GOOD
NUMBERS HERE.
AND REALLY MOSUTCO WERE
WORSE AND NONE WERE BETTER.
WHEN THE'SLACEA ARETA
SPECTRUM WITH PREVIA COMPAD TOPM
WITHOUT PREVIA.
AND BY THAT, THERE WASOREMM
OVERALL.
THERE WAS MORE SMM WITHOUT
TRSFUSION.
DEFINITELY MORE HYSTERECTOMY,
SHOCK, HEMORRHAGE, AND URINARY
TRACT INJURY.
THER WAS ALS GREATER LENGTH OF
STAY, TOTAL CRGES, AND TOTAL
COSTS.
IN DIFFERENT BIND OF
SIMILARLY CONDUCTED
META-ANALYS, JAUNIAU
ESTIMATED THAT FR THE
LIRATURE, GREATEHAN NINE AT
AMONG THOSE WH HTORY OFTO BE
PRIOR CESAREAN DELIVER AND
EITHER A LOW-LYI PLACENTA OR
PLENTAREVIA.
BUT AGAIN, TRE WERE LIMITED
DESCRIPTIONS OF THE PLACENTAL
APPEARCE, SO HD TO DRAW SOME
OF THE CCLIONS A THEY
COLUDE, AGAIN, THAT THEAIN
LIMITATION ISMI THE QLITY OF THE
DIAGNOSE PREVI ANDHAT WE'RNDW WE
W-LYING PLACENT IN THE
CLINICAL DIAGNOSIS OF PAS AND
CONFIRMATORY HISTOPATHOLIC
DATA.
SO JT A FEW OTH THINGS T
THINKBOUT WN WE WERETHINKING ABD
DRIVERS OF PAS MORDITY.
WE KNOHAT THERE -- YOU KNOW,
IF YOU LOOK AT ATUDY, IT'S
GOING BE REALLY IMPORNT TO
KWHAT THE DELIVERY TEAM.
AND THE CENTER MAKES
TREMENDOUS DIFFEREE.
ARE THEY EXPERIENC, AREHEY
DOINTHIS REGULARLY, ARE THEY
INPERIENCED?
S THIS A KNOWN ACCRETA INADVANCE
IN TERMS OFVERS OFDIFFERENCE
MORBIDITY.
A LOT OF STUDIES INCDE THIS
OCCULT ACCRETA OR MICROSCOPIC
ACCRETA.
AND PATHOLOGY BUT ESSENTIALLYY
THE PCENTA DELIVERS AND
THE'S SOME MYOMETRIAL FIBERS
ANTHAT GETS PULLE IN.
WE KNOW SOME OF THESE PATIENTS
HAVE ABSOLUTELY NO PROBLEM.
I S A LOT OF TSE PIENTS
WHO COME IN FORONSULTATIOOR
FURE PREANCY BAUSE THE
PLACENTAL PATHOLOGY C BACK,
VAGINAL DELIVERY, NO HEMRHAG
BUT THE PLACENTA CAME BACK WITH
SO MYOMETRIAL FIBERS AND NOW
THEY'RE CONCERNED.
SOMEEOE WHO HAVE THE
IT IS A BIGEAL.RS HEMORRHE AND
BUT IT'S IORTANT TOT' KNOW, ARE
THASASES ALSO MIXEDN WITH
THOSE WITH PREVIA ANDHOSE
WITHOUT.
AGN, DIFFERENT MORBITI
POTENTIALL AND AGAIN A LOTF
PEOPLE WHO HAVEAS WITHOUT
PREVIA HAVE A VERY MORBI
EXPERIENCE.
I DON'T MEAN TOINIMIZE THAT,
BUT TRE'S A RANGE.
WE ALSOEED TO CONSIDER WHO OR
WHAT SHOULD DEFINE PAS.
SHOULD THIS BE ALL
STOPATHOLOGIDIAGNOSIS A THE
MANY HAVE PROPOD THAT.
WE'RE GOI TO MISSHOSE WHO
HAVE THE CLINICAL DIAGNOSIS AND
PAOLOGY, PHAPS THEY HAVE A
RETAINED PLA SEP, THE PLACENTALT
FUNDAL ACCRE AND THEY'RE
MANAGEMENT.RGO EXPECTANT
AND FALLY, WHAT SHOD WEO
WITH MIKE SCOPIC MICROSC AND OCT
ACCRETA.
SO A LOT OF U GOT EXCIT ABOUT
IS ICD-10 CODE.
CRETA, AND MANY RESEARCHERS
HAVE P TOGETHER SORT OF WAYS
YOU CAN EIMATE IN LARGE
SOMEDY HAVE ARETA, AND NOW
THERE'S THIS ICD-10 C THAT
CAS O PLACENTA ARETA.
WE DID A VALIDATION STUDY AT
STANFORDSINGLE INSTITUTION, SO
THAT'S A LIMITATION.
T WE SEARCHED PRODURAL
REPORTS AND TRYING TODDRESSRGICL
HOW MANY WERE ASSIGNED THE
CORRECT CODE.
WE USED THIS PATHOLOGY TO
CROSS-REFERENCE WH THE
PATHOLOGY DATABASE.
WE DID NOT INCLU OULT
ACCRETA, SO THAT'SOOT PAS FOR
E PURPOSE OF UNDERSTANNG THE
CODE.
SOSEERE PEOPLE WHO REALLY,
MA JUSTRU HAD IT AND WE
FOUND THAT THEOSITIVE
PREDICVE VALUE OF THEOD
REAL WASN'T SO GREAT.
I THINK WE NEED T USE CAUTION
WHEN WE THINK ABOUT THESE DA
IN TSPPROACH.
E PRIMARY REASONS THAT THECODE T
WAS AIGNED IN A LOT O CASES
OF OCCULT ACCRETA,5%.
THERWERE CASES THAT HAD
CLINIC EVIDENCE OF PLACENTAL
ADHEE BUT WITHOUT THE
HISTOPATLOGIDINOSIS,O IN
THIS STUDY WESED THAT AS A
GOLDTANDARD.
AND ATST CASES THAT HAD THE
INRRECT CODE AIGNMENT TENDED
WITH THE CORRECT ASSIGNMT.SE
SO FORXAMPLE, THOSE WHO HAD
HYSTERECTOMY AT DELIVERY TENDED
NOT TO HAVE T INCORRECT CODE
SIGN, BOD TRANSFUSION,
ADMISSION TO THECU AGAIN.
JUST WT TO -- BECSEE'RE
TALKING ABOUT SURVEILLAE AND
CODES ANDORT OF LAR
INDICES., SMM CO-MORBID IT
SO WE KNOW THE SMM INDEX IS AN
IMPORTANT QUALITY INDICATOR.
WE CAN USEHAT FOR
SUEILLANCE, QI AND RESEARCH.
WE KNOWT'S BASED ON ICD
PROCEDURE CODESROM THE CDC'S
21 INDICORS, AND CO-MORBIDITY
INDIS ARE INTENDED TO REALLY
SUMMARIZAND SORT OF DO A RISK
ADJUSTMENT FOR PRE-EXISTING
CONDITIONS.
IN YR INSTUON A LOT OF
PEOP COME I YOUR TERTIARY
CARE CENTER, WITH SEVERE
MATERNAL MORBIDITY.
GHNSTIT INSTITUTIS DOINGUST FOR
OVERL BASE OND WHAT THE
BASELINE CHARACTERISTICS AND
PATIENT POPULATION ARE.
JUST WANT TO CAL OUT THE
ADJUSTED RK RATIO FOR PAS
RELY IN TS CO-MORBIDITY
INDEX I HIGHER THAN FORNY
OTHER CDION.
R SMM OVERALL IT WAS 30.5 AND
.OR NON-TRANSFUSIONMM, IT'S
SO I WANT TO TALK A LITTLE BIT
MO ABOUT DRIVE OF
VARIABILITY IN THE OUTCO,
DELIVERY TMND THESING ON THE
INSTITUTN.
AS MOSTF US I THIS ROOM ARE
AWARE.
, THERE'S SOMETHING THAT
THE CONCT OF CENTERS OF
EXCEENCE WHICH REALLY RTF
GHLIGHTS THAT EXPERIENCE AND
REURCES MA FER.
MATTER.
WE KNOW TS WAS DEFINED B
HAVING RIGHT TEAM IN AN
INUTION, HAVING INTENSIVE
AVAILABILITY OF TRANSFUSION
SERVICES AND BLOOD.
AN A PAPER FROM UTAH, THEY
UND EN TRE WAS A CENTEOF
EXCELLENCE LEV OF CARE
AVLABLE, THERE WAS FIVE FOLD
REDUCEOMPOSITE MATERNALRBIDITY,D
TRANSFUSION MORE THAN 4NITS
AND LS ROPERATION WITHIN THE
FIRST WEEK.
SOMEONE WHO JUST H A BABY WHO
NOW HAS A HIGHER RISK OF
THROMBMBOLIC DISEASE I
PARTICULAR, IT'S NOT AOOD
OPERATINOOM.CK TO THE
AND ONEEASON THAT THESE
FINDINGS WERE BETTER IS THERE'S
STANDARDIZATION OCARE
CE YOU START TO WKOGHER,
D DOOMETHINGITE, W
KNOW THAT YOU GET BETTER AT IT.
YOU IDENTIFY THE GAPS,OU
IDENTI WHAT ARE THE PROBLEMS,
AND IN A RETROSPECTIVE COHOR
STUDY THAT KARIN FOX CONCTED,
THEY LOOKED AT A
MULTIDISCIPLINARY ACCRETA TEAM
WHEN THEY ALSO ESTABLISHED A
PROTOCOLECAUSE THAT'SHAT YOU
DO WHEN YOU HAVE A LARGE TEAM,
AND TYOMPARED THIS TO TIR
DA WHEN THE WAS A
NON-MULTIDISCIPLINARY CARE, SO
WHEN THERE W NO PROTOCOL.ON
THEY IDENTIFIED THER WAS LESS
MEDIAN BLOOD LOSS WN THEY
TEAM.Z THE MTIDISCIPLINARY
EV AFTERHE PROAT WIL COULD,
THEY STARTED TO BEECOGNIZED
A CTER THAT DID AOT OF THESE
DELIVERIES AND THE HAD A LOT
MORE ACCRETAS, DESPITE THA THE
OUTCOMES WERE MUCH BETTERER
THE PROCOL.
WE KNOW MY INSTITUTIONS, ANY
ONE OF ALL OF THESEPEALTIES
MAY BE INVOLVED IN OUR
DELIRI.
BUT I WANT TO JUST CALL OUT
ANOTHER AREA BAUSE I THI
ISN IMPORTANT GAP THA
I'MG W ADDRESS THE
OFTEN DIAGNOSED AT DIVERY.
AND FOR ALL THI IF'RE
GOING TO HAVE THE RIGHT TEAM IN
THE ROOM, YOUEED TO KNOW ABO
BUT IN A PROSPECTIVE COHORT
STUDY INORDIC COUNTRIES, THEY
COLLECTED AOT O DATA ON A LOT
OF DIFRENTHINGS AND ONE
ACCRND
AND IDENTIFIEDT WERE
DIAGNOSE AT DELIVERY.
NOW THI IS LARGE DATA, IT'S
THEY WER USING THE WASNITIONS
BUT IN RETROSPECTIVE COHORT
LOOK AT YOUR PATHOLOGY DABASE,
WE SEE A LOT MORE ACCRETAS THAN
ONE MIG EXPECT.
A DIFFERENT STUDY BUT IN ONE OFF
THE TLES, IT SHOWS THAT 7 OF
THEIR ACCTAS WERE NOT
SUSPECTED, AND IN ITALY.
STANFORD, MORE THA HF WERERD
NOT SUSPECTED ANTENATALLY, THEY
WERE DIAGNOSED AT DELIVERY.
AMONGHOSE, IF YOU LOOD AT
THE NUMR OF ACCTAS THAT WE
WHEN IT GET A LITTLE WORSE,
THEN DEFINITELY THERE'S A MUCH
HIGHERIAGNOSTIC -- OR ABILITY
TO DIAGNOSE.
18% O INCRETAS WER MISSEDESSENT.
NONE OF THE PERCRETAS WERE
MISSED.
WENOW 95% OF MIKE SCOPIC
ACCRETAS WERE NOT SEEN ON
ULTRASOUND.
THE QUESTION I THINK WE CAISES
ASSUME THAT OUTCOME FROM A
DIAGNOSIS AT DELIVERY ARE GOING
TO BE WORSEND THAT'S NOT OFTEN
ACKNOWLEDGED IN THESE LARGE
DATASETS.
SO WHEN CNSELIN A PATIENT,
IT'S HARD TO KNOW AGAIN WHO WAS
THAT PATIENT?
JUST IN CLOSING, CRITICA
S INMM TRENDS, WE NEED MEASURE
RESECH WITH CONSISTENT
DEFINITIONS, STANDARDID
OUTCOM MEASURES A SOME
DELINEATION OF E POPULATIONS
WE NEED HISTOPATHOLOGIC
DEFINITIONS, CLINICAL
DEFINITIS, YOUEE TO CALL
OUT WHEN WE'RE CALLING MICRO
SCOPIC ACCRETA PAS IN GENERAL IN
STUDY, CALLINGUT WHEER THE
STUDYNCLUDED PASITH PREVIA
OR PAS WITUT PREVIA.
WHENAS IT DIAGNOSED
WAS IT DIAGNOSED PRIOR TO
DELIVERY WHEN YOU'VEOT THE
TT PEOPLE, LOTS OF BOD AND
LOTS OF IVs AND, YOU KNOW,
NTRAL LIS AND ALL TT TO
GIVE SOMEONE BLOOD QUICKLYR
OPERATING OM?D IN THE
AND W WAS THE TEAM PRESENT?
I THINK ALL O THIS WOULD EBLE
A LOT MORE RELIABLEURVEILLANCE
SYSTEMS ANDLSO MORE ACCURATE
DIVIDUALIZED PATIENT
COUNSELING
OF CNICAL GUIDANCEECAUSE WE WET
KN A LOT OF THESE ACCRETAS ARE
GOING E DIAGNOSED IN THE
OPERATING ROOND EVERY NOW AND
THEN, SOMEDY WHO MAY NOT BE
EQUIPPED MAY SEE A SURPRISE
ACCRETOW D WE TTHEM TO
RECOGNIZEHAT, HOW DOE TEACH
THEM TO ROGNI THAT?
ANDE ALSOEED FUND
MULTICENTER RESEARCH TO REDUCE
PROVE QUALITY EDENCE FO
THOSE BEST PRACTICES OF WHAT WE
KNOW IS A HIGY MBID
NDITIO TO ENABLE HIGHER
QUALITY RESEARCH, AND FINAL,
TO REDUCE RESEARCH SILOS.
THK YOU S MUCH.
>> DR. LYELLTHANK YOU SO M DH.
WE'REXCIT FOR DR.FSHAR'S
TA NEXT.
>> GOOD MORNING.
I TH THANK T ORGANIZERS FOR
CREATING THI SCE SPEAKING
ABOUT BIOLOGY, KIND OF IN EPI.
SO I HOPE YOU -- I CANSE THE
NEXT0 NUTE TO CONVIE YO
THAT BIOLOGY ACTUALL TOUCHES
ERY SINGLE ASPECT OF THE TALKS
INCLUDING ULTRASOUND PREVENTION
AND L'S JP RIGHT IN OF WHY
BIOLY MATTERS.
MY DISCLURES GENALOT
FOR PATENT ON SOME CIRCULATING
TROPHOBLT TECHNOLOGY.
DR. LYELL STARTED OFF WITH
THATE OF SMM, BUT I HOPEO
INSPIRE THAT WE HAVE DONE
ER.
THIS I FM ALMOST AENTURY
O, 90 YEARS AGO, SENIOR
THESIS WHERE THERE WAS 36 CASES
WHAT YOU CAN DED AS
72% OF THE PREGNT PEOPLE DIED.
WE HAVE DONE BETR.
AND THIWAS A HISTOLOGIC
COIRMATION OF ACCRETA.
SO INSPIRING, AS WE PS
FORWD.
BU HE'S WHERE WE HAVE NOT
MADE PROGRESS.
1937.
AROUND THEIME WHE WE START
DESCRIBING HISTOLOGI ACCRETA.
WHAT IS THE BASIS WHAT IS THE
BIOLOGY,OW DOES THIS TOU
WHATE DO?
MALDEVELOPMENT CH UTERUS,
METHING IS MESSED U WI WITH WITH
TH SOIL.
THERE'S EXCESSIVE GROWTH OF THE
CHORIONIC ELEMENTS, I LOVE
THIS INSUFFICIENT ANTI-FERMENT
PRODUCTION
THERS NO STOPIGNAL.
ELEMEN AND UNFORTUNATELY N
MADE SIGNIFICANTROGRESS IN THE
BIOLOGY OF THEISEASE THATE
HA IN ESSCE CREATED
SUICALLY.
SO LET'S MOV P L THI CLASSIC
DEFINITION.
YES, WE TRE IT AS THE GOLD
ANDARD OF THIS VIL
INTERDIGATGGH BUT I
PE TO CONVINCE YOU IS MO
THAN THIS.
I HOPE WE THINKF INVASIVE ONLY
TO OUR AREA.T ARE NON-NATIVE
I LOVE, LOVE PLANTING AND
RTICULTURE
SO THIS IS A NON-NATIVE SPECIES,
THIS IS A INNOVATIV SPECIES.
PLACENTAS AROT INVAI SI. THE
NORMAL PLACENTA THAT DEVELOPS IN
BIOLOGY, THE VILLI AROUND THREE
EKS, YES, IT STARTS INVING
SO YES, I TOOK THIS PICTURE FROM
INTEREST SILVER AND MYSELF, WE
AR T PBLEM
THIS IS NOT A CANCER.
THIS IS A SPECTRUM.
SOME OF THIS THA WE TRY TO DO
IS WHAT I THINK SPSHE
BIOLOGICAL UNDERSTANDING.
SO WHO WE ARE, AND DR. LYELL
POINTED TO SOME OF THIS BASIS,
THE LITERATUR ISILLED WITH AN
ABILITY TOPLE THIS,
RIGHT?
MAP, IEP,ORMALLY INVASIVE
PLACENTA, SOME MORE OTHE SAME
BUT SO MUC OVERLAP.
AND THEOAL OF THE LANGUAGE
WITH PLANTA ARETA W REALLY
WHAT I THE CONSEENCE, WHAT IS
THEBVIOUSET OBSTETRICAL CONSEQUT
UCHES US?
WE'RE AROHING IT AS AAY
COMPILATION OF WHAT WE S IN
THOPERATING RM, WHAT WE
COUPLE WITH ULTRASOUNDND WHAT
WE SEE LATERN ISEALLY GOING
TO PUSH US FORWARD.
SO LET'S ABANDON THIS CONCEPT OF
INVASION AS THE PROBLEMTHE
PAOPHYSIOLOG
THIS PCENTA, THIS HYSRECTOMY
SPECEN THAT'S SEEN INUR PATH
PATH GOINGO SAY?OR WHAT IS
WHAT WE SAW PRENATALLY, WHAT WE
SAW INTRAOPERATIVELY, TT IS
PART OF THIS.
SO I THINK THIS IS A HUGE, HUGE
THEME, BUT LOT OF THIS IS
GOING TO BEHY AND WHAT'SOING
ON, BECAUSE THERE'S ALWAYS A
LAYER.
INVASI.EVER TRU TRUE
THERE'S ALWAYS A LAYERF
PROTECTION.
WHEN MY KIDAS CUTER MUCHAS
SMLER, BUT REALLY FOUR ASPECTS
AT WE'RE GOING TOHINK ABOUT,
WHAT WE'REOINGYOU KNO
WE'VE BEEN SO FOCUSED ON THE
SEED AND THAT SCAR PLACENTATION
BUT THERE'S THE DESI D
ENVIRONMENT WHH'M CONVINCED
IS THE BASIS OF THIS DEASE
WE'V CREATED.
THE PLACENTAL CIRCULATION, IT'S
NOT NEOVASCULARIZATION LIKE
ONCOLOGYOULD THI ABOUT.
IS IS TRU NOREVELOPMENT
BIOLOGY.
THEN OPERATO TECHNIQUE, THIS IS
WHAT WE CAN DOETTER AND I
THINK WILL BE THE INSPIRATION
MOVING FORWARD.SO ONWARD TO UND.
I COMPILED SOME WORK PUBLISHED
SOME FROM US, SOME UNPUBLISHED,
ABOUT TING TO UERSTAND THE
ALLACENTA.
IT'S A NORMAL PHYSIOLOGIC
PROCESS.
HOW CAN WEK AT TND
FIGU OUT WHAT'S BEEN GOING ONN
THUGHOUT GESTATION FROM THE
SPECIM THAT WE SEET BIRTH.
ISS SOME MEMRS FROM MY
TEAM.
THUGHOUT A OF THIS, IT'S
TRULY A VILLAGE AND I'LL
ACOWLEDG THEM AT THE END.
MUCH O THEIR MOLECULAR STUDIES
ON ACCRETA TAKE THE PLACENTA, W
MOOSH ITOGHERND TNK
ABOUT WHAT ARE THE CHANGES AT A
CELLULAR LEFERL THATAUSES THIS
OCCURRENCE.
VERY ELEGANT WORK, MEMBERS IN
IS ROOM WER PART OF IT.
THEY LOOKED ATHE SINGLE GENES,
ADITIONAL P SAID WHAT GOES
WH GOES DOWN, AND THESE
ARE GENES THAT ARE RESPONSIBLE
FOR NORMAL EPITHELIAL
MENCHYMAL TRANSITION, TNGS
WE WOULD THINKHANGE IN NORMAL
BIOGY.
SUSAN FISHER'SROUP DID MICRO
AR, YOU KNOW, STANDARD MRO
ARRAYS.
THEYUT TOGETHER ACCRETA
ECIMENS FROM ACCRETAS VERSUS
PRETERM BIR, LOOKED AT THE
GENES, THEY GO UP AND DOWN,
CREATING A CCADE.
BUT A LITTLE BIT OF THE ISS
TH SOME OF THE BULK AND
SEQUENNG IS IT PS EVERYTHING
TOGETHER.
SO I LIVE I L.A., I BUY $20
SMOOTHIES ARE GREAT, THEY TASTE
REALLY GOOD, IS IT TANGY, SOUR,
BUT THE POWERF SINGLE CEL
WHICH I HAS REALLY FOUND ITS SPE
IN MATERNAL FETAL MEDICINE, I
INDIVIDUAL CELLULAR COMPONTS
THAT COME TOGETHE IN THAT
SMOOTHIE.
AND THIS IS SO IMPTANT FOR THE
BIOLOGY, BECAUSE WHO IS SAKING
TO WHO?
IT'S NOT J THE TPHOBLASTS.
WHERE IS T DECUA, WHAT
ENDOTHELIAL CELLS I IT SPEAKING
TO.
OTTORSAVE NOW PUBLISHED
PREPRINTS ON THIS WORK LOOKING
AT ACCRETA
SO WESE AN ACCRETA AT THE SITE
OF MOS ADHERENCE COMPARED TO A
SITE NOT - BECAUSE THE ENTIRE
PLACEN IS NOT ADHERENT TO THE
SAME DEGREE, ANDE TK
CONTROLS.
AND WE S WHAT'S DFERENT?
SO EACH O THESE INDIVIDUAL DOT
ARCELLS, WE THEN ASSIGN THEM
TO THE TYPE OF CELL T ARE, WE
SIGN THEM TO THE DISEASE THEY
INTERACTION AND WHAT'S CHANGED
IN AN ACCRETAERSUS A
WHAT'S CHANGEDN AN ADHERENCE
VERSUS NONDHERENCE SITE.
ANTHEN WE CAN PUT TOGETHER
KNOWN SIGOGLING PATHWAYS,E CAN
LOOK AT INDIVIDUAL GENES, AND WE
T MEMBES AND GENES
DIFFERENTILY EXPRESSED IN
ACCRETA.
FOR THOSE THAT THINK
BIOGICALLY, THERE'S NOO
SURPRISE.
THE LL SHAPE DIFNT,
CELL SIGNALING IS DIFFERE, THE
COMMUNICATION DIFFERE.
AND THEN WHAT ARE THE PATHWAYS,
GUESS WHAT,LOOD VSEL
DEVELOPMENT, NO SURPRIS
THIS IS SIGNIFICANTLYIFFENT
IN ARETA.
HOW I RESPONSE TO GROWTH
FACTORS, ANDHEN THE ACTIVELY
LAMENT YOU KNOW, BASEMENT
MEMBRA IMODERATED.
THESE ARE THINGS WE WOULD
IMPLY ANDIND OF CAN
HYPOTHESIZE EVEN JT
EMBRYOLOCALLY THIINGBOUT
NORMAL PLACEAL DELOPMENT,
BUT WHAT THEN ISNSPIRING IT,
HOW CAN WE THEN GO BACK AND
AFFECT THESE SIGNALI CASCADES.
COUCOMMUNICION, WE LOOK AT THEL
INDIVIDUAL GES, INDIVIDUAL
CELLS TT A DIFFERENT A
THEN WEE THE SPECIMENS AND
WEAP INDIVIDUAL AREAS OF
SLID AND WE CAN LOOK AT THE
CHANGEIN THE GENES AT SPECIFIC
AREAS.
AND SAY WHO IS LITALLYALNG
TO WHO?
WH IS DIFFENT ABO THIS
SLIDE OF ADHERENCE VERSUS IN
ANHERA OF T SAME
PLENTA.
ONE OTHE BIGGEST CHAES WE
SAWERE IN CLAGEN GES.
SPATIAL TRANSCRIPTOMICS AND
SITES OF ADHENCE, THE
MODULATION OF THEOLLAGE IS
COMPLETELY, COMPLELY
DIFFERENT.
THEN WE TOO CLAGENS AND SAID
HO DOES COLLAGEN SPEAK, HOW DO
THE CELLS SPEAK TO ONE ANOTHER?
LOOK AT? THIS LITTLE CIRCLELOT,
EVERCES STING AROUND IN
THEY'RE COMMUNITING.IENDS,
AND YOU CAN SEE THEEC OR
THE SOIL THAT'S DRIVING MTF
THE COMMUNICA.
'SALKING TO THE ENDOTHEAL
CELL, AND IT'S REALLY JUST K
OF SPRINKLG CONVERSIONS TO
THE TROPHOBLAS, WHICH IS A
VERY, VERY DIFFERENT PARADIGM
THAN TRATIONALLY THINKING
ABOU THE TROPHOBLASTS BEING THE
DRIVER OF THE SNALING.
STRONGER CONNECTION BETWE CELL
TYPES.
SO BECAU COLLAGEN WAS SO
DIFFERENTIALLY EXPRESSED INHE
THE EXTRACELLULAR MATRIX, WAR
STARD LKING AT SURGICALSPIMENS.
FROM THE OR, FRESH
HYSTERECTOMY SPECIMENS, DECIDED
MOST ADHERENCE VSUS
NON-ADHERENCE LERALLY JT
BIOP, FIXED TM AND IMAGED
THEM.
SPATIAY RESOLVED LABEL-FREE
IMAGING, STANDAR HSG IMAGI.
HARMIC GENATION.
IT REALLY LETSOU LOOK AT THEOU
COLLAGEN SUCTURE WITHOUT
HAVING TOO A STAINING.
ANWH WE CAN SEE CLEARLY,OU
E PURPLE IS COLLAGEN 1 AND
3.
BEAUTIFULYOMEIUM, V,
JUST AUTO FLUORES ESSENCE
BACKGROUND,IE L LIKE
FLOATING AWAY, DOING ITS THING
THIS ACCRETA SAMPLE AT A SITE
THATS NOT ADHERENT.
THIS IS QUITE DISTINC THAN I
THE SAME PLACENTA, THE SAME
PATIEN T COLLAGEN 1 AND 3,
PURPLE AGAIN, THAT'S REALLY,
REALLY INTDIGITATED THROUGHOUT
IT'S LE A BEAUTIFUL SCARF THAT
MES ITS WAY THROUGH THE THE
ENTIRE SPECIN.
YOU CAN LOOK CLOSER.
SO WE TAKE EACH O TSE,ND WE
HEM IMMEDIATELY.
UAN SEE IN 3D, W GETEEPER
MYOMETRIALORDER.LLYTAYS BY T
WE CAN ACTUALLY CORRELATE THIS
TO ULTRASOUND THAT WE DO WH
SIMILAR SHG THNOLOGO YOU
CAN DO SHG ON ULTRASOD AND
COUPLE THE ACTUAL SURGICAL
SPECIMEN AND ITATCHES
BEAUTIFULLY.
VERSUS AT THE SE OF ADHERENCE. S
YOU SEE THESE SERPENTE
AKE-LIKE COLGEN 1ND
3 WITHIN THE VILLI, WITHIN THAT
SAME PLACENTA OF T SAME PISHT
AT A SITE THAT'S ADHENT.
OUR EXCITEMEN WREDICTING,
RIGHT?
YOU CAN ACTUALLY MODULATE THIS
ENATALLY AS WELL.
SURGICAL SPECIMENS, ANDE
REACHED OUT TOHOSE THAT HAD
CREATED A MOUSE MODEL OF
ACCR
LO OF CAVEATS WITHIN THE MICE
AND, YOU KNOW, DEFINITEL MOUSE
IS NOT A HUMAN B IN A WAY TO
SAY HOW CAN WLOOK AT THE
WEN THE HUMAN SPECIMENS ING THAT
A MOUSE, BUT WE TOOK SHG AND
ADDED ANOER KIND O
TECHNOLOGY, NON-STAINING
TECHNOLOGY, FLI
THIS IS A BEAUTIFUL
SPECTROSCOPIST TT WE
COLLABORAT WITH.
ON THE TOP ROW, YOUE CONTR
MI, ONHE BOTTOM, YOUAV
CRETA MICE, AND JUST VISUALLY
IN THE MOUSE,OU SEE THE
DIFFERENCE.
GORGEOUS BORDER, THAT PLACENTA
IS RIGHT THERE, NIC LINE,
INTACT.
AND IN TH ACCRETAODEL THEY
HA, YOU SEE THAT IT'S
DIUPTED.
BUHAT WE'RE DOINGERE I
WE'RE ADDING FLIM AND SAYING
THAT LOOK AT THE COLLAGE LOOK
AT THE YELLOW AND T TURQUOISE.
NOT IN THE SAME PLACE AND VERY,
VERY DTINC AND DIFRENT
WE SEE THI OVER AND OVER AGAIN
IN MICE T WE'VE CREATED,
SIMILARLY TO THEIRS, AND W CAN
RECAPITULATE IT AND AUALLY
LA THE AMOUNT OF COLLAGEN
AT THIS BORDETO GET A
DIFFERENT PLA 16 TAITION AND
DIFFEREN BDER BETWEEN THE
TWO.
SO THE SURGICALPLES WERE A
WAY THAT WEAW THE GROSS
DIFFERENCES IN COLGEN.
CLEARLY CLEAR THAWAS INCITED
BY THE SINGLE CELL AND SPATIAL
SOLVED TRANSCRIPTOMICORK.
THEOUSEORROBORATED THAT, AND
EN HOPEFULLY TOU THET AO
TIENTS IS HOW CANPA WE LOOK ATTE
MODEL IT.
SO WEOOK TO HUMAN UTERINE
FIBROGUY
FIBRLASTS.
WE PLATED THEM ON AISH, WE
DESYDIZE THEM, MAKE THEM
REPTIVE TO PREGNANCY, YOU ADD
AORMONE COCKTAIL TO THEM,HEY
SECRETEGFPG1 -- THEY BECOME
PLUMP READY CELLS FOR A
SUBSEQUENT PREGNANCY.
TH WHAT WE DO IS THEY AUALLY
CREATE AN ECM THAT WE CAN IMAGE.
THEY CREATE AN ECM.
KNOW WHAT TO DO CELUST
EY A PROGRAMMED TO CREATE A
BEAUTIFULATRIX.
WEO THEURGERY ON I
THISS STANDAROUND MAKER IN
A DISH, AND WE ASSUME THIS I
OF LIKE OURESAREAN SCAR.
SOELLS I GREEN ARE THESE
MAN UTERINE FIBROBLASTS, WE
EA THATR, WE OPERATE ON
THERNLGS A THEY CLOSE.
GREAT.
WE CAN PLATE THE DIS WITH DISH.
COLLAGEN, WE COULD NOT PLATE IT
WITH COLLAGEN, WE CAN ADD
DIFFERENT MATRICES AND WE CAN
THINGS CLOSE, WHICH ARELY TSE
INSPIRING FM A SURGIL
PREGNANCY ON TOP.SEQUENT
SO YOU HAVE A SURGERY, THEOUND
IS CLOSED,ND THEN WE ADD
TROPHOBLAST CELLS ON TOP.
THIS IS JUST A SPLE WITH ONE
LINEF TROPHOBLASTS.
THERE'S MULTITUDE, THERE'S
PRIMARY CEL, AND THEN WE ADD
CELLS AND SAY HOWO CELLS
OSE?
SO THE WOUND IS CLOSED, GREEN IS
CLOSED, AND THEN THESE
OPHOBLAST CEL, WHICH SIGNIFY
PREGNANCY WHERE DO
THEY GO IN RELIONSHIP TO T
SCAR?
THEY GO IN, DO THEY GO ON
TO DO THEY GO IN ERENT
PLAC?
D THAT'S WHERE WRE MODELG
NOW.
SOOU TAKE THE FIBROBL,
GHT, FIBROASTS THEOUNDS
D WHAT THEY ACTUALLY D IS
I ALLUDED TO THAT. ECM.
SO WHITECMHAT THE CELL
ITSELF HASREATED.
THIS WND IS TOTALLY CLOSED.
YOUUYS S GREEN IN THE
MIDD, THIS IS GREEN
ERYWRE.
BUT T AA THAT THE SCAR
FORMED, SO THE HYSTEROTOMY HAS
NO ECM IN IT.
THIS WAS THEITE THE
PREVIOUS SCAR.
ECM.T THIS IS THE CELLS ENDENOUS
TROPHOBLAS DO NOT CREATE ANY
MAY TRICK.
SO NO WHITE HE.
TONS OF WHITE HERE, NO WHITE IN
THE TROPHOBLASTS.
DED WDESIDWELL CELLS, THE SOILS
SO WHEN WE LOOK AT TS AFTER A
SUEQUENT PREGNANCY, ADDIN THE
D, ADDING THOSE TROPHOBLASTS,
YOU SEE IN T SUBSEQUENT
EGNANCY, THE TROPHOBLASTS
DON'T GO NEAR WHERE THERE'S
WHITE.
THEY STAY AWAY FROMHE WHITE
EA.
TROPHOBLASTS ARE -- I'M SORRY,
TH'RE GOING WHERE THERE'S NO
EC
THEY'RE STAY AGO I WAY FM THE
WHIT THEY'RE GOING IN THAT AREA
RIGHT IN THEIDDLE, WHICH MAKES
SEE.
TH'S WHAT WE SEE WHERE THERE'S
A SCAR, THAT IS WHERE T
THERE'S SOME KIND OF
CO-HERE SIGNA THAT IS BEING
CREATED THERE.
WE CANHEN CNGE THISASED ON
IF WE ADD COLLAGEN OR DON'T ADD
COLLAGEN TO THAT AREA OF THE
SCAR EXOWB, .
WHEN T NO COATING, NO
COLLEN, THEY DON'T CARE, THEY
GO EWHERE.
THEY'RON T MIDDLE, BM,
TOP.
ECM OR NOT, THEY STI GO THER
BUTTHHEN WE ADD THAT COLGEN
CLEAR OF THAT AREA.TEER
MATTERS, MTIPLE PEOPLE HAVE
BUT WE CAN MODELS.
TH NICHD KNOWS THIS AND MOLES
OF PREGNCYESRCH A
PLACENLESEARCHAMEROM
VETERINARY ANDATE AND
AGRILTURE.
AND 11%F -- IF THI WOULD HAVE
DOESN'T COME OUT ON ITS OWN.ENTA
THEYCTUALLADD AITTLE
EXTINGUISH OF COLLAGENASE TO G
RID OFHE PLACENT
YOU GO IN,OUNO THAT LER,
I KN IS SO TEMING.IT UP.
I KNO-- BUT IT SAKS TO YOU.
YOU IMAGINE ADDING A LITTLE BIT
THIS IS T BAS OF HOW WE CAN
SO IN SUMMARY,OLLAGEN
DISORGANIZATION CHANGES IN
TH MICRO STRUCTURAL ALIGNMENT
AT SITE OF ADHENCE IS A
HALLMARK OF ACCRETA.
THIS IS TRUE IN THE SURCAL
SAMPS WE GET AND IN THE MOUSE
MOL.
THHE COLLAGENATRI IS
ESSENTL FOR WOU HLING AND
HOW TROPHOBLASTS GO TO WHERE
THEY GO.
U KNOW, THE LERUR
THE THE DERM LERATURE IS
FU OF BEAUTIFUL BIOLOGY
RELATED CLOSURE AND HEALING,
AND SOEALLY IHINK THAT'S
WHERE WEEEDO GET A LOT OF
THOUGHT FOROVING FORWARD.
AND THATOST SURCAL SCAR FIX
OCESS OF THE MYOMETRIUM REALLY
LEADS T LOS OF INTEGTY AND
DISORGANIZED MYOCY M LAYER.
THE REASONHAT PLANTIN THE
LOWER URINE SEGMENT IS WORSE,
WE JUST SAWHAT IN THEAST
TALK, ERE'S LESS MYOCYTES
SO IT'S JT NMAL BLOGY., YOU
THERE'S DEPN OF COLGE
AND FIBRIN, TRE'S EDEMA,
INFLAMMATION, I HAV'T SPOKEN
ABOUT TH IUNE MODULATION
THAT'S HERE AND THAT'S A HUGE,
HUGE MOVE FORWA.
BUT ONE KIND OFLEANT IN T
RO O WHAT I'M SPEIN ABO
AND THINKING ABOUT IS I'M
STUDYING THATLACENTA AT BTH.
THAT PLACENTA IS KIND OF DONE,
RIGHT?
LIKE, IT'S GONE THROUGH 34 OR
FI WEEKS OF GESTATION SO WE'RE
SSING A LOT OF THEIOLOGY
THAT'S HPENING REALLY, REALLY
EARLY ON.
IF TRE'S WAY TO LOOK AT SOME
PREGNANCY, I THINK TT'S WHERE
WE'RE AT.
FLIM IMAGINGHAT WE' DOINGHG A
WITH ULTRASOD COUPLING CAN
INSPIRE SOME OFHIS WORK.
SO A LUID BIOPSY THE WAY
GOING FORWARD.
THERE'S GNG TO B WHOLE TALKS
ON TS.
MANY GROUPS ARE DOING THIS WORK,
AND THIS I--'M GNG TO STAY
RIGHT ON TIME.
SO I KIND OF GIVE LITTL TEASERS
OF TS.
WANT TO G A LITTLE TEASE,
BUT UNDERSTANDING TLOGY
CAN REAY, REALLY HELP IDENTIFY
CRETA BIOMARKERS, DECREASE THE
INCIDENCE, BUT REALLY IT SHOULD
TOUCH ERY SINGLE ASPECT OF THE
WHY, LIK WHYSHY PREA WITH
ACETA WORSE THAN IN
NON-PREV?
AND IT'S ALLBOUT T BIOLOGY.
SO WITH THAT, IT'S THE SOIL,
SEED, WATER, AND THE OPETOR.
AND ANKS FOR TO THE TEAM A WE'LL
ST RIGHT ON TIME.
>> EXCELLENT,BVUSLY I'M
EXCITEDO INTRODUCE NEXTEN.
DR. ABUHAMAD WHO WILL BE
EAKING ABOUT ULTRASOUND.
THANKOU
>> ALL RIGHT.>>
THANK YOU FOR YOUR BRILL
WORK, AS ALWAYS.
SO I'M GOING TO GIVE YOU AN
OVERVI ON THE ROLE OF
ULTRASOU IN SCREENING AND
I'LL STAY A HIGH LEVE AND
SHARE SOME THOS WITH U
BASED ONY EXPIENCE ANDOME
OF THE LERATURE.
THE ADVIS BOA OF THET I'MN
FOLLOWING COMPANIES UNRELED T
MY TK TODAY.
SO THIS IS A COMPL AREA,
DESPITE EN W MAKE A DIAGNIS
SOMETIMES IT LOOKS VERY EVIDENT
BUAOTF PEOPLE HE
ATTEMPTED TO REALLY TRY TO
STANDARDIZE THIS APPROAC AND
TH EUREAN GROUP CAME TETHER
IN 26 TO T TO STANDARDIZE
TH MARRS OF PLACENTA ACCRETA
AND FIGO, IN 201HEY ADAPTED
E EUROPEAN CONSENSUS GROUP
CLASFICATION ALSO.
UNITED STATESIDE, A WITH THE
ADERSHIP O SCOTT, WEAME
TOGETHER IN BOSTON SEVERALEARS
AGO NOW WITH THE EORSEME OF
THE SOCIETIES, REALLY TO DO
TWO THINGS.
ONE, TORY TO STANDARDIZE THE
THE AROACH TO HOW DO WE DO THE
ULTRASOUND FOR PREGNANCIES WHEN
WEUSPECT THE PRESEE OF
SO LET MEAKE YOU THROUGH SOME
OF THEARRS THATST TODAY,
ING TOTART WITH THE FST I'M
TRESTER AND THEN SECOND AND
THIRD, THERE'S A L OF OVERLAP
AS IILL SHARE WITH YOU BETWEEN
THE MARKERS THA W USE IN THE
FIRS AND SECD D THI
EGNAY.
FIRST TRIMESTER, IS THE CAN
SEE THELE UTERUS, ANDEAN
ASSESSRE THE GESTATIONAL
SACK IS AND ONE OF THE MOST
IMPORTANT OR MOST CITED MARKER
FOR -- AS RISK FOR PLAA
CRETIS THE GESAL SAC
IMPLANTED IN THE LOWER HALF OF
THE UTERUS.
AND USING THE LENGTH OF THE
UTERUS EXCLUDING T CERX, YOU
QUADRANTS AND IT BECOMES AN EASY
APOACHO MAKE A DIAGNOSIS
OTHAT THERTANT TO
CESAREAN SR PREGNCY, AOITY
N ENTITY, IS A GESTATIAL SAC
IMPLANTED INHE SCAIN SOME
WAYS, ON IT ORNSIDE OF IT AS
U SEE H I ALSO A
GESTATIONAL SAC THAT IS IN THE
LOWER URINEEGMES.
NOW, NOT A GESTATIONAL SACS IN
TH LOWER UTERI SEGNTS END
UP IN THE PLACENTA ACCRETA
SPECTRUM OR PLURIPOTENT.
THIS I NOT THEAME PREGNANCY,
T TH HAVE THE TENDENCY SO
GROW TOWARDS THE LEAST RESISTANT
SPACE.
SO THERE'SN OORNITY AND A
WIOW IN THFIRSTRIMEER TO
SUSPECTHE PRESENCE OF AN
ACCRET ANDF YOU CO TO THE
END OF THE FIRST TRIMESTER, 13,
14 WEEKS, IT BECOMES LESS EY
TO ME THAT DIAGNOSIS A THE
SAC WOULD TDO GROW UP
TOWARDS THE FUNDU.
AS YOU LOOK AT THEK GESTATIONAL
SAC, I THINK IT' REAY
IMPORTANT TO LOOK B MORE
CLOSECAUSE THAT COULD BE A
LINK OR AT LEAST GIVE YOU A CLUE
TO T PSENCE OF ALACENTA
ACCRETA.
AS YOU SEE IN THIS PGNANCY,
YOU SEE HOW THE PLACENTA IS
THERO THE CESAREA SECTION
SCAR.
THIS IS AREGNCY THAT
PROBABLY STARTED AS A CESAREAN
SCAR PREANCY AND THEN EXPANDED
T UPPERNT WITH
AN IORTANT PART, OUR SECOND
TRIMESTER ULTRASOUND MARKERS
THAT WEEFINE VERY WELL IN THE
LITERATURE FOR A LONGIME, ARE
THEY PRESE IN THE FIRST
TRIMESTER.
ONE OF OUR FELLOWS SEVER YEARS
AGO DID A STUDY LKING AT
CONFIRMED ACENTACCTA
SPECTRUM PATIENTS VERS
PATIENTS WHO HAVEREVIA BUT
DO NOT HAVE AN PLACENTA ACCRETA
SPECTRUM AND LOOKING AT SERAL
AND YOU CAN SEE THAT PIENTSNDTR.
WHO END UP WITH A PLANTA
ACCRA SPECTRUM HAVE A LOT OF
THE CLASSIC MARKERS WE USEN
THE SECOND TRISTER, SUCH AS
THERESEE OF LACUNAE, MORE,
LARGER, MORE FLOW EITHER ON
GREYSCE OR COLOR DOPPLER
TH TACUNAEER SE.
ALSOVEN THE UTE RAH-PLACENTA
INTERFACE INT CLEAR ABNORMAL IN
SO RELNG ON THESE CLASSIC
GNS THAT WE USE IN THE SECOND
TRIMESTER I REALLY IMPORTA
ALSO IN THE FIRSTRIMESTER.
HERE S EXAMPLES, PREGNAN
AT 8 WKS.
YOU SEE THAT THERE IS A BIT OF
HERE AND IF YOU LOOK CLOSELY AT
THE PLACEA, THERE ARE -- WE
N'T CALL TM LACUNAE IN THE
FIRST TRIMESTER, MAYBE VASCULAR
SPACES BUT YOU CAN SEE HOW
IRRELAR TH PLACENTA IS IN A
PLACENTA PREVIA.
COLOR DOPPLER ALSO CLEARLY SHOWS
THE EXTENSIVE VASCULARITY,LS
THE PRESENCE OF LACUNAE WITHIN
THOS PLACENT, PER ASSAY.
NOWPER SE.NOW TH LOSS OF -- THAT
DEFIS ALACENTA ACCRAS
ALSO PRESENT INST TERM OF
PREGNANCY.
IF YLY CLOSELY, LOOK AT THE
LOSS OF T SPACE BETWEEN THAT
PLACENTA AND THE CERVIX.
I' GOI TO COME BACK TO THIS
PREGNCY LATER ON TO SHOW YOU
THE PROGRESSI IN THIS CASE.
AGAIN, IF YOU LOOK AT THIS
PREGNANCY THE A 11 WEEKS,
SEE IRREGUR BORRS OF THE
PLACENTA, AND YOU SEE THESE
CYICPACES IN THE PATIENT
TH ENDED UP WITH AN ACCTA.
WHATBOUT MARKE IN THE SECOND
SO ONE OFHE MARKERS THAT IS
ALWA CITED IS PLACENTA
LACUNAE, AND THAT'S PROBAY --
THAT HAS BEEN SDIEDOST IN
THE LITERATE.
IF YOU LOOAT THE LITERATURE IN
MOREETAILS, THE MORE LACUNAE
YOU HAVE, THREE OR ME, LARGER
IN SIZE, IRREGULARITY OF THE
BOS RESENCE O HIGH
VELOCITY AND TURN LT BLOW
WITHIN HAVE BEEN CORRELATED WITH
THE PRESENCE OF PLACENTA ACCRA
SPECTRUM.
A LOT OF THIS CAME FROM THIS
RELYMPORTANT PAPER IN 1992
OF DR. FINBERGROM ARIZONA THAT
RI-BAS THE NUMBER OLASSIFYHE
LACUNAE.
WHAT ISMPORNT TO NOTE, AND
THAT HASEEN A BIT LOST IN THE
LITERATURE IN THATN HIS
POPULATION, WHEN HE DID THE
CLSIFITIONS, ALL HIS
PAENTS H PRIORESAREAN
ANGRADE 2R MORE, MEANIGRANGEVIAP
HAVINGOURACUNAE ORORE, HAS
100% RISK OF PLACENTA ACCRETA ON
IT'S REALLY IMPORTANT TO KNOW
THAT Y CANNO THIS DATA
AND ERAPOLA TO PREANES
WITHOUT A PREVIA ORITHO
PRIO CESAREAN SECTIONS.
LACUNAE BECO REALLY LESS
IMPORTANT BECAUSE THE ARE QUITE
COMMONN LOW RISK PREGNANCIES.
DR. PHILLIPS LOOKED AT A COHORT
THAT DID NOT HAVAN ACCRETALY AND
ULTITELY, AND LK AT HOW
OFTEN D WE PLACENTA ACCRETA
SPECTRUM MARKERS IN THIS
POPULATI WHEN WE LOOK
OBJECTIVELY AND WELL-DENED, IN
A WELL-FINED WAY.
LACUNAE IS QUITE COMMONN TSE
LOW RISK PREGNANCIES, WER
YOU'VE HAD PRIOR CESARN
SECTIONS OR T.
YOU CAN SEE THA ANY BLOOD FLOW
COONLSO IN THOSE.IUITE
EVEN WHEN YOUAVE MORE THAN ONE
MARKER, WHENOU SAY OKAY, I I
HAVE THREE OR MORE MARKERS, PLUS
LACUNAR MORE, HAVE THOSEOWUR
RISK PREGNANCIES, HAD THESE
MARKERS.
TRITIONAY USE IN A SETTI
OUTSID O A PREVIA OR PRIOR
CESARE SECTION REALLYOES N
WORK IN THAT COMPLEX.
LOOK AT TS PLACENTA RIGHT
HERE.
LOOK HOW EXTENSI T AMOUNT OF
LACUNAEXIST.
THIS IS A NORMAL PLANTA.
EAR RETRO PLACENTAL SPACE
BEHIND.
THIS IS N AN ISSUE AT ALL FOR
THOSE PREANCIES.
MULTIPLE VASCULA L LACUNAEAVE
HIGHREDICTIVE POWER IN
ASSOCIATIO WITH THE -
DINISHING SUBSTANTIALLY.
HE'S AN EXAMPLE OF A PLACENTA
PREVIA WH A LARGEACUNAE THAT
ISAEN FNT OF THE CERX,
CLEARLY AN ACCRETA,EE RIGHT
HERE.
HE'S A SINGLE LCUNA, SOM
PLACENTAL THIENIN AS YOU SEE
RIGHT HER AGAIN, A SIGNIFICANT
RISK FOR AN ACCRETA.
WHYWH DOACUN FORM?
UNEAR REALLY,UT IT IS
PRABLY THE STRUCTURE OF
PLACENTAL TISSUES WHEN IT'S
EXPOSED TOHE HIGHELOCITY
ALLY UNCAR WHY TYORM,S
ESPECILY OVER THE CVIX IN
PLACENTA ARETA.
NOW DO N MISTAKE, LACUN WITH
LARGE VCULA LAKES AS YOUEE
INHIS CASE WITH A FEEDI
SSEL AND YOU CAN SEE THAT
CELY, BRINGG BLOOD INT A
SINGLE LEG WITN THE PLACENTA.
THAT HAS NO CORRELATION WITH
POTHECOMMON FINDING IN THE OLD
LITERATURE WITH DITIONSUCH
AS STRIKING COLOR DOPPLER WHEN
POSTERIO BLADDER WALL.R BEHIND A
I WA TO CAUON YOU WITH
ADVANC TECHNOLOGYND
ULTRASOUND N EVERY PLACENTA IS
GHLY -- WE DON'T RELY ON THIS
PER SE BY ITSELF.
WHAT IS IMPORTANT TO NOTE IS
WHAT HAS BEEN REFERRE TO AS THE
RAIL SN, SEEING BRIDGING
VESSEL BWE THE PLACENTAL
SIDE AND THE UTERINEIDE, THA
HAS BEEN HIGHLY CORRELATED WITH
NO INCREASED VASCULARITY AND
PAS, AGAIN, PENETRATING VESSELS,
REALLY IMPORTA.
IEALLY, REALLY HHLIG T
IMPORTANCE OF CERVICAL INVASION
IN THOSE PREGNANCI.
IF YOU SEE VESSE CROSSING FROM
THE PLACENTA INTO THE CERVI
THAT HAS AERY HH CORRELATION
PLACENTA ACCRETAPECTRUM.
ANALMOST ALLF THOSE ARE IN
ASSOCIIONS WITHLACENTA
PREVIA.
HERE'SNOTHER EXAMPLE HERE, YOU
SEE E SIGNICANCE OF CL
INSIONS IN THIS PLACENTA
PREV PIENTS WITHHE
PLACENTA ACCRETA SPECTRUM.
ANOTHER CE HERE TOIGHLIG,
HOW ITANT IT I TO LOOK FOR
CUNA WHICH A LOT OF TE A
ACTUALLY VASCULAR SPACES,ND
YOU SEE THE ECK PANICS AND PANID
OGRESSION OF THESE VESSELS
WITH CERVICA INVASN RIGHT
RE
ANOTHER CASE HERE SHOWING
EXPANSIVE CERVICAL INVASN IN
TH PATIENT, AND STUDIES HE
SHN THAT CERVICAL CERVICAL LACUN
THE RVIX, THESE ARE THE
PRNANCIES THAT REST IN
GNIFICANTLOOD TRAFUSIONS
AT THE TIMEF CESAREAN
AGAIN IT REALLY IMPORTANT TO
UNDERSTAND THE EFFEC OF
OCESSING AND THE IMAGE.
THIS IS THE SAM IMAGE HERE WITH
FILTERS, AND HER WITH -- I
AYED A LITTLE WIT THE IMAGE
ALL THESE VCUR SPASU CAN ME
FILTER AND YOU HAVE A LOW GAI
AND SO FORTH.
ADJUST YOUR ULTRAUND SYSTEM W TO
FAR AS YR EVALUATIO
WHAT AUT THE RETROCENTAL
CLEAR SPACE?
AGAIN, VY, VERY IMPORTANT.
HERE ARE THREE PLACENTAS WIT
NOAL RRO PLACENTAL CLEAR
SPACE.
THIS IS THE MT IMPORTANT
ULTRASOUND MARKE HAS NOT
GOTTEN REALL THE CREDIT THAT IT
SERVES BECAUSE THIS IS WHAT
FINES AN ACCRETA, THE LOSS OF
THIS MARKER.
MA AND IS REQUIRED FORAGNOSIS.
SO HERE'S THREE EXAMPLES.
U CAN SEE EVEN WHEN YOU HAVE A
YOU TEND TO LOSE THE THE T CERX,
DIFFERENTIATIONETWEEN THE
PLACENTA AND THE CERVICAL
TISSUE.
AGAIN HERE ON THE ANTR
DOMINAL WALL, YOU C SEE THE
CLEAR SCE. RETRO PLACENTA
NOW,NOTHER MARKER IS THE
PLACTA THAS THICKED IN
YOU S THE THICKNESS, YOU CAN
USE ULTRASOUND PARAMERS TO GET
THE FULL PLACENTA IN ONE AGE
AND YOU CAN ASSES THE THICKNESS
AND THIS DATA FROM T U.K.
GROUPHAT'S REALLY HIGHLIGHTED
TH ISHAT YOU SEE WHEN AREARKER.
YOU OPEN TTERUS, A BULGING
LOWER SEGMENT WITH A LOTF ST
TIB LAIRTS OUTSIDE.
NOW HOW TO OPTIMIZE YOURULTROUN.
WE DON'T HAVE LOT O
INFORMATION ON THI A I WOULD
HOPEHAT THIS GROUPHI WOULD COME
WIT SOME STANDARDIZED
APPROACHOW TO DO THE
ASOUHEN YOUUSPE THE
PRESENCE OF PLACENTA ACCTA.
YOUHOULD ALWAYS USE THE
TRANSVAGINAL APPROACH F ANY
THE PRESENCE OF AN ACCRETA.R
U HAVE TO EVALUATE THE
PLACENTA IN REALTE, ASSESS --
MINIMI PRESSURE ON THE ABDOM
USING THE TNSABDOMINAL
APCH BECAUSE A B O
PRESSURE COULD REALLYAKE THE
RETROLACENTAL CLEAR SPACE
DISAPPEAR, AND LOOK FOR CERL
INVASION AND HAVE A PROCOL ON
TE
REMEMBER THE PLACEA IS A
THREE-MENSIONAL ORN, SO U
HAVE TO ASSESS THE FULL PLAULNTA
TO LOOK F FOCAL ACCRETAS ANG
THE Y.
NOW, CERT, STRIFNG THE RISK FOR
BLEENG, WE TEND TO SAY THIS IS
SUGGESTIVE FOR ACCRETA BUT ALSO
WE ASSESS THEISKOR BLEED
LIKE THIS ISLELY A PATIENT
AT SIGNIFICANT RISFOR BEDING
AT TIME OF DELIVER
THIS IS PATNT THAT I KNOW I
HOSPAL, IERY LOW RISK FOR
BLEEDING.
A PATIENT LIKE THIS WHERE THERE
IS SOME LOSS OF THE CLEAR SPA
AND THICKENING, THIS IS
INRMEDIATEISK.
THAT CANELIVER AT 37, 38NCY
U DON'T HAVE TO DO AN EARLY
DELIVERY, BECAUSE THERE'S
RISKOR BLEEDING IN THOSE
PREGNANC
NOW, THERE PROGRESON OF PAS
RKERS IN PGNANCY?
AND AT'SN IMPORTANT QUESTION
THAT WE ARE THE PROCESS OF
EVALUATI ON A LARGE CT OF
PATIENTS NOW.
I SWED YOU EARLIER AT 12NCY THAT
WEEKS,UT THE ONLTHIN I
COULD SEE ON THE ULTRASOUND IS
ONE ESAREANTION IS THE
SPACE ANDHE PSEE OFNTAL CLE
PLENTA OVER THE INTERNAL LOSS.
FULLLTRASOUNDT7 WEEKS,
LOOK ATHE INVASION OF THE
CEIX IN THIS PREGNANCY WITH
SIGNIFANT VASCULARITY HER AND
SOME LACUNAE INSIDE.
THISS A PATIENT THAT HAD
JUST TO SHOW YOU HOW IMPORTANT
IS HAVING A HIGHSE OF
INERESS T FIRST
TRIMESTER.
THIS PATIENT ENDEDP WITH ECMO
FR SIGNIFICANT RESRATORY
FAURET TIME OF DELIVERY.
I'M USING THIS PICTURE WITH HER
RMISON.
CHILDREN DAYSFTER SURRY.
SO WHAT IS THE W ROLE O M?
SECTIO ON MRI IN THE GROUPSG
FROM UTAH, THE LEADERSHIP OF BOB
AND OTHERS, HAV LOOKED AT THIS,
AND CLELY MRI SHOULD NOT B
THE FIRST LINE FORCREENI FOR
PLACENTA ACCRETA.
IT COULD B MISLEADING IN SOME
VENUESASHEY HAVE SWN THATYOU CNT
INCORRECT DIAGNOSIS IN ABOUT 21%
OF THE TIME.
SO WE HAD TO BE CAUTIOUS,
CERTAINLY U NEED AOT OF
OEXPERTISE IN THAT BUT YOU HAVE
TO BE CAUTIOUS IN RELYI ON AN
MRI.
IS THERE AOLE FOR MRI IN THIS
ARENA?
MAYBE IN POSTERIOR PLACENTA,
PATIENTS HAVE MULTIPLEURRIES
WHERE THEY HAV FIBSED AND YOU
CAN'T SEE REALLY WL BUT MY
PERIENCE, IT'S VERY RARELY
NOT BEHE FIRST LE. AND SHOULD
SOME THOUGHTS FOR DISCUION FOR
THE GROUP.
I THINK WE NEE TO WORKARD
STANDARDIZATION OF TIE GNOSTIC
RATERS F ULTRAUND
DESPITE WORK TT'S BEEN DON I
THIN THE'S CONFUSIONN THE
LITERATUREH THE ROLE OF
LACUNAE, PCENTAL CLEAR SPACES
AND SO FTH.
I THINWE SHOULD RE-THINK T
VALUE OF FIRST TRIMEST
ULTRASOUND IN PASCREENING
DIAGSIS.
A LOTF THE ACCRETA PATIENTS WE
AGNOSED IN THE SECOND
TRIMESTER NOW HE SOMEIGNS
TH WE CAN S IN THE FIRST
IMESTER.
TIONAC IS, B THERE AREJESS
SOME IMPORTANT PARAMETERS THA
WE CAN USEND TRY TO DEFINE.
I THINK WE NEEDO CLEARLY
DEFINE FALSE POSITIVE AND FALSE
NEGATIVE DIAGNOSIS.
KING A FALSE POSITIVE
BJECTED PATIENT TO EARLY
OF MORBIDITY ALS ASSOCIATED
WITH THIS, LET ALONE INCREASED
COST OF CARE, SO WE HAVE TO B
ABLE TO CLEARLY DEFINE TSE
MARKERS AND MAYBE WORK
COECTIVELY TO HA HAVE SOME
MEANINGFUL -- IT'S CONFUSING
BEUSE NOBODY RELIES ON ANY
DEFINITIONS IN THESE MARKERS
REALLY.
BUT BECAUSE I'VE SHOWN YOU THAT
IN T NORMAL PREGNANCY TRE'S
A LOT OF LACUN AND A LOTF
HER MKES, A.I. WOULD
RUGGLE TOEALLY DIFFERENTIATE
NORMAL FM AORMAL.
SO HERE NEED W LARGE DATABASES
END UP WITH A REGISTRY FORWE
PLACENCCRETA SPERUM, PART
OF THAT REGISY SHOULD BE, I
STRONGLY BELIEVE, ULTRAUND
REGISTRY TTS WELL-DEFINED
CASES WITH WELL-DEFINED IMAGES.
AND T FUTURE WILL PBABLY BE
A COROINATIONFLTRASOUND
MARKERS WITH BIOMARKERS AND I
HOPEFUL THAT THAT WOULD HELPENHY
OF ULTRASOUND.LT
SO THANK YOU VERY MUC FOR YOUR
ATTENTION.
>> THANK YOU SO MUCH.
WE'RE ING TO TURN OVER TO
FORHIS SESSION AND I ALSWANTA
TO ACKNOWLEDGE DR.HIP WHO IS A
PANELIST FOR THIS DISCUSSIO
ALSO.
>> GREAT.
N EVERYBODY HEA ME?
AY.
ANKS.
THOS WERE THREE FANTASTIC TALKS
TO GET US STARTED HERE, SO WE'RE
GOING TO SND THE NEXT BIT HERE
I WANT TO OPEN THIS TO TSSION.
GROUP AND SEE WHAT SOROF
QUESTIONS AND COMS PEOPLE
HAVE AND I'LL TRY AND KEE
TRACK.
IN THIS ROOM, WE'LLSE HUMAN
SOMEBODY CAN HEL US WITH THE
ZOOM SEEN TO CONVERT IT OVER
SORE ABLE TO SEEHE CHAT?
>> YES, WE WOU MODERATE.
>> PERFECT.
LET'S STT HERE.
>> THANK YOU.
WONDERFUL PSENTATIONS AS
ALWAYS
THIS ISARIN FOX.
I HAVE TWO QUESTIONS
ONE FOR DEIRDRE AND YALDA AND
E OTHER FOR DR.- MAYBE IT'S
THGHT OF AS MORE COMMONLY
MINOR RI FTOR, BUT THERE IS
FERTILIZATION ANDROBAY THE
BIOLOGIN THE CROSSTALK THERE
BETWEEN THE DECIDUAND
ESPECIALLY PRIOR PRESERVED
BRYOS IREASES THE RK, AND
TO RECALL IN THISOO FOR US
ESPECIALLY THAT IVF USES
INCREASELSO BY ABOUT THREE
FOLD SO THINK WE HAVEO
KNOWLEDGE THERE MAY BE
SOMETHING THERE.
USING F BUT WEAY WANT TO OT BE
IT.
AND THENOR DR. YOU ABUDAMAD, I
THINK WE NEED TO LOOK AT A WAY
LOOK ATHE UTERUS, NOT JUST
THE PLACENTA.
MAYBEOUEE THE WOMAN HEAD,
E YOUNG W'S HEAD, THE O
WOMAN'S HEAD DEPENDING ON WHAT
YOU'RE LOOKING AT AND SEEING
TH IS REALLY ESSENTIAL.
I' OPEN THE FLOOR.
>> THANK YOU, KAROR
BRINGING THA
I WAS TKING LESS ABOUT THE
RI FTO AND MORE OF ABOUT
LITERA,UT YES, IS ATHE
CAUSE.
I IN TO QUANTIF EXACTLY HOW
CH THE RISK IS IS VERY
CHALLENGING, AND IT'S NOT CLEAR
IS IT MEDICATIONSS I THE
PROCEDES, IS I PLACEMENT OF
THOSOU KNOW, WHEN YOU PLACE
THE EMBRYO INSIDE THE UTERUS, I
THINKT THERE'S -- THERE'S A
LOT O OPPORTUNITY TOEALLY
EXPLOREOR THAT.
THANK YOU.
>> SO THE SOIL LET ME TURN I
ON.
TOUCHES B ON YOUR FITD THA
QUON AND YOUR SECOND TO LOOK
AT THE ENTIRE UTERUS.
SO THE ENVIRONMENT THAT THE
ACTUAL -- THA DESYD YOU'LL
LAYER IS RY IMPORTANT
OF MANCHESTER LOOKING AT THEUT
EARLY, EAR PLACEAL
IMPLTAON AND ACTUALLY WHE
IT IS INVADINGORMALLY INTO T
DECIDU SO TNKHOSE GUPS
TH REALLY STU IVF AND
IMPLANTATIONRE SET UP TO ASK
THAT QUESTION IN A VERYLEGANT
S I THINK IT'SOMETHING
TO THINK ABOUT B REALLY I
WOULD SAY MOREHAN IVF, JUS
WHAT ISHE EIRONMENT OF
IMPLANTATION?
>> I THINK THAS A RLLY
IMPORTANT QUESTION, KARIN, AND
ONE THING THAT WE HAVE FOUND IN
OUR MULTIDIIPLINA REVIEWS OF
THESE CASES THAT WE DO THAT IS
MEANINGFUL TO MS THE IVF
ENTS, A LOT OF TIMES WE
DON'T SEE THE TYPICAL SIGNS THAT
WE WLD WANT TO SEE ON
ULTRASOU AND THEY' VERY
CHALLENGING TO DIAGNOSE.
SO I THI WE DEFINYEED TO
BETTER UNDERSTAND THEM TO MAKE
SOME PROGRESS HERE.
>> CERTAINLY AGREE, KARIN,
BECAUSE EN WE LOOK AT THE SER
VICK WE'REKING AT TH
UTERUS, WE'RE LOOKINGT THE
THICKNES S THINESS OF T
UTERUS BECESMPORNT IN THE
LOSEGMENT SO IT IS NOT IN
ISOLATION BUT ALSO I PART OF
THE EXAM IELF.
GLL BEFO
>> BORE YOU START, IHOUGHT
YOU WE GOING TO BE NICE.
>> LL TELL YOU,E DON'T --
THEY'RE NOT ALLOWED TO PUT THAT
IN THE REPOR
WH WE SAY YOUAVE TO MEASURE
THEE OF THE ARETA, HO
MUCH DISRUPTION THERE IS,HICH
IS- BETTER DESCRIPTI.
DIFFERENT IMPRESSN,IFFERENT
PEOPLE DON'TNOW, WHAT DO
YOU THINK ABOUT THA
>> S DIAGNOSING FAL -- IS A
VERY CHALLENGING DIAGNOSIS.
>> REALLY.S W --
AND IT SHOULD BE BASED ON EITHER
A FOCAL INVASION OF THE
SCULARITY FROM THE PLACENTA
SIDE OF THELACENTA IO THEEN, SO
MYOMETRIUM, OR A CLE LOSS OF
THEETRO PLACENTA CLEAR SPACE
FROM MULTIPLE ANGLES LOOKING
INHAT.
BUIT IS NOTNASY DIAGNOSIS
TO MAKE, AND I AGREE WHOU,
IT SHOULD BE MADE WITA LOTF
EXPERTISE ON THE SIDE OF THE
MA TIMESE MISS IT AND IT'S A
FOCAL ACCRETA AT THE TIME OFIM
DELIVERY.
>>HY NOT DESCRIBEHAT'S
THERE?
SEEING.E EXACTLY WT YOU ARE
I HAVE TO -- MICROSCOPIC
ACCRETA, REMINDS ME, YOU KNOW,
ING THE TERM MICROSCOPIC
ADENOMEIOSIS.
-- MROSCOPIC ACCRETA MEANS
>> I THINK IT COMES DOWNO
LOT OF PATHOLOGY REPORTS, T
JUST IN MY ITITUTION BUT
SEWHER BECAUSE I GET THESE
PATIENTS COMING INND THERE
LOOKING AT WH HAPPENS IN THE
THERE IS A HIGHER RISK OF
IT'S NOT BIG, BUT I DON'T THINK
IT'S AN AREA THA WE SHOULD
ENTIRELY IGNE.
I THINK, THOUGH, THE CLLGE
BECOMES MANY OF THESE PATIENTS,
MOST OF THESE PATIENTS WILL D
WELLN A FUTUREREGNANCY AND
THEY SEE TS WOR ON A
PATHOLOGY RE.
>> SO THE PROEM IS, ARE W
GOING TO SCARE THE PATIENT YOU
STARDOING LOT OFEXPECT TO DO,
INRVENTIONS --
IF EVERYDY COULD JUST STATE
YOUR NAME BEFORE YOUR COMMENTS,
THATOULD BE GREAT
WE'LL GOVER HE.
>> THOSE WERE GREAT TALKS.
THANK YOU ALL.
ST IN TH INTEREST OF
STIMULATING CONVERSION, I
ULD LE TO ASK GROUP
QUESON THAT -- LOV TO HEAR
YOUR ONIONS IN THE WHOLE
GROUP.
YOU GUY GAVE GREATKS, AND
SOME OF THE THINGS THA YOU SAID
WERELACK, YOU KOOK,E OFHE WAY
WE'VE -- OUR NOMCLATURE IS
KIND OF OUTTED WITH REGARD TO
THPATHOPHYSIOLOGY ANDHAT
SO OF OUROMENCLATUREOESN
NECESSARILY REFLECT CLINICAL
RISK SO WHAT CAN WE DO ABOUT I
SO THAT WE DON'T -- STHAT WE
USE TERMINOLOGY THAT REFLECTS
OUR CURRE UERSTANNG OF
PATHOPHYSIOLOGY IN TERMS OF
INVAON, YOU KNO A STUFF
LIKE THAT, IS THERE NOMENCLATURE
THAT WOULD BE BETTER TO USE, AND
TH WOULD BE BETTER TO USE TO
HELP US MORE CNICAY, AND
WE'RE NOT HAVING A DEBATE ABOUT
BRIEF YA AND IVF, BUT I THINK
MOST OFS WOULD AEE THAT
REGALESS WHATT IS, THE
SES THAT ARE PRECESAREANS AND
PREVIA ARE CLINICAY
DIERENT THAN A FOCAL ACCRETA
WITHVF.
AND SO IS THERE A WAY THAT WE AS
A GROUP C COME OUT WITH SOME
NOMENCLATURE THAT WOULD B MORE
REFLECTIVE OF WHAT WEURRENTLY
KNOW AND ALSO MAY MORE USEFUL
CLINICALLY
THANK
THATAS BOB SILR.
>> THANKS, BOB, FOR RSING THIS
QUESTION
AND I THINK DESTE THE FACT AS
YOUAN SEE MULTIPLE
ORGANIZATION ANDOCIETIES HAVE
ATMPTED TO -- I'MOING TO
LK ABOUT THE ULTRASOUND SIDE,
HAVE ATTEMPTED TO STANDARDIZE
THE ULTRASOUNKNOW NOMENCLATURE R
THESE RKERS.
THE MAJOR PROBLEM WE FACE IS
THAT A LOT OF THOSE STUDIES ARE
RETROSPECTIVE STUES THAT ARE
T WELL DESIGNED, THATAVE USE
DOLLARS DIFFERENT DEFITNS SO
THE DATA WE HE HAVE TO WORK
WI TO TRY TO STANDARDIZE IS
FLAWEDN MY OPINION.
I'M HIN THROUGH THIS MEETIHI
HE, WE COME UP TO COLLE SOME
REAL RETROSPECTIVEATA ON
IMAGING, ON SURGICAL APPROACHES,
FOR, IN A LARGEATABASE
THAT WE CAN THEN USE TO REALLY
LIKE I GAVE SHORTLY THE EXAMPLEE
OF LACUNAE.
EVERYLACENTA I SEE HAS
MULTIPLE LACUNUN.
IT'S THEACK OFF GOOD
PROSPECTCTELY COLLECTED DATA
THAT WE NEED TO BE ABLE TO
ARRIVE AT SOMETANDARDIZAZAON
THAT WOULDLD MAKAK SENSE FOR
EVERYBODY.
AT'STH MY PERSONAL O ONINI
LOOKING G OM THE ULTLTSOUND SI
SIDEDE
>>>> ISST CLINICALLY RELEVANTT O
THE P PIENT IN THE OPERATING
ROOM IS THE QUESTION.I THINK THM
I FORGOTOTOUR QUESTION OUOU OH,
THE POINT EARLIER ABOUT FOYOYOY,
CAL,NOT FOCAL, IT'S AN ACCRETA..
YES, IT'SSLACKCKNDNDHITETE
NEVER COMPLETELY ADHERENT.
BLEEEENGNGHAT WASASLLUDED TO IN
A C CPLPL PAPERS DR. ABUHAMAD IS
WHAT WE CAN D DO VERY E ELY ON
BIOLOGICALLY AND B ULTRASOUND.
SOS THE PATIENT AT A HIGH RISK
OF THAT FIBRINONO LAYER NOT
COMING OFF BECAUSE THAT'SSHAT'S
ING TO BE RELATED TO THE
AMOUNTNTF BLEEDING ANDND THE
SURGICAL APPROACAC THAT W S SULD
BE TAKING.G.
SO M MIFY THE LANE IN
DEDERIBIBI, I AGREE.
>> YEAH,H, AGREE WITH BOTH OF
THE COMMENTSS SO FAR.
AND JUST A LITTLTL B B -- NOT
LALAUAUA NEEDS TO CHANGE.FERENT
ANDHAT'S VERYY IMPMPMPNT.
AS WEETTER UNDERSTAND THE
DR. EINERSON'S PAPER FROM N NND
FOUR YEARS AGO OPENED MY EYES TO
A DIFFERENT PROCESS, AND I THIHI
THERE'S MORE LITERATUREE TO
SUSUORT THE LACKKK O I IASION AD
IT'SORE AN EVOVOTION IN O O
UNDERSTANDING OF HOWOW PLACENTA
ACCRETA DEVELELS.
SO NECESSARILY, LANANANE WILL
CONTINENENEOO CONTINUE TO DEVELN
THIS.
>> I HAVE A QUESTION ABOUT THE
OLOGY.
IT'S NOT JUST FOR DR. AFSHAR,
BITS FOR THE WHOLELE SPECIFICAL,
IN ADVERSE PREREANCYUTCOME
WHEN WE TAKE THE PLACENTA AFTER
DELIVERY, NOT ONLY FROMHE
PATIENTS WITH PASAS BUT EVEN N E
CONTROL,AUSE AT NTE END TO
TETE THESE BIOLOGY, YOU HAVE
TO HAVE T T C C COL.
HOW CAN WE BE CERERIN THAT WHAT
WEWEE SEEING ISS NOT A A A RESPE
TOTOOMETHING ELSEE THAT'S NOT TE
CAUSEE OF T T PAS, INCNCDING THE
COMPARISON WITH THEONTROL,
BECAUSE THEESPONSE E HE
CONTNTL IS ALSO THERE TO
SOMETHING ELSE.
ANANWHEN WE SAY THAHA PAS ISS
ALLYLY A DEHISCENCE, WHY ARE WE
LOOKING ATHELACENTA ALSO
LY OR, ANYNYY, AND SECECD,
SHOULD WEE BE LOOKING AT OTHER
ETIOLOGIES, NOT JUST THE
OLOGY, B B THE WAY WE CLOSE
THETERUS, THE WAY WE TAKE CARE
OF THESEATIEIESER THEIR
PRPRR C-S-STION ALSO IS PROBABY
MORE IMPORTANT IN THIS REGARD
THTH THE BIOLOGY..
I AGREE.
BUT YOU ALLUDE TO THE POINT
OF - - -D I HOPOP I WAS VERYY
CLEAR, I 10000GREE...
THTH PLACENTA IN THE OR IS
COOKED/D/DE PLACENTA,, AND SOME
OF THEHEOLKS THAT ARERE A AE TO,
BY ULTLTSOUND, BY BIOI BIOMARKEY
THE PLACECEA EARLYN, LOOKTOOK AA
THAT C CSURE, HOW DOES THAT ONEE
OR TWO LAYER OR DOUBLE O OR
WHATEVER ELSE YOU PUT IN THERE
CLOSURE E KE A DIFFEFENCE.
SO I0000GREE.
ALL OF THE WORK THAT WAS
WAY THE MYOMETRIUM AS WELL, SO
THE SCACAIN ADDITION TOO THE
PLACENTA.
SO STOP BLAMING THE PLALANTNT
>> WE'RE L L LNG FORWARD TO
TALKINGBOUT THE NICHE AND THE
SCARRING IF THE FOURTHH SESSION
TOTO
>> WE'REREOING TO COME OVER HERE
NEXT.
>> SCOTT SHAINKER.
THANKS F F THE G GAT TALKSKS
THIS MAY BE A IMPORTANTNT-
>>>> INTNTDUCE YOURSELF.
>> I DID.
SCSCT SHAINKER.
>>WE TRY TO COME UP WITIT
NOMENCLATURE, STATA DAITION OF N
LANGUAGE TO PATHOLOGY FIELD HAS
AS WELL BUT ACTUALLY WE DON'T
USE IT.
WE'RE STILL USISI THE TERM
ACCRETA, EVEVE BOB USED THE WORR
THAT SAID IT'S NOTOT INVASION.
IT'S US, SO W N ND T T T COME UP
WITHTH- WE NEEDD TO ACCEPT
THESE -- ALL THEHEORK THAT WE'RE
ALREADY D DOING AND JUST MOVE OO
CATEGORIESESRYONON DESCRIBES
AS.3 NOW, HOPEFULLY, BUT I
DON'T KNOW IF I NECESSARILYLYLYU
ALAL THINK ABOUT THIS, D DO WE D
TO R RNVENT THAT WHEELEL R OR DE
NEED TOOUSTIND OFOFCCEPT IT?
YOU PUT A LOTOT OF WORK INTO T T
AND --
>>>> MAYBE -- I DON'T K K K I HE
WITHEEDD TO REINVENT THE WHEEL.
MAYBE WE NEEEE TO LOOK INTO THE
BRBRES A AITTLE BITORE.E.
I THINK WHAT I'M ASKING OR AT
LEAST PROPOSING OR HOPING FORORS
THATATE CAN REFINEE T T
DEFINITIONS THAT WE HAVEECAUSE
THEM. CONFUSINGNGVEVEBODY WITH
TO SOME EXTXTT.
AND T T PROBLEM WE'RE STUCK WITH
ISISE'RESING THEXISTING DATA
DEFINITIONS AND ASS YOU KNOW THE
DATA IS NOT ACCURATE.
I THINK THE VASCULARITY OF H H
VASCULARARARON C COROPPLER
MEANAN NOTHINGNG I TODAY'S
EQEQPMENT, IT MEAEA ABSOLUTELEL
NOTHING.
IAN MAKE EVERY PLACECEA LOOK
LIKE AN A ARERERE IF THAT'S THEE
DEFINITION.
SOSO'M HOPING THAT WITH US
COLLECTING MEANINGFUL DATA
OSPECTIVELY IN A STANDARDIZEZE
WAY, WE CAN THEN SAY THIS IS A
LACUNAE THAT MAKES SENSE. IT'SNF
IT HASASAS FLOW IN IT AND THE
PRPRENCE A AER PREVIA.
OTHEHEISIS IGNORE A A THE
THTHE ARE THE THINGS THAT I'MHA
HOPIPI FOR THAT WEE CAN COME
TOGETHER AND REALLY PROVIDE SOME
INFORMATION TORE THE WORLD ABOUT
WHWH M MTERS INLTRASOUNDLTLT
DIDINOSISSNDNDHAT DOESN'T.
>> I DON'T THINK W NEED TOO
REINVENT THINGS.
MODIFICATION ARE I THINK IS IN
LINE AND HOPEFULLY THAT'S S E
THING THATS ES OUT OF THIS
TWO-DAY SESSION.
I WANT TO BEIEI A KNOWLEDGE,
WE'V'V TALKED ABOUT SORT OF THE
LOT OF G GD WORK DONE TOO THATA
WE C C BUIUI UPON, AND AGAININI
MOMOFICATION BECAUSE THEREREBOUT
O MANYYY GAPSOR HOW C CMON
THIS PROBLEM I I
>> I WOULD ADD ONE C CMENT TO
GIVE YOU AN EXAMPLE, W WRE
STRURULING WHAT TO DO WITH THE
FIRST TRIRISTER ULTRASOUND IN
THE PATIEIE W WH ONE PRIOR
CESAREAN SECTION, , R INSTANCE,
TO D DE.
THERE'S NO NATIONAL STANDARDS ON
THE STANDNDD SAYS DO NOT USE
UNLELE IT'S INDNDATION-DRIVEN.
GIVEVE THEORBIDITY OF THIHIT?
DISEASE, SHOULD WE BE DOING
FIRST TRIMESTERLTRASOUNDS
WITH -- ESE ARE THINGS WE
COULD HELP WITHHHING TO
CONSENSUS ABOUT.
>>CHRIRIRIA DUZYJ-B-BIAK, IF
IS ROOM O OF EXPERT CAN'T COME
TO A A CONSENSUS ABOUT W WTT A
ULTRASOUND DIAGNOSIS IS, THENN
READING A 76805 DEFINITELY W W W
KNOW WHO TO REFERER INTO OUR
EXPERTRT EYES.
SO I'D'DOVE FOR USO
STANDARDIZE NOMENCLATURE ALSO
FOR WHO NEEDS REFERRAL, WHO
WARRANTS THEHEEFERRAL TO COMOM N
TO THEXPERT EYES TOEGININ
WITH, BECAUSUS TO DR. LYELL'S
ORIGININ POINT IN HER
ESENTATION, IF 70% ARE
DIAGNOSED UNTIL THEYRE IN THEHEE
O.O.O., THEN WE N N NOOVE
DIDINOSIS UPSTREAM, SO I THINK
MENCLATURE IS REALLY IMPORTANT
THERE TOO.
>> I WANT TOO ADD JUST ONON THIG
ON THE FIRST T TMESTST
ULTRASOUOU IS, I MY PERSONAL
OPPORTUNITY FOR THE D DGNGNIS
ANFO SCREENING F F PLACENTA
ACCRETA B BAUSESESES MUCH EASIER
TO DO THAN YOU DO IN THEHEECOND
D THIRD T TMESTER BECAUSE YOU
SEE THEULL PLACENTNT
SO THIS ISHYT'T'T' R RLLY A
WIWIOW U UNG WORDS FROM --
WINDOW I I THE FUTURE,E,OW THEHE
WINDOW -- IF WE COME TO O
AGREEMENT OF HOW TO STANDARDIZE
AT, THAT, I THINK, , A A HUGEE
SERVICE.
SOMEMEINGGG J JT BUILDING ON TH,
WE HAVAV'T TALKED ABOUT T T
NON-PREVIA ACCRETAS, YET WE K KW
THAT THEY'RE MORBID,D,HEY
HAPPEN, IN MY EXPERIENCNCNC AREE
ONES THAT WE HAVE TOTOTLY MIS
MISSED -- IN S SEOEO WHO REALLYR
RISK FACTORS, BUT THAT'T'
SOMETHING, HOW CAN WE DO BETTETE
ATOSING NON-PREVIA
CRETAS?
I'M CURIOUS TOO KNOW YOUR
THOUGHTS IN GENERAL ABOUT HOW WE
CANMPROVE THAT, BUT ALSO O
THE FIRST TRIMESTER..
>> THE FIRST TRIMESTER COULD BE
ANAN IMPORTANT WINDODO THEN,
BECAUSE WE COULD SEE MAYBE A LOT
OF THOSE PLACENTAS HAVE ACTUALLY
STARTED AS A LOW LYING PREVIAS
AND MIGRATED POSTERIORLY, AND
THERER COULD BE --UT I AGREEEEEE
WITH YOU, THEY ARE VERY COMOMEX
TO D DGNOSE AND DIFIFCULT AND WW
PRPRABLY MISS A LOT OF THEM.
ESESCIALLY ON THEOSTERIOR SIDE
THAT HE WITH CANANANEE, BUT
THERE E ULD BE A WININW IN THE
FIFIT TRIMESTER.
I DON'T HAVE THAT. WE ARE
LOOKING INTO THIS NOW, BUT --
>> QUESTION HERE, B BNG THE MOST
SENIOR PERSON IN T P P P ROOM H,
YOU DON'T ADDRESS THIS ISSUE
NOW, , U'LL BE INHE SAME
SITUATION WE ARE WITH
HYPERTENSIVEISORDERS OF
PREGNANCY.
WE H HE CONFUSED THE HEALTH OF
EVERYBODY, H HERTENSION,
PREEEEAMPSIA, WHOO IS -- AND WHO
IS NOT.
I HAVE -- MORE WITIT - --
HYHYHYENENONONMORERE THAN 45HA
WE ARE STILL TRYING TO DEFINENE
WHAT WE DID..
IF YOU DON'T DEAL WITH THIS NOW,
YOU WILLL B B--BOBO THIS 1 1
15,, 40 0 ARS F FM NOW THE WAYAE
DID.
THIS IS WHY IT H H TO BEONON
RIGHTT NOW.
>>>>HANKS.
HOPEFULLLLTHAT'S WHY WE'RE HERE.
THEREAS A COMMENT OR A
QUESTION FROMEHIND YOUOU
RISTINA?
>> MY NAME JEANILMAN, I'M FROM
DUKE..
I APPRECIATE THE COMOMNTNTHAT --
DEDEDENG THIS DISEASE SHOULUL
MPLE SEE UNDER THE GRANULAR
MICROSCOPE AND COMEEACK T TO WHA
IS GOING TO MATTERO THE
PATIENT, AND IN ORDER TO
RERERE--AVAVTHE GREATEST
IMPAPA,,T BECOMES OUR
RESPONSISILITY TOREATE STRATAA
OF -- AND RECOGNINI IT'SS A
LTIPIPX DIAGNOSIS,S, SO IT ISS
VERY MUCHHIKE PREECLAMPSISI
WHERE THEREAS TO B A
CONSIDERATION OF PROXIMITY TO
THE ORIGIGIGI INJURY TOHEHE
UTERUS, SO PROXIXITYO A SCAR,
NOTT JUSTHE PREVIA, BUT
PROXIMIMY TO THE P POR SCAR,
BECAUSE IT DEPENDS WHEHE YOU'RE
DOING THE ULTLTSOSOD OR WHAT
ULTIMATELYECOMOM OUR JOB IS TO
LAY OUT THE TABLE THATT TALKS
ABOUT THE PRIMARY RISKS AND THE
PRIMARY MARKERS, ANDHEN HOW
MULTIPLE COMBINATIONS OF THEHE
CA LEADO LOW IPT INTERMEDIDIE
OR HIGH RISK STRATA FOFO M MININ
DECISIONS FOR DELIVIVY TIMING,
SOURCES.S.OCATION ANDNES N NESSY
>> THANK YOU FOR THAT COMMENT.
WE'RE GOING TO GO O OR HERE,
STT WITH JASON AND THEN
GEOROR.>> JASONON- C CUMBIA UNU.
TALKS. ALL FOR T T REALLY GREAT
WHAT'S T TOLE O MRI INUHAHAD.
DIAGNOSIS AND I GUESS MANAGEMENT
IN GENERALAL
>> W WLL OFTEN USE IT IN
SUSUSU DECISION-MAKING BUT IS
>> I THINKNK THERE'S'S CONTROVEY
HAT.
AND I THINK SOME OF THENK STUDIS
AND II KNOWRETT AND F -- HAD AEY
NICE PAPER ON THE EXPERTISE THEE
HAHAHA IN CREATIV T TTRI
SOMETIMES IS MISGUIDED IN
GUGUING YOU ONE WAIVERS US
OTOTR, EVEN FALSENN POSITIVES
AND FALSE NEGATIVES AND I SHARED
THE SLIDE WITH THAT.
I I ININ THE V VUE OF AN MRI IS
HIGHLY DEPEPDENT ON THEGHGH SKIL
OF THE SONOLOGISTS T T TTTOU HAE
TIN YOUR UNITS AND THE
TRANSVSVSVAL APPROACH TO THE
PLACENTA.
IF MOST OFOFHE PATHOLOGY IN THEE
PLACENTA IS IN N EE LOWERERER
SEGMENT,
THEHEI THINK
TRANSVAGINAL UNDER SOUND ISERER
REALLY SUPERIOIO TORI I INEALLY
DEFINING -- INVASIONS W W WREHE
POSTERIOR -- ALL THAT.
-- WHERE YOU CAN DEFEFE THE
DEPTHS OF INVASION INTO
SELECT PLACENTAS,T LEAST IN MY
RERE OF THE L L LATATE.
I EVER R NOTOTOT THAT I I SAYAG
GOOD O OR B B, BUT I DON'T THIHI
EVER ORDERED AN MRI OUR LAB
REDEFINE THE DIAGNGNIS.
VARIEDRORO INSTITUTION TOEMELY
INSTITUTION.
DR. S H
RERA IS ACTUALLY
GOING TO TALK A A LITTLE BIT ABT
IS GOIOI TO BE GREAT.ON, WHICH
>> SO HANG TIGHT FOR T TT.
WEWEL GO TO G GRGE NEXT.
>> I JUST WANTO GO BACKKO
KNNOMEMELATURE, AND TALK ABOUT
WHETHER DO WE CONSIDER
ULTRASOUND OR IMAGING, IF MRI -F
THE OTHER O O, THESE DYING
NOSTIVE TESTS OR ARE THEHE
SCREENING TESTS?
AND ALTHOUGH WHILE THIS MAY
SOUNDD TRIVIAL, NOMENCLATUREE
TRIVIVL, IT'SS ACTUALLY NOTOT
CAUSE E WE ARE SAYING THAT
THE DIAGNOSIS IS DONON AT
DELIVERY, L L'S SAY, EITHERYY
PATHOLOGY Y Y YHE PATIENT
OUTCOME, THEN THE ULTRASOSOD
BECOMES A SCREENING MODALITY.
AND IT'S IMPMPTANT T DEFINE I I.
BECAUSE EN YOU HAVE FALSE
POPOPOVE, FALSESEEGATATE.
YOU ACCEPT THAT.
AND THEN ALSO,O, YOU INTERPRET T
BASESE O O THE PHE-TEST
PROBABILITY.
PROBABILITY IS HIGHER THANTESTAA
SOMEBODY WITHOHO PREVIOUS
C-SECTION, EVEN THOUGH THE
FINDINGS ON ULTRASOUND A A THE
SAME, N N YOUR POSOSTESTST
PRPRABILITY IS DIFFERENT..
WE ACKNONOEDED THAT, IF THERE
IS SOMETHING WE NEED TO ACCEPT
AT THIS CONFERENCE, TO G GO BACK
TO WHAT BA HRK A IS SAYING, IS
DEFINING WHETHER IT'S A
SCREENENG TESESOR A DIAGNOSTIC
TEST.
OBVIOUSLY MY OPINION IS IT'T'T'
SCSCENINGGEST AND WE SHOULD U U
AS SUCH, SO WE STATA WITH A
PRE-TEST PROBABILITY, THE TEST,.
HEREREH HEUNCH MORE PEOPLEEE
IN THEORNER.
>> HI, THISSAHIDA
CHAKHTOURARAI'M ASKING A QUESTIG
US BACK TO T T BIOLOGY F FM A
MEMBER OF THERANCH,
DR. GIRARDI, WHO WASSKING
SPSPIFICALLY ABOUT, FOR Y Y, DRF
CELLS YOU'RE USISISI FOR THE
PLACENEN ON THE PLATE, THE GJGJG
THREE CELLS THAHA A A
CARCININENIC INSTEAD OF -- SO IF
YOU COULD EXPLAIN THAT.
>> SO WHEN WE CREATED THE
ACCRETETN A A DISH, LS CELLS IN
RED -- THESE ARE KNOWN AS
RCINOMA C CLS, ABSOLUTE NOT
SO THEY'RE EASY Y WORK WITH.
WHEN WE CREATE THE MODEL,, WE'E'
DONE THIHI WITH TWO OTHER CELEL
LINES THAT AREREASILY AVAILABLE,
WE'VE ALSO CREATED THEMITH
PRIMARARCELL LINES, BUT PRIMARY
WITH EACHH -- WE'RE DOING THATSS
KIND OF IN PARALLEL.
SO JUST FOR EASE AND CREATING
EEISIS
DISH BUT ABSOLUTELY
ACKNOWLEDGE A L LTLE BIT OF
DIFFERENCE IN BIOLOGY.
>>>>>> THERE'S A A COMMENT O ORN
RAIGHT IN THE BACK THERE.
>> Y Y, THANKNKOU.
N YOUU HEAR ME?
HIT THEUTTON.N.
>>>> THERE IT GOES.
OU HEAR ME NOW?
ALIGHT.
ANK YOU.U.
MY NAME ISSS ALEX.
ANK YOU FOR GREAT TALKS.
I I INTRIGUED BYO HOW DO YOUOU
BIOLOGOGALLY EXPLAIN S SE OFHE
ULTRASOUND FINDINGS T TT WE'R'R
LKING ABOUT?
THE DISRURURUN OF THE DECIDUA
CAUSES THIS L LK OF STOP OR THE
TROPOPBLASTS, BUT WE AREEEING
ABNORMAL PLALANTATIOIO AWAY FROM
TH SCAR, SO I WONDER IF WE HAVE
VE - TRANSLATION FOR THAT.
>> THE ONLY THREAD WE'REEEINGGEE
SOSO FARSS THE EXTRACELLULAR
MATRIX THAT'T' CREATEDED
SOSO THE S SR DEFINITELY D DS HP
ACCELERATE THAT FIBRINOID
DEFINITION THAT T CANCTUALLY
CREATE IN VITIT, BUT W WN
THERE'SS NO SCAR, WETILL SEE
SOME ENDOGENOUS PRODUCTION.
SO SOMETHIHI THAT I DIDN'T SHARE
AT ALL, WORK FRORO MULULPLE O MR
ININITUTIONS, IS RELATATOHEHE
IMMUNE MACROPHAGEE C CMUNICATIT,
DEFINITELY INCREASES THAT, BUTR
THERE' S SETHING STILL GOING ON
UNRELATED TO THE S SR.
SO I T TNK THE NE MU COMPONENT S
SEE PLACENTA ACCRETA AWAY F FMEE
THE CESAREAN SCAR, BUTUT T TRE E
A LOTF OTHER PROCEDURES, D &
Cs, PROBABAY T TNGS THAT WE
DON'T WELL ASCERTAIN WUR CURRENY
THATATAN DAMAGE T T D DIDUA AND
THE MYOMETRIUM ANDANAN LEAEA TOO
THIS DISTANT FROMM THE CESARARAR
>> ANNE ROBERTSTS UCSD.NENE
I HAVE A QUESTION FOR DR. AF
ELELELT TALKLK EVEVEBODY, VERY
ELEGANT TALK.
MY Q Q QION IS, WHY IS IT THAT
SOME PATIEIES G G AN ACCRETA,
BUT THEN WE H HE INCRETAS AND
MOST IMPORTANTLY PERCRETAS,
WHWH-- WHAT GOES ON THERE THAT'S
CAUSING THAT?T?
>> THANK YOU, DR. ROBERTS.
I WOULDCTUALLY R RSE IT AND
YY WHY D DO MOST PEOPLE NOT GET
D I CON'T KNOW, BUT MOTHER
NATURE BYYATURAL HISTORY HAS
NE THATTXPERIMENT FOR US.
SO I THINKNK UNDERSTANDING THE
RMAL SCACAREPAIR IS WHERE IT'S
AT.
AIN I HAVE NO IDEA BUT
FOCUSING ONHEN I HAPPENSNS
RIGHT IS SOMOMHING WE DONON DO
AS MUCH.
IT'S H HDEDE TO STUDY ACCESS TO
THE TISSUE IS LIMITED,E
SEE IN EXTREME FORM.
SO I THINKT'S WITHIHI THAT
SPECTRUM, AND I DON'T HAVE THE
ANANER,
MOMO CASES NOT OCCUR.HY DO
>> I THINK THAT'S A GOOD MOMOMOM
EXCELLENTTOB OF STAYING ON AN
TIME, SO THANK YOU VERY MUCH TO
THE PANENESTS FOR A WONDERFUL
SCUSSION THIS MORNING.
I WOULD ENCOURAGE EVERYBODY TOO
TAKE A LOOKT YOUR B B B.
YOUR STICKERERN YOUR BADGE
NOTES WHICH W WKING GROROROOU
WILL JOIN.
IF YOUOUE A GREEN BA GREENSTICKU
WILL BE JOINING DISCUSSIONNNNUP
WE DO HAVE A 10-MINUTE BREAK,
MAYBE 9 MINUNUS NOW, S S S PLEAE
FEEL FREE TO USE T TACILITIES. >>LL T T T WAY IN T T BACK TO THTH LEFT.
THE BREAK..B BK, EVERYBODY, FROM
I THINK WE'RE GOING TO GO AHEAD
AND GET STARTED WITHHE SECOND
SESSION, PREPANG FOR PASAS
RGERY, AND CHRISTINA HERRERA,
PLEASE GO A A.
>>>> I'MSSISSSNT PROFESSOR,OR
RECEREED TULTIDISCIPLINARY
S TEAMEA AT PARKLANKL HEALTH LTD
II HAVE AESEARCEA IMAGEMAMA IN
AGING AG MANAGEMENT OF PAS.
I AM FUN FD BY THE NIH AND A THE
CHD, STHANK YK FOR HAVING
ME HERE TEAY..
SO PAS IS A TOPIC IN WHICH I
THINTH THE T'S SIGNIFICANT
ANXIETY DERIVED FROMRO THE
HEARD IN THE EARLIERLI TALKS.E'E
WE ALL WANT TO BE PREPARED FOR
WHEN WE ON AN ABD AEN A AND IT
LOOKS LIKE THIS PIC PRE HER H ON
THE RIGHT, WHERE YOUOU SEE THE
FANT HAS BEEN DELIVERED --
THERTHS LARGEGELA CENTRAL BOWLS,
HYPERVASCUASRITY ALONGHE
ENTIRE UTERINENE SEGMENT,NT
ULTIMATELY THIS HAS BEEN
CONSISNSNT WITHLICAL GRAILD
3 -- T-- OECTIVETI OF MY TALK
ARE FIRST TO REVIEWIEW CURREURRE
LIMITATIONS IN PREDICTING PAS
MORBIDITY, SECONDON TO DCRIBE
THE ROLE IN PRE PERATIVE
DIAGNOSI P AND STAGITA OFF P AN
COMPONENTSTSF IDE I PREOPERATIVE
PAS STAGING SYSTEM F
ULASOUNDOUEALLY IS THE KEY FOR R
THE INITIAL SEENING FOR PAS.AS
AND THE MOST -- THE FIRST STE S
IN MOSTOSOS ALGORITHMS ARE SCREN
PATIENTS HIGH H RK.
WE'VE KNOWN SINCE THE T STUDY IN
200620HOSE WERE HHESTST RISK TIP
THIPICALLYLY HAV HAVRIORORISTORF
CEAN AS WELL AS PLACENTANT
PREVIA..
IVF I D D D THINK IS INCREASINAY
BECOBENG A CONCERN.RN
FORCE IN 21 OUTLINEDED THESEK
DEAF SITIONS TNST RAISED CONCERN
FORHE PRESENCE OF LACUNAE,
ADDITIONTILYLY PLACENTCENT BULGE
PORTENDD PASS SEVERITY MORE IN I
THE ACCRETA RANGE.
I DO THINKNK THAT DIAGNOSIS CANE
MADEMAS EARLY ASS THE FIRST
TRIMESTER.
EVEN THOUGH SUSPICION FOR IORORS
SECOND OR THIRD, WE KNOW THOSE
WITH CESAREAN --N AND THATHA TE
WITH -- PLANTATION CEN REAN ALSO
REMAIN AT RISK.
EN DEMONSTRATED HDE ON THE
TOPIC PRC NANCY.Y. CES CEAN SCAR
THISORREORTED WITH --H END E UP
HAVING BLADDLA INVOLVEOLNT
IN THEARARIGHT I'M SHOWING YOU
OWER PNTATION -- CESAREAN
TIMES ONS
SHE DIDN'T HAVE ANY CLINICALGRAL
HYPERVASCULACUTY PAS PAS GRADINF
3A.3A
I REALLY HE BEENNTERESERESES IN
ERS OF PASSE OF POWER
VASCULARIZATIZAT ALONGHEBLDE IN.
WE FOUND BOTHH I I CES CEA C
ECTOPIC PREGNANCIES AS WELL AS
LOWER PLANTATIOATATITH PRI P
SAREAN THAT THAT IS SOMEWHAT
HAVE PAS THATEQUIREUIES ON TO
ST
ECMY AND THATT CORRELATES
WITH THESE INCRENCES VASCULAR
INDICES COM CRED TO TOMEN WHO DO
NOT.NO
SO IMAGE A ISHOWING Y A
WOMAN THAT WENTN TO RUIRE
HYSTERECTOMY VERSUS B, AATIEAT
CESAREAN DELIVERIVAVING A
MULTIPLE META-ANALYSES HAVE
DEMONSTRATED IED TED TAS T
ITYY OF ULTRASORADRA AND MRR TO
SCREEN FOROR PAS.
EYEY TYPICALLY HAVE DEMONSTRATED
LATIVELY HIGHIGENSIENVITYTY AND
SPECIFICITY.
I THINK MOST OF THE T STUDIESES
ARE ARMITED BY THE FACT THAT
THEY ARE AT HIGH VOLUMEE CENTERS
THAT SPECIALIZE I I PAS CARE.ARR
ADDITIONALLY THE THE A LOT O O
HETEROGENEIT IN TERMS O O W'S
CLUDEDUDN TERMS OTHE PATIENT
POPULATIONTI HOW HOW APP APPH TO
SCREENING AND DIAGNOSIS
PERSONNTERPRETING THAT DATA ASE
WELLWES THE OHECOME USED FOR THE
DIAGDISISFFF PAS, WHETHER THAT
WAS MADE OPERATIVELYERSUSSUSSUS
MOREOVER IF ANY OFHESE STUDIESES
REALLY USE -- INTRODUCEDN 2019
RESPECTIVELIV.
WHILE MOST STUDIES GIVE THE
ABILITY TO SCREENEE AND PDICT
PRESENCE OF P, THINK FEW
OF THE STUDIES AUALLY ADDRESS
WITH PAS SEVERITY.CLATELA
ERE WAS THISTUDYDY IN 2018
AT LOOKED PROSPECTIVELY AT 210
PREGNANT INDIVIDUALS.
EY H PRIORRI CES CEAN AND A
ABILIBI OF ULTRASOUNDV ITIGATED
SCIENCE TO CORRELATETETE BASED F
THE HISTOPATHOLOGY.
LOSS OF THE CAREERONE,
LACUNAE, BLADDER WALL
INTERRUPTIONON ANDND
HYPERVASCULALATY...
SPSPIFICICY AND POSITIVE HIGIG
PREDICTIVE VALUE WERER LIMITEDED
PARTICULARLY IN THEHE MORE
INTETEEDIATE RANGE OFCCCCTA.
A STANDARDIZEZE ULTRARARAD
APPROACH IN THE SECECD AND THIRD
TRIMESTETEIS A AILABLE.
AT MY INSTITUTION IN 2020 THEY
DEVELOPED THE PLACENTNTCCRETA
INDEX USING BOTH CLINICAL ANDND
ULTRASOUND FINDINGS TO YIELD A
PRIOR CESAREANS ALONG W WH THEHE
PRESENCE AND RATING OF LACAC
LACUNAE -- THEHERESENCNCF ANY
PORTION OF THAT PLACENTA BEING
ANTERIOR PREVIA AS WELL AS S
SSELS CAN YIELD A SCORE --
POSITIVE PREDICTIVEALUE,
NENETIVE PREDIDIIVE V VUE, THE
LIKELY IT T THAT PAS ISROR
PRESENT.
THESESLTRASOUND VARARBLESES
NONOBLY ARE A AAINED AFTER TRANS
ABDOMINAL AND SAGITTAL AND
FILLEDED M MERNANAEDLADDER.LLYLY
THE ORIGINAL INDEX WAS FORMED
USING R RROROECTITI -- PRIOR
CESAREAN AND EITHER R ACENTA
PREVIA OR LOWYING PLACENTA IN
THE THIRD TRIRISTER.
ABOUT H HF F THE WOMOM
UNDERWENT HYSTETECTOMY.
AND USININ A A THRESHOLD SCORERF
GREATER THAN 4, WE FOUND THAT
THE PAI H H AN A ALITYO
PREDEDT O O A A A 8 8 AUC.
THE PAIAS BEEN VALIDATED
REPEATEDLY IN BOTH RETROSPECTIVE
AND PROSPECTIVE STUDIES, AND
MOST S SDY, IT HAS A G GD TO
EXCELLENT AUC OBSERERD.
WE H HE HAVE CONONONED AT OUR
ININITUTION TO REFINEHE P AI.
WE S S SED TO MEAEARE THE LENGTH
OFOFHERANSVERSE IRRRRULARITIT
ALALALTHE INTERFACE AS WE
GHT THIHIWOULD CORORSPOND
WITH WHERE SURGEONS HAD
PREVIOUSLY BEEEE
SHOWN INHISMAGEGEN T T
LENGTH OF TRANSFERSTING THAT
IRIRGULARITY.
WE DEFEFE THIS A A THE LARARST
AMETER OF CONFLUENT V VSELS ON
A SINGLE IMAGEBSERVED IN N E
2D TRANSFEFE COLOR DOPPLER.
ITITAN INCLUDE BOTH THE BLADDER
WE FOUND THAT WHENNE ADDEDHISM.
OUR PAI, IT SLILILIY INPROVED
THE AUC TO78 .89 AND CERTAINLY
LARGER STUDIES A A NEEDED T
CONFIRM IFHIS PROVIVIS
ADDITIONON DIAGNOSTIC
DISCRIMINANANA.
ULTRASOUND IHINK HAS
SPECIFICITYYIMIMATIONS.
ECIFICALLY INN THAT
INDETERMINANT RANANAN
NORMAL, AND WHEN IT'S BAD, IT'SS
REALAL BAD.
BUT OUTSIDE THOHO TWO,,HINK
'S D DFICULTO D DFERENTIATE.
WE ALSO K KW OUR FIELD OFIEW
USING ULTRASOUND ISRIMARILY
ANTERIORLY ALOLO THAT
THEREFORE, ASSSSSMENT OF EITHER
LATERAL, POSTERIOR OR SUPERIOR
N BE L LITED AND MISS THOSE
AREAS OF INVOLOLMENT.WE KNOWWHAN
WHEN THEY DON'TAVE A PRIORORL
HISTORY OF CESAREAN BUT RATHER
SK FACTORSRSUCHSS IVF, PRIOR
MYOMECTOMYMYR D D DATION ANDND
YPICICLY THOSE INVASIONS CAN
TYPICACAY OCCUR IN AN ATYPICAL
AREA, AND I DOO THINK THEHE
ULTRASOUND IS LIMITED IN
IDENTIFYING PAS OUTSIDE OF THE
LOLOR UTERINE SEGMENT.
I'LL NEXT REVIEW W E ROLEOL OF I
IN PAS MANAGEMENT.T.
SO AFTER MANANEAEA THE VALUEUEUE
ADAD OF MRI H H BEEN UNCERTAIN.
WE KNOW ITT HAS BETTETE SPATIAL
THEMAMA ON THE RIGHT WHERE D
WE'RE SEEING MULTIPLE2 DARK
LINEARAR BANDS HIGHLIGHTED HERE
IN YELLOW.
HIGHERENSITIVITY HAS CERTAINLY
ENEN O O OVED WITH MR BUT THAT
MAY BEELECTION BIAS D D TO --
ADDITIONAL LIMITATIONS INCLUDE
IS NOT AVAILABLE EVERYRYERE,
INTERPRERETION R RAINS
BJECECVE, AND AS OFET NO
VALIDATED STANDARDIZEDEDEPORTITI
IS IN USE..
MR MARKERSRSAVE BEEN SHOWN T T
CORRELATE WITH NEED FORM
HYSTERECTOTO.
RKERS INCLUDE --- FIBRIN DEP
NIGMS WITH ODDS RATIOS BETWEEN .
MORE RECENTLY MR MARKERSAVE
BEEN BETTER DEFINED.
THE SOSOSOY OF ABDOMOMOM
IN 20200AMAM OUT WITH ARIOLOGY
NSENSUSTATEMENT HIGHLIGHTING
THE RECOMMENDED AS WELL ASSSHAHA
I'M SHOWING IN THEEE PARENTHESES
UNCECEAIN MARKERSRS O O PAS
AS YOU CAN SEE, M MY O O O T TSE
MARKERS ARE SIMILAR TOO
OR ABNORMAL VASCULARITY,,UTBULGE
OTHERS ARE MOREE SPECIFICCUCH AS
THE T2 DARKK INTRAPLACENTAL BA
BANDS.
--- BASED ON THIS CONSENSUS
STATEMEMT AND WE HOPE TO REPORT
THESE OUTCOMEME IN THE FUTURE..
JUJUEMONSTRATING THE MULTIPLEN S
T2 DARK LINEAR BANDS ANDND
PLACENTALULGE.
SO I'VE DONON THIS WORK ALONG W
TODADA W W COMPARE THES HERE
ULTRASASND PAI TOOO OUR
STANDARDIZED RADLOGY APPROROH
WHICH INCLUDES PRORODING
GREATETE DIMENSISI OF INVASION
AS W WL AS A RADIOLOGIGI
IMPRESSION, GREATEST D DENSION
OF INVNVION WE'VE DEFEFEDED AS T
SINGLELE PLANE,HE LARGEST THATT
S EITHEHE2 DARK LINEAEA BANDS
LENGTH O OINVOLVLVENT ALONGNG
THE BLADDER-S-SOSAL INTERFACE OR
RARARAISIS IMPMPSSION IS JUST
THATATRERECTIONN O OINVASION
BABAD ONON IMAGING.
SO WHAT I'M DEMONONRATING HERE
IN THIS IMAGE ARE SOMEXAMPLES
OF THAT GREATESESIMENSION OF
INVAGUE.
THENEN THESE ARE LITTLE MORE
OBVIOUS.S.
ACENTA ACCRETA..WERE DEEMED AS A
I WANT TO SHOW A LITTLEE BIT MOR
RE, THTH GREATEST E EMPLE OF
INVASION HERE IS 28 MILLIMETERS.
ON THE CORRESPONDING WEIGHTED
IMAGE, THIS CORRESPONDED WITH T2
DARK INTRAPLACENENEN B BDS.
THIS I IHE TREUL -- SEQUENCE,
WHICH IS A -- SEQEQNCE, THE
LACUNAE WILL APPEAR WHITE..
IN THISASE SPECIFICALLYY THE
PLACENTA D D DELIVIV BUT WEE HAE
PLACENTAL IMPLANTATATN SITE
BLEEDING CONSISTENEN WITH --
PATHOLOLOL GRADEDE.
WE DID WANT TOO COMPARE
THRESHOLDSDSOR NEAR-PEPEECT
SENSITIVITY, CAPTURED MOST OF
THE PATIENTS DIAGNOSED WITH PASS
AT DELIVERY.
WE FOUND THAT THATT S SSITIVITY
COCOELATED WITHIN ULTRASOUND PAI
CUTOFF OFREATER THAN OR EQUAL
UAUATO 3.5.5
ON THE X AXIXIIS THE U URASOUND
PAPA AND ON THE Y AXIS IS THE
GREATETEIMENSION O INVASION
BY MR, AND THEN INNN THEHE BLUEE
TRIANGLES WE'RE SHOWINGOMEN
E PINK CIRCLESES HADAD CESAREAN
DELIVERY..
THESE DEMONSTSTTE WE DODOAPTURE
THE MAJORIRI OF WOMEN WHO END UP
NEEDING AYSTERECTOMY.Y.
AT T TS 96% LEVEL OF
SPSPIFICITY AND POSOSIVEALLY
PREDICTIVE VALUE OVEVEVE THAT
ULTRASOUND P PAI.
THE POSITIVE PREDICTIVE V VUE
FOR UNDER S SND S WAS 80% VERERS
6363
THE SENSITIVITIESND NEGATIVEE
PRPRICTIVE VALUESSERE SIMILAR.
I DO THINK THIHI IS CLINICALLY
MEANINGFUL.
IN FEW P PIENTS S REMOVE THE
CONCERN FOR P P AND THOSE WITH
GREATER -- LESS T T T 2 2OR
BETTERERELINEATED THOHO WHOWOUL.
WE ALSO WANTED TO E ELUATE IF
THERE'S AN -- THRESHOLD SO WE
LOOKOK AT THE PAI IN THE THIRD
TRTRESTER ANDND DEFINED OPTIMAL
THRESHOLDDD OF6% SENSITIVITY AS
WELL ASS AN OPTIMALAL THRESHOHOF
96% SPECIFICICY.Y.
THAT SENSITIVITYTY WAS CONSISTET
3.5 AND WE FOUND A CUTOFF OF
THEREFOREEE DEFINEDNY, SOOO
INDEDERMINATE RANGEAN B BWEEN
3.5 AND 8 AND WE PLAN TO LOOKK
REALLY MOREEPECIFICALLY AT T T
VALUE ADD OF MR WITITN THIS M ME
PRESENTLY U UNG BOTH MR
WE HAVE FOUND LATERER DELIVERY F
POSSSSLE IN CERTAIN PATIENTS
WITH LESS I I IT MORBIDITY.
IF THEHE MR IS N NATIVE, WE PLAN
BABAD OFF THE USUAL OBSTETRICAL.
WE'V'V'V DEFINEDED ACCRETA AS LS
HAVE INCREASAS THE GESTATIALD WE
AGE A D DIVERY.
WE HAVE TOO R RORT IN THEHEEXT
YEAR U UNG T TSE THRESHOLDS.
WEWE U UD -- WE TYPICALLY DELIVR
ACCRETA/ININETA AROUND 36 WEEKS,
WE HAVE GYNECOLOGIC ONCOLOLY
THAN -- WE DO HAVE A A MANUSCRIT
BASED OFF OFF THISSS MANAGEMEMTR
REVIEW.
SO OPTIMIZINGGG OURUR PREDIDIIOF
PAS.
I THINK OURBIBITYTYO PREDICTCT
PASS IMPROVING BUT IT'SAR
DARDIZED APPROACH.USING A
CAPTURE A A REPORT ULTRASOUND
AND MR DATA.
FIRST STANDARDIDING VALALATING
APPROACH FOR THISSND SHOULD BE
MORE WIDIDY IMPLEMENTED.
INK SECOND OUR CRITERIA FOR
MR REFERRARA NEEDDO BE
ESTABLISHEDND VALALATED, AS
LL A A WE NEED TO JUST HAVE A
INTERPRET THE A REPORT.HOW WE
I DO THINKNK THAHA F FURE
PUBLICATIONS, WE SHOULD ALL BE
WORKING TO INCNCPORARA FIGIG
CLINICAL AND PATHOLOGICAL
GRADING WHEN FEASIBLE, THERE MAY
BE ADDITIONAL VALUE ADD OF MR IN
THOSE C CES THAT MANAGAG
RE CONSERVATIVELY.
COME TOGREEMENT WHEN THISTO
IMAGINGG IS ATTAINED.
I'VE PROVIDED HERERER JUST HOW E
ARE SCREENENG AT MYNSTITUTION,
IDENENFIED HIGH RISK IN THE A
FIRST TRY MESS TE I USUALLY HAVE
CESAREAN ECTOPIC PREGNANCY,
DODOG ADDITIONAL IMAGING AT 10
TO 13 WEEKS LOOKING ATHE
VASCULAR INDICES.
IN THE SECOND T TMESTST,, WE'RE
SCREENING ALL OF T TSE THAT HAVE
A PRIOR CESAREAN ANDNDND AT 18 O
W WKS AND THEN WE'RE DOINGNG
CONFIRM THRI ULTRASOUND AT T
WEEKS.
WE DO THAT AT L LSTST O OE JUST
CAUSE THERE IS A DEGREE OF PLA
PLACENTALL- TROPHISM -- AS THAHA
CONCNCN RESOLVES.
ANY OF T TSE THATFAVE A
POSITIVE -- MR AT 30 T 3 3
I DID A PAS PREDICTCTN, EACH
ININITUTION SHOULD BEEEN
INTUITIVE PROCESES
WE'VEE P PCTICED THE60 REVIEW
OF ALLF OURE.
WE REVIEW WITH THE
MULTIDISCIPLINARY Y Y S SFOR
ANY OFF OURUR UPCOMING CASESEE
REVIEWEWOTH THE ULTRASOUNDTTTR
TOGETHER..
THOSE OPOPATIVEINDINGS ANDREVIEW
DELIVERY O OD AND F FALLY WE
BRING IN PATHOLOGY WHERE WE LOOK
AT BOTH T T T GROSSND
MICRCOCOC TO TRY TO
CONTININLLLL IDENTIFY AREASAS FR
IMPROVEMENT IN OUR ALGORORHM.
THINK THAT ARE OCCASIOIOLLY
MR P PCENTAL RENDERINGNG CAN
TUALLY BE HELPFUL IN SURGICAL
PLANNING.
THIS ISHOWNN THEEE LEFT IS A
3D RENDERING OF THE U URUSHERE
THETERUS IS RED, THE PLACENTA
IS GREEN, AND THENHERE'S
BLUE LITTLE PART INHERE THAT'S
THIS WASE AT 27 WEEKS, ONTION.
THE E GHT I'MHOWING YOU T T
UTERUS W WH THEHE PLACENTA IN SU
ATATAT WEEKS.
I DO THINK THATT THIS RENDERING
WAS HELPFUL IN THAT A A
DEMOMOTRATES A SYMMETRICEATURE
THAT ACTUALLY A LARGE AREA
POSTERIORXTENSISI AND WAS
HELPFUL IN LETTING US KNOW WE
SHOULD MAKE A -- DECISISN
THAT -- TOO THE POSTERIOR SIDE..
FINALLY I DO THINKY THE
APPLICATION OF AI I LL L LELY
ENHANCE OUR PREDICTIVE
CACABILITY IN THTHTHUTURE.
MY OWNWNRERE WORKING TO SEGMENT
THE UTERUS AND THELACENTA ON
MRO DISTINGUISH MULTIPLE
CHARACTERISTICS OF T T T PLACEN,
OXYGENATION, P PEUTION,
DIFFUSION, ALSOOOKINGNG AT
TEXTUAL DIFFERENCES..
THE IMAGE ON THE TOP RIGIG IS
PLACENTA IN THEHEHE AMNIOTIC
ACADADY -- I IF THE MANUALL
SEGMGMTATITI, BASICALLY THEHE
LINES A A THE ALGLGITHM THATT HS
BEENEN -- - ER THEOLIDIDOLORS.
D D E B BTOTO IS SHOWING A 3DD
RECONSNSUCUCONROM MANUAL
SEGMENTATION AND A AORITHM
APPLICATION.
SO I THINK UNFORTUNATELY MOST
SEGMENTATION AT THISISOINT IS
NOT FULLY AUTOMATATAT BUT I THIK
ONCE IT IS AUTOMATED IT WILL TEE
CRCRSE OUR PROCESSSSG TIME AND
MAY REMOVE THAT SUBJECTIVITYY OF
INTERPRETATION THAT CURRENTLY IS
ESENT.
SO IN CONCLUSION, I THINK WE'VE
ACHIEVED IMPROVED ABILITY T TO
PREDICT WHO HAS PLACENTARETA
ECTRUM BUT WE NEED TOOO
STANDARDIZE OUR APPROACH A AWELL
AS REPORTITI OFF ULTRARAUND MR
TA.
IO THINK THAT MR CAN BE
UTILIZED TO ENHANCE S SCIFICITY
ANDD POSITIVE PREDIDIIVE VALUE.
WE USE OUR MR ALONG W W W OUR
ULTRASOUND TO ASSIST IN BOTH OUR
DELIVERY TIMING AND P PNNING.
FOR PATIENTS WITH LOWER CONCERNN
FORNVASION -- ROUTINELY
DELIVER AT LATER GESTATIONAL
AGES.
THINK AS WE DEVELOPOPREDICTIVE
MODELS, IT'S CRITICAL THAT WE
CONTININ TOO VALIDIDID AND I
ININRPORATION OF A.I. W WL BE
BENENECIALALF INTERPRETETION
THATE CURRENTLYLY HAVE.
AND I'D JUSTIKE TOHANK
EVERYONENE AT MY INSTITITION, TT
WE HAVAV A MASSIVE PLACENTA
ACCRETA TEAM AS WELL AS A
RESEARCH TEAM PARTICIPATINGNGN
THIS R REARCRC
SO THANK YOU.
>> NEXT WE'RE GOING TOAVE --
EAKING FOR DR. FARBERPEAKING
ABOUT ANESTHEHEA, TRANSFUSION
AND CRITICAL CARE
>> THANK YOUVERYBODY FOR YOUR
FLFLIBILITY THIS MORNINGNG
DR. FARBER, UR KNOWWHE WOULD
OBABLY NEED TOO BEE INTUBATAT
HERSELF TOOISS OUTN GIVING A A
TALK AND I'M HAPAPO SAY SHE
S A NATURAL A AWAY.
E'S DOING OKAY BUTUTUT
UNFORTUNATELY WAS STSTL TOO O LL
BE HEREEHIS MORNINI.
SHSHIS LISTENING ONLINE RIGHT
NOW.
I'VE CONFIRMED THAT.
SO I HAVE TO GIVE HER AUICK
LITTLE APOPOGY FOR WHATTT
GOININ TO DO TO HERER SLIDES.
II DO WORK WITH HER CLOSELY, IIO
RESEARCH WITH HER, I'VE HEARD
HER R LK M MY TIMIM, BUT I HAVAV
TOIVE THE D DCLAIMER, I'M NOTOT
AN A ASTHESIOLOGIST.SO MOVING O.
THESE ARERE DR. FARBER'S
DISCLOSURES. HAVE NOTOTNG TO
ADADONOP OF THAHA
SOME O O THESE. QUICKLY THROUGH
I HAD A CHANCEEO REVIEW HER
IDESND THEY'RE VERY
COMPRERENSIVE, BUT SOME OF THEM
DO O ORLAP WITHALAL THAT WE'VE
HAD THISORNING.
THERE ARE FOUR AREAS OF
ANESMHESIA KNOWLEDED GAPS THAT
SHSH WANTEDO EMPHASIZE, THE
FIRST ONE BEING THE PRE-DELIVERY
PLPLNING..
WE KNKN, THEHE ANENENESIA TEAM
THIS.ARETTY ESSENTIAL PART OFF
THIS ISS A A ART GOINGHROUGH
THE RISK FACTORS F F POSTPARTUM
APPLYINGO EVERY SINGLELD BE
BIRTHING PATIENT IN THE HOSPITAA
THTHE DAYS ANDMPHASIZING IN
THTHHIGH RISIS CLOM, SUSPECTED
PLACENTA PREVIA ANDLACENTA
PREVEV ARE THE VERY TOP OF THEL.
WEWEALKEDBOUT PRIOR CESARARN
AND PLPLENEN PREVIA BEING AT THE
VEVE TOP IN BOLD, THOSE ARE BY
R THE MOSTBVIOUS, THE MOST
STAND OUTURININ RESEARCH, AND
THAT HAD T T T HIGHEST ABSOLUTUT
RISK OF H HINININ PAS.
SHE LISTED MANANER RISK
FACTORS AT THE BOTTOM, INCLUDING
MORNININ WE TALKED ABOUT THIS
IMPORTANT RISK FACTORS, T TY
CONSISTENTLY AREREHOWN H HE AS
FACTORS I ITHE LITERATURE, BUT
WEWEE TALKINGBSOLUTE RISKS FOR
SOME O THESESE SUCH AS WITH IVF
THAT'SROROBLY NOT M M MN
2 2 3%.
U MULTIPLY THAT BY THE ENTIERM
POPULATION, IT'S HARDD TO
RESEARCH WHEN YOU HAVE AN
ABABLULU RISK LIKEHAT.
WE USE ULTRASOUNUN A LOT WHEN
EACH OTHER.NICATING RISKS TO
CERTAIN U URASOUND FACTOTO OR
AGING FACTORS OR ANY KIND O OF
RISKSKTRATIFIFATION FACTORS THAT
CACAOT JUST PRERERE THAHA PHE
PLACENTA WILLE ADHERENT, BUT
IT CAN ACTUALLY PREDICT THE
MORBIDITY IS ADHDHENT, H H T T
RISKSKTRIK STRATIFY THEM FURTHE.
SO H HE S S REALLY WANTED TO
EMFA SIELS HOW THEHE OTHER P PPE
ARE BRINGING UP ASELL, USINGSI
A.I., U UNG MACHINE LEARNING TOD
BIOMARKERS, BUT ULTRASOUND
OMARKERSRS RISK FACTORS,
MORE ABOUT THEHE AND CANEARN
PLACE OFARE AS WELL AS SET UPT
THE RIGHT SURGEGE REAL FOR THEM.
SURGERY FOR THEM,ND
USING BIOMARKRKS TO ADD TOO T TT
STRATIFICATION..
ACCRETAS ARE -- H HING A PREREA
WITH A AN A ARETA IS JUST LIKE
RE GRAPHICICLY MORBID ANDWIWI
OBVIOUS TOTOTO
THESE KIND OHOTOS AND THESE
KIND OF IMAGES DEFINITELY GET
A ASTHESIOLOGISTS' ATTENTION
AND IFTEN SEE T TM WITHH THEIR
FACES DOWN AT THE OTHER END OFF
THE TABLE WHEN WE'RE LOOOONG A T
PLACENTA A AER WE G G INTO THE
ABDOMEN BECAUSE THEHEREREOING TO
RESPONON M M M DIFFERENTLY T TA
UTERUSUSHAT LOOKSKSKS LIKE THISN
TO A UTETETE T TT HAS A MORE
NORMAL EXTERNAL EXPERIENCE AND I
THINK WE'R'R'R UNDERAPPRECIATITI
BLE AFTER THEYEE SOMETHING THE
LILILIHAT.
TALKING G ROUGH AS A TEAM, LIKE
WHAT ARE WE GOING TO DO
SURGICALLY TO MINIMIZE THE BLOOD
ININRVENTIONS THAT HAVE BEEN
PUBLISHED FROM VARIOUS
INSTITITIONS.
THIS IS USING A UTERINE STAPLER.
USING CONSERVATIVE MANAGEMENT,
I'M HAPPY WE'REREOINGNGO HAVE A
LE B B OF DISCUSSION A AUT
THISISODAYAYULL WILL A NEW I IA
MAYBE IFE JUST COMOMETELY
ANGE THE WAY WEE TREAT THESE
PAPAENTS, WE CACAHAVEVE A BIGGEE
IMIMCT ON CUTUTNG DOWN THEHE
MORBRBITIT
IT'S A DIFFERENT SURGERY, IT'S
DIFFERENT T Y OF A AESESNG THE
PATITITI IN THE O.R. AND WHAT'S
THE ANESTHESISIOGIST'S ROLE
THROUGH THAT PROCESS.
USING A HYBRID OPERARANGNGOOM,
AGAGN, SOMOMOM CENTERS DO THIS
ROUTINELY A A SEEM TO DO A
PRETTY I I ISSIVEEE WITH IT.
NOT ALL CENTERS ARE THE SAME.
NOT ALL HAVE THE SAME ACCESS TO
SOURCECECEND I THINK W WRE
STILL FIGURING OUTHAT'S THE
RIGHT WAY TO DO THIS AND WHAT'S
RIGHT S S SON FOR USING
IT, ANDDOW DO W WE HAVEHE RIGHT
RESOURCES.
SO FROM AURURCAL CONSISIRATION
AND AN ANESTHTHIA QUESTION, I
K THEHE MOST COMMONN ONE THAT
I'VE HEAEAEA MENTIONEDED THAT SE
ALSO MENTITIED HERE ISISHAT
SHOULD WE BE DOING WITH
UTEROTONONS, SH AS A SMALL
ESTION IN COMPARISON T TA LOTOTT
OF THESE BIGGER P P PRERE
QUQUTIONS THAT YOU'VETI BEEN
ANSWERING, BUT SHOULD WE B
SOME PEOPLEAY ABSOLOLELY
NEVER, Y Y'RE G GNG TO MAKE YOUR
TIENT HEMORRHAGE, A A WE TALK
TO CENTERSRSHAT DO IT ON EVERY
SINGLE PATATNTNT
NOTT THAHA HARD OFF A QUESTION O
ANSWER BUT SOMETETET FOROR US TO
WHEN S SULD WE BEE USING UTERINE
CONSNSVATION, ARE WERULY GOING
ARE THE ANENEHESISIOGISTS' ROLEH
IN THAT.
OBVIVISLY THENESTHESIA TEAMAMT
THE HEAD OF THEHE BED IS THINKIG
ABOUOUIN MUCHHREATER DETAIL
THAN WE OFTEN ARE WHEN WE'RERE
CONCENTRATING ON SURGEGE..
THESE ARE THEHINGNG THEY'RE
TRAVAVAVS ACCESES HAVING AR RDY.
RAPID INFUSER,, HAVING A --- LI,
AND IMPORTANT TO T TM, WHERE AND
WHEN WE'REREOING TO CONVERT TOGT
USING IT FROM THE BEGINNINI.
COMMUNICICION WITH THE SURURURS
IS REALLLL ESSENENAL HERE.
THEYEYEED TO KNOW WHATE'RE
THINKING AND WHAT WE'RE SEEING
AND HOWE COMMUNICATETE THE BLOOD
LOSS THAT W WRE SEEING, WHICH
CANNHANGE QUICKLY.
OTHER PEOEOE H HE DESCRIBED T T
US INHE.R. FOROR HOW WE
INTERPRET T MORRHAGE.
THERE'S RATE OF BLOODOD LOSS.
WE CAN COMMUNICATE OH, THE
PATIENT IS BLEEDING,G, BUT I IS
BIBIBIFFERENCE WHETHER -- PER
HOUR OR LITER OF BLOLO IN AEW
MINUNUS S OBVIOUSLY REALLY
CRITICAL COMMUNICATION THAT'S
GOING TO CHANGE THEHA ANESTHESIA
TEAMAM APPROACH.
WE -- P PTING A A TOURNIQUET,
THINKING ABOBO THIHIHI THATT CAN
STOP B BEDING Q QCKLY IFF NEEDE.
A BIG TOPIC THEHE DAYS, WHETHERR
WEWE PLACE A -- IN TERMS O WHO
GETS I I HOW WE USESE IT, CAN
USE IT, WHO HAS ITT AVAILABLE,
BUT JUST THINKING A STETETE BEYD
THAT, WHATT ABOUT JUST
COMPRESSSSG THE AORTA?
YOUUU DON'T NEED TO O VE THE S E
KIKI OECHNICALAL RESOURCES IN
YOURUR O OR.
WE WERE GIVINGG A T TK TOGOGHER
PRETTY STRTRKY HOW MANY PEOPLE
ININ THAT ROOM, OB,STHESIA, ASS
WESLL AS OB, HAD COMPRESSED AN
AOAOA DUDUNG A POSTPARTUTU
HEHERRHAHA, PROBABLY F F MOREE
UNITED STATES.R SEE IN THEHE
BUBUBUMPORORNTNT TO THINK ABOBOS
THE FAIRLY -- CAN MAKE A BIG
DIFFERENCE.
ANDD HERE'S A PAPER FROM ONE OF
OUR COLLEAGUESESOWN IN COLUMBIA,
JUST ABOUT -- JUST R RINDING
LE HOW TO D D THIS AND THAT
AS A FAIRLY LOW
TECH INTERVENTION THAHA CAN MAKE
A BIG DIFFERENCE.
OUSLY E ERY H HPITATA THAT IS
GOING TOGO GIVEE A A ATA CARE
SHOULD HAVE AASSISI
HAPPEN TO HAVE P PNT OF H HARE,
THE E HOLASTIC TESTING, I THINK
ANESTHESIAIA OR OBB ANESTHESIA,
WHETETR R IS I I GOING T TO MAKA
DIDIERERER IN T TMS OF PATIENT
CARE AND PATIENTRANSFUSIONON.
-EUALLY S SNT YEARS
COCOUCTING A RANDOMIZED TRIALO
TRY TOOO ANSWER THAT QUESTIOIOAD
LEARNED HOW HARD IT IS TO DO A
RANDOMIZED TRIAL TO ANSWER THIHI
QUESTIONON
WE ENROLLED 250 PATIENTS,ND
THAT WERE -- WHOHOHO ACTUALLY DD
RARAOMIZED THEM T EITHER MANAGAG
WE FOUOU USING THE ROTEM DIDN'T
KE A DIFFERENCE BUT WE ALSO
DIDN'T P PSCRIBE TOUR
PROVIDERS HOW WE SHOULD FRANCE
FUSE THE PATIENT, BUT W W W SAWI
THEEE RESESTSTS THEY WERE ALLLLD
TO TRANS TRANSFUSE THE PATIENTSS
TIMES WHERE THEY ITOLLOW A
PRPROCOL, THERE WAS A
DIFFERENCE.
IT WAS SECONDARY OUTUTME SO I IT
NEEDS A LITTLE MOROR
INVESTIGATION, BUT STILL A LOT
HOW T TO USE TOOLS LIKE THISO
MAMAMA TRANSFUFUON.
SO IN TERMS OF M MOR QUESTSTNS
WEHOULD BE THINKING ABOUT,
WHWH ARE THE PROCEDURES WE
SHOUOU BE DOING TO DECREASE
BLOOD LOSS, SHOULD WE BE USINGNG
CELL S SVAGE, HOW SHOULD WEEEE
USING C CL SALVAGE, CAN WE PICK
OUT WHICHHATIENTS AREOING TO
NENET FROMOMT.T.
AND THEN SHE ADDED IN HERE
TRANEXAMIC ACID, WE GIVE KNENE
JERKRKRK ANYBODY HAVAVG
SHOULD WE BE USING IT IN THESE
CASES?
DOCA IT MAKE S SSE TO GIVEN
EASY MEDICAL INTERVENTION TO
SOMEMEDY WITH MASSIVE SURGIGIL
BLOADING?
PRPRABLY LOW RISK B B THE
QUESTION STILL ISN'T A AWEWED.
EVERYBYBY HERE T T T HAS AN,
ACCRETA CENTER I'M SURUR HAS A
MULTIDISCIPLININY TEAM AND A LOT
OFROTOCOLS IN PLACE WHICHCHCH IS
GREAEA FOR SUSPECTED CASES.
THE CASES THAT ARE NOT P PKEDH
UP, THE PATATNTS WHOHO B BE ARET
SEEN B B ULTRASOUND OR I IGINGNR
WHO AREN'T PICICD OUT EVEN BY
RISK FACTORS BY THEIR COMMUNITY
DESCRIBE T T DIFFERENCE.ERE T
THIS ISS YOUR ANTICICATED ACCREA
RERERRED INTO THE CENTER, THIS
IS YOUR UNSCHEDULUL A ARETATA AD
THIS IS HOW IT FEELSLS DURINGG H
OF T TSE CASES.
WHICH IS WHY FOR PATIENTS WHO
HAVE AND STUTUESESAVE SHOWN
PATITITS THAT DON'T HAVE A
PRPRIA SEEM TO HAVE LESS --
HESISITE TO USE THE WORD
INVAVAVE BUS LESS VASCULAR, LESS
MORBRBCCRETATA BUTAVE A LOT
OF BLEEDININININHE O.R..ROBABLY
BEFOREHAND ANDHEIR SURGICAL
TEAM ISN'T PREPARED.
SO SHE WENT OVER HERE, THINK WE
KNOW ABOBO HAVING A C CTER OF
ITAL COMPONENTS OF YOURAT ARE TE
ACCRETA CENTER,R, NICE R REARCH
SHOWNN IMPLEMENTING AN ACCRETA
CENTER AND HAVING STANDARDIZED
CARE IS GOING T T DECREASE
MORBIDITY.Y.
ANANTHEN T TS IDEA THAT, AGAGA,
NOT SO MUCH TO THOSE OF US S O
ARE RUNUNNGCCCCTATA CENTERSRS BT
TO PEOEOE IN OUR GENERER
COMMUNITY, W W W THEY SHOULD BE
DOINGGGN THEHEPEPE UP A CASAS
AND THEY SEE SOMETHIHIHAT
LOOKS BAD A A HOPEFULUL
SOMETHINGGIKE THIS ISISETTING
PICKCK UP AHEAD OF TIME BUT
THEY'RE NOT ALWAYS.
ANDD THAT'S THE THING WE TEACH
OUR RESIDENEN, IS HOW DO YOU
THINK ABOUTHIS IF YOU'RE IN
IT OKAY TOLOSE THE P PIENTHWH IS
BACK UP?
HOW DODO YOU T TNSFER?
THIS I IA THAT EVEN IF YOU'REE
NOT AN ACCRETA C CTER YOUOU NEED
TO HAVE A PROTOCOL OF WHAT
RE GOING TO DO I IN PATIENTNTNT
LIKE THIS.
HOWO M MAGE UNANTICIPATEDKLIST N
ACCRETET.
IT GOT O O THERE TOHE
Ms -- TEMPORARY OBSTETRICIAN
O MIMIT RUN INTOO T TS
SITUATION, PROBABLY C CAVE A
MUCH BIGGER -- IMPORTANT T TNGS
HAVEVE P P PCOLS FOR ALL CENTERE
EMERGENCIES AND WE DON'T EVEN
SAY EMERGENCY, W W CALL IT
VARIANCE.
EVERY TIME SOMETHING I NOT
WITHIN COMPLETELY N NMAL ON OUR
UNIT, THERE I IS AN ACTIVATIOIO
SYSTEM AND IT RAMAM UP.
SO WE STATA ATT LEVEL ONE WHEN
THE BLOOD PRESSUSU IS HIGH, ,
WHEN THERE'S BLEEDINGG THAT'S
MORE THAN EXPECTED, AND GET INTO
A STSTE THREE WHERE WE'RE
CALLING IN EXTRA SURGEONS.
BUT THIS IDEA OF CARE MODELEL
THAT ARE TAILORED T T YOUR
NTER, , YOUR RESOURCES, TO
THE TYPES OFF PATIENTS THAHAHAOU
SEE, AND KNONONG WHAT THOSE
RESOURCESSRE AND WHO W W YOU CAN
CALL.
THE HEMORRHAGE CART IS ALL
HOSPITALSS THAT DO -- OBSTETRICS
SHSHLD H HE.
EASY TOO PUT ATOCOL ON PAPER,
TEACHING EVERYBODY IN YOUR
COMMUNITY TO IDENTNTY AND REFER
WHOLE DIFFERENT BALL G GE A A AE
CONTINUOUSLY WORK O O THAT.
AND THEN SIMULATION.
THE ANESTHESIA TEAMS DOO A
WONDERFUL JOB.
THEY RU RUN THE SIMULATION IN OR
HOSPITALAL
SHE'S SHOWING EXAMPLES HERE,
RESOURCES TOGEGEERERER H HPNY
CRETA SINCE IT'S A HIGH IMPACAC
BUT RELATIVEVEVEOWOW FREREENCY
EVEVT.
AND I R R RY APPRECIATE THATT SE
EMPHASIZED HERE, YOU KNOW, IT'S
NOT A SPECICIC ANESTHESIA
QUESTITI BUT UNDERSTSTDING HOW
IDENTIFY, REFER, M MAGE FROM
WHATEVER SETTINGNG PERSONNS IN,
AND THAT'S GOING TO IMPACT THE
OBSTETRICIANS AS WELL AS THE
ANESESESLOLOSTS, HAVINGG
BACKUP,,THER ANESTHESIA
PROVIDERS WHO ARE IN SMALLERER
CECEERS WITH THE SURPRISE
ACCRETA,A, JUSUS AS IMPORTANT TO
HAVE THOSE PROTOCOLS I PLACE
AND PROVIDE SUPPORT.
THEN IMPORTANTLY, SHEHE HADAD TE
WHOLE SECTION HERE E OUT THE
CERTAINLY -- HAS EVOLVED OVER
THE YEARS..
'S A BIGIG TEAM, AND L LTLE
CONTROVEVEIAL 1 1YEARS AGO,
MAYBE NOT AT C CTROVERSIAL NOW
IS DO YOU DO NEWERER AXIXIXI
ANESTHESIA AT ALL, AND I WANT TO
SAYAYBE 10 OR 15 YEARSGO,
NEURAXIAL L ESTHESIA FOR SOMEONE
WITH PAS O OMORE SEVERER P P.
IN GENERAL ANESTHESIA, OBVIOUSLY
E AIRWAY ISS SECURUR A ATHE
YOUVOIDHEYPOTOTSION THAT
COMESITH SYMPATHECTOMY.
IF YOU'R'RRURUING IT WITHHH AN
IDURAL, THE PATATNTNTS GOING
TO HAVE HYPERTENSION.
OFESUSCITATION, AND AVOID VALIUM
MANAGEMEME OF AN EPIDURAL
CATHETER INN A PATIENT WHOAY BE
SIGNIFICICTLY COAGULOLOTHIC.
EVEVYBODY HAS PATIENTS -- WEE
OWOW ACCRETA PATIENTS WANT TO BE
AWAY.
PATITITS WHO REMEMN AWAKE
ROROH T TIR CASE MAYE
QUICKER TO BONONWITH THEIR
BABIBI.
- -WHOSE BABIES ACTUAUAY STAYY
IN THE IR F F THE ENTIRE JOURNEY
OF THE PAS CASE AND THERE'S MORE
BONDININGOGOG ON WITH T T
PARENTS AT THAT TIME.
YOU AVOID A VERY IMPORTANT TOPIC
FAILEDED INTUBATIONN A A
ASPIRATION.
WHATAT DOES DO TOO AIENT BEINGNG
AWAKE FOR AURGERYRYIKE THAT
THAT CAN BEHAT CRITICAL.L.L.
AND THENVOIDINGGG HER LONG
POSTPARTUM VENTILATION AND
IS I I I SUMMARYHAT S OUR OB
ABOUT USE OF GENERAL VERSUSUTUE
NEURAXIAL ANESTHESIA.
IF YOUOUOOK HE IT PUBLICATION
LOOK ATT THE PUBLICATIONTES, T .
PRIMARY INTERACTION ANESTHESIA
IS NOT I A M MAJORITITOFOFHE CA.
AT OUR CENTER, 73% WHICH WAS AT
THE HIGH END.
'S NOW DOWN TOUT --- SHEHE
MAY KNOW BETTER -- 1 1R L L L
SO JUST TOO DETAIL HERE, W
PUBLISHED THISTUTU ABOUTSING
NEWER AXIAL ANESTHESIA.
IS AN IMPORTANTNT RESEARCH POIN,
PATATATSS WITH SUSPEPEED PASAS
FROM 1997 TO 2015.
I REALLY WANT TO EMPHASISI THAHA
BECAUSE WHEN W WRE DOINGNG
REREARCH ON P PNNING AND
EXECUTION OF C CES, WE HAVE TO
TALKBOUT S SPECTED PAS, NOT
NFIRMEDDAS.
DO NOT H HE A PATATLOGY
REPORT WHEN W WRE PLANNING OUR
PATIENT'S SURGERY.
IT'S IMPMPTANT TO T TNKNK ABOUT,
BECAUSE H HING S SE NON-ACCRETAS
IN THERE IS GOING TO MAKE
GOING G NTNTDUCE NEW MORBIBITYS
TORAISISS.
IF P PIENTS ARE SUSPECTED OF PAS
AND IT'S A FALSE POSOSIVE
REEN, THEY'R GOING TOAVEE A
LATETETETERM DELIVERY
POTENTIAIAY AND COMPLETELY
DIFFERERT ORIENTATION OF THEIR
ININSION.
THEY MAY HAVE A DIFFERENT PERSON
ING THEHEHE SURGERYRY
RHAPS THERE'S SOME WHOHO HAVE A
HYSTERERTOMY BASED ONNNUSPICION
D DON'T HAVAV P P CONFIRMRM ON
THEIR P P PLOGY.
SOSOEALLY IMPORTATATAHEN WE
THINK ABOUT RESEARCH
SPECIFICALLY ON SURGIGIL
TECHNIQUE.
BUT IT WAS ALL PATIENTSSHO WERE
THRESHOLDS FOR SUSPICION ANDLOW
LOOKED ATTHE MODE O ANESTHESIA
MORBIDITY BETWEEN STRAIGHT
NENEAXIAL ORRR PRIMARY AND GENEL
THESIA.
THIS WAS OUR F FW CHART.
95% OF THE PATIENTNT HAD PRIMARY
NEURAXIAL ANESTHESIAIA
RATE HYSYSRECTOMOM WAS
RELALAVELY LOW A AT 62% BOTOT2%
BECAUSE WE INCLUDEDDLL
SUSPICION EVEN MILD SUSPICION
GOING BACK TO THE EARAR 2000s.
D T T T 12% HAVEE ANESTHESIA.
WHWH IT WAS H HTERECTOMY, IT WAS
21%.
AGAIN, THAT'S P PBABLYY LOWER
NOW.
AND THROUGHOUTMERGENEN CASES,
THESE WERE ALL PATIENTS WHO W WE
SPECTED AND HAD A NONONMERGENT
SO THE BOTTOM LINEAS, WE
COULDN'T CARE MORBIDITY OUTCOMES
BETWEEN THE GENERAL AND
NEURAXIAL B BAUSESE THE PATIENTS
WERERE TOO DISSIMILAR TO DO THA,
AND BEBEUSE THE RATE OF GENERAL
ANESTHESIA WASOO LOW, B B B IT
WAS A FAIRLY NOVEL, BUT IT
SHOWED WE COULD PUT PATIENTNT
THROUGH AN E EIRE PRORODURE
DER NEURAXIXI ANENEHEHEHE AND
THEYEY COULD GET THROUGH SAFELY.
I W WL SAY J JT THAT STATEMENT
ALONE GENERATED A A A LOT OF HAE
MAIL BACKK IN 2015.
LOTORE NOW.ELE ARE ACCEPTEDT A
ALTHOUGH I'D SAY PROBABLYY D
CENTERERCONVERT TO GENERAL
ANESTHESIA AT THE TIMEF
HYSTERECTOMY, AND I T TNK IT'S
ALSO REALLY IMPORTANTNT TO
EMPHPHIZE THAT WE HADADF THE
CONVERSIONS THREE PATATNTS WITIT
A DIFFICULT AIRWAY.
TOTOMPHASIZE.LLY IMPORTANT POINT
WE'RE WORKING AT A CENTER WHERE
WE HAVE BEEN MANY
ANESTHESIOLOGISTS IN THE ROOM
WHEN THERE'S AN EMERGENCYCYN
IF Y Y HAVE ONE OR TWO AND A
PATIENT HAS A UNSECURED AIRWAY
ANDD MASSIVE HEMORRHAGAG WITH AN
ACCRETA, THEN IT NOT SAFE FOR
THEM TO HAVE AN UNSECURED
AIRWAY, SOHEY MAY N ND G GERERER
ANESTHTHIA UP FRONT.
I WILL MOVE ON QUIUILY,
RUNNING OUT OF TIME.
ANOTHER VERY IMPORTANT POINT,
PAPAENT EXPERIENCE, WHICH I
NTIONED, WE CAN D W T TSESE
PROCEDURES WITH THE PATIENT
DER N NRAXIAL ANESTSTSIA.
WERYO HELP PATIENTS
UNUNRSTAND THATHEY W WL HAVAV
CONTROL OVER THEIREVEV OF
AWARENESS, W WN PATIENTS HEAR,R,
THEY'REOT UNDERGOING GENERAL
ANESTHESIA.
SOME ARE AFRAIDDF THATT, OF
BEING PUT TO SLEEP IN A A
POPONTIAL LIFEEATENING
SITUATION.
OTHERS ARE VERER CONCERNED ABOUT
BEING AWAKE IN A PROCECERE
AT'S HIGH ACUTITI.
MANY OF OUR P PIENTSS D DO UNDEO
SOSO LEVEL OF SEDEDEDN DURING
THEURURUR.
TO THE POINT W WE'RE PROBABLY OL
DOING SOMOM GENERAL ANESTHESISI
WITH A NATURAL AIRWAY.
THERE'S AITTLE BIT OF RESEARCH
OUT THEREBOUT WHAT ARE T T
PATIENTSN IMAWL TAIAIVEE, A A
PROJECTSTSAVE D DCRIBIBEEING
VERY MORBID S SUATIONS A AUND
SEEIEI BLOOD HANGING, REALIZING
SOSO THINK THERE'S A LOTOT OFY
SEARCHCHPCOMING AND IN
PROGRESS JUSUS T T HELEL UNDERSD
WHAT'S THE R RHTHING TO DO FOROR
THESE PATIENTS FROM THAT
PERSPECTIVE.
HIHILIGHTED MANY POINTS HERE
THAT AREUST A FEW OF
ANESTHESIA-RELELED T T TS THAT
NEEDED RESEARCH.
IIHINK W WE HAVE A REALLY
NDERERL GROUPPP OF OBSTETRIC
ANESTHESIOIOIOSTS WHO ARE VERY
INTERESTED INN THIS AND SPEND A
VERY MOTIVATED TO DO RESEARCHHDE
AND I'M HAPPY THATE'RE KEEPIPI
THEM IN MIND.
SO SHE IS ONLINE, SHE WILL BE
ASKUEUEIONSNS AND I'LLL ANSWER -
SHE CANAN ANSWER T TOUGH ME, BUT
THANK YOUOUOR YOUR ATTTTTIONND
R LETTING ME SPEPE.
ENDOVASCULAR INTERVENTIONNN TO
PREVENT OR TRERE HEMORORAGE.
>> GOODD MORNINGNG
IT'S A DELIGHT T T T B HERE.
I REALLYPPRECIATE THE FACTT
THAT THIS I ISOINGN.
AND PART OF THE REASON IS
BECAUSE I'M O O, A A IAD
FORGOTTEN HOW ACTUALLY OLD I
S.
I WENT BACKOOKING AT MYY FIRST
SLIDID ON THIS, AND REALILID
THAT WEE DEVELOPED A
MULTIDIDCIPLINARARPROTOCOLNNN
1919, SO 3 3YEARS AGOGOHEHE WE
HAD D D ENTS THAT HAD SUSUSCIOUS
ULTRASOUOUNDININNGS, AN MRI AND
PLACEMENT OF BILATERAL ILIACC
ARTERY BALLOON CATATTERS, WHIHI
STARTING TO BE DONE AT VARIOUS
CENTERS BOTH IN THE U.S. AND
INTERNATIONANAY.
SO WE LOOKED AT THIS BACKHEN
AND ACTUALLY IN 2001, WEUT
TOTOTHER THIS DATA.
THISIS WAS JUST THE ULTRASOUNDS,
AND T T MRIs WHICH WERE VERY
HELPFUL INERMS OF STAGING THE
PATIENTS, NOT NECESSARILY MAKING
THE DIAGNOSIS.
CATHETERS INHE ANGIOLAB AND WENN
WOULD INFLATE THEALLOONS, MAKE
SURE THAT THEY WOULD STOP THE
BLOOD FLOW ANDNDOU'L'L NOTICIC
THAT THEY'RE IN THE INTERNAL
ILIACC ARTERERS, NOT T T UTERINE
TERIES, NOT THE ANTERIOR
DIVISION, BUT THE INTERNAL I IAC
ARTERIES.
WE LOOKED AT OURATIENTNTND WE
FOUND T TT WE HAD 23 INHE
CONTROLROUP THAT DIDN'T HAVE
BALLOONS AND 17 INHEALLOON
GROUP.
INTERESTINGLY ENOUGUG AND
IMPORTANT,T,HIS IS W WRE I THINK
WE REALLYAVE TO LOOK HARD TOO
FIGURE T TS DATA O O O IS WE HAD
22% PERCRETAS I ITHEE CONTROL
GROUP 94% PERCRCRAS IN THE
BALLOON CATHETER GROUP.
D THIS IS ALL M- THESE WER
ALAL PATATNTS THAT HAD
HYHYERECECMIES, SO WE HAD
PATHOLOGIC CONFIRMRMION O O
WHETHER OR NOT THERE W W A
PERCRETA.
13 OF THOSE PATIENTS IN THE
CONTROL GROUP HAD COMPLEXEX
PERCRETAS, IN OTHER WORDS, THTHH
IN T T PELVIHE SIDE WALLS, THEY
REREN THE C CVIX,ND THIS WAS
OBVIVISLY ANMPMPTANT THING..
E UNFORTUNATE THIHI WAS THAT
WE DIDN'N' REAEAY FIND T TT WE
IMPROVED THE BLOOD LOSS, AND
ALTHOUGH IN FAIRNESS WE H H H A
MUCH MOROR DIFFICUCU GROUP IN TE
BALLLLN GROUP,ND WE ALSO
LEARNENESOMETHING WHICIC W W NOT
TOTO INFLATEHE BALLOONS
IMMEDIATELEL W WCHCHCHS WHATT WW
WERE DOING, INSTETE TO WAIT
UNTIL THERE WAS EVIDENCE OF
BLEEDING AND THENNFLALA, WIT
THE IDEAHAT WE WOULDLD DECREASE
COLLATERERER FLOW INTO THE
SURGICAL BED.
WAS THAT WE HAD MANY FEWERND
SURGICALAL COMPLPLATIONS IN THE
BALLOON GROUP, SO THIS WAS AT
LEAST AN IMPMPTANT THING AND
MADE US CONTINUEE THIS A A AACH.
AS I SAID -- BALLOONS U U LATE
WAS A VERY IMPORTATA PART OF
THIS.
NOWHE IMPORORNT THINGNG I TAKE
AWAY FROM THIHI WHOLE MEETING
THAT WE'RE HAVING IS REALLY
KING THE CORRECTIAIAOSIS.
D IT'S NOT PROBABLY THATTT ALL
INVAVAVE PL PLACENTASEQUIRE
TERVENENONAL PROCEDURES, B B
THE E RE I IASIVE THE PLACENTA,
THE E RERE AGGRESSIVE THE APPROC
NEEDS TO BE.
C CRSE A A WE'E'ALKEDBOUT,
THTHE PATIENTS REALLY SHOULD BE
TRIAGED D FACACITIESSHERE
RI CARE T TM AVAILABLE.INIAN
SO IN ACCRETAS, IT MAY BE THATT
THERE'S NOT A NEED FOR
ININRVENTIONAL RADIOLOGY.
WE DON'T NEED TO PUT IN BALLOONS
IN THOHO PATIEIESS OR DO ANYTHIG
ELSE WITH THEM.
UNLESSSS THERE'S A PLAN FOR
CONSERVATIVE MANAGEMENT,T,N
WHICH CASE YOU'RE GOING TO NEED
AN INTERVENTIONALADIOIOGIST
PROBABAB TO D AN EMBOLLIZATION
AT SOME P P P.
IN THE PERCRETAS, THERE'S
VARIETYF DIFFEFENT
INTERVENTIONAL THINGS THAT CAN
BE DONE,NCLUDING THE BALLOON
CATHETERS, YOU CAN DO
EMBOBOIZATIONLOWING THEHE
DELIVERYRY Y Y CAN D POST
SURGICAL EMBOLIZATION, OR YOU
CAN DO POSOS SURGERY WITH
CONSERVATIVE MANAGEMENTTT AND TN
SO W W LOOKED AT OUR D DA LATER
IN 2017 AND WE DID FIND IN
PATIENTS WHERE WE PLALALA BALN
BALLOONS, THAT T FACT T ERE WAS
S DECREASES I INN PLATELETS ANDD
ALAL KINDS O O TRANSFUSISI
REQUIREMENTSTSHAHA THOSE PATIENS
NEEDED.
SO W W FELTT THAT THERE WAS
PROBABLY A GOOD REASONN W WWERE
DOING THESESESVEN THOUGH IT
WASNSN PERFECT.
THERE'S AN I IERESESNG STUDY
THAT CAMAMAM OUTROM THE - - SYSM
WHERE THEY TOOK ALLHOSE
CENTERS THAT ARE DOING PLACENTAA
OBSTETRICS AND LOOKING AT THE
PLACENTA PATIENTS, AND FOUND
THAT THERE'S CENTERSHAT JUST
WENT DIRECT TO CESAREAN
HYSTERECTOMY.
THERERWERERERE PATATNTS THAT DID
SURGRGAL LIGATION AND THERERE WR
WHERE T T T D D BALLOONONPLALAS
OCCLUSION.
E INTERESTING THING ABOUTUTHIS
TO ME, AND THIS AGAIN G GS BACK
TO THE IMPORTANCE OF D YOU N ND
WITH JUST AN ACCRETETATIENEN
SO YOU CAN SEE THAT IN THE
DIRECT HYSTERECTOMY,Y,HOSE
PATIENTS, 40% OFF THEMAD AN
ACCRETA, ONLY0% OR 21% HADAD
PERCRETA..
AND IN THE SURURCAL LIGATIOIOIO
THTHE WASASAS HIGHEHE PERERNTAGF
PAPAENTS WITHF A PERCRCRA AND
PATIENTS HAD HER KREEAS.HOSE
SO IF YOU LOOK AT THE ESTIMATED
OOD LOSOSITH THE SURGICAL
LIGATION IT A AOSOS4 LITERS,
BALLOOT OCCLULUON, 1800, AND SO
HYSTERECTOMY, ABOUT 2600.
CREASE IN THE TOTALERTAINLY A
TRANANUSION REQUIREMENTS IF YOU
USE THE BALLOLOLO THE OPERATITI
ROOM TIME WAS LESS, AND T TSESE
TIENTS HAD BALLOONON OCCLUSION,,
DID NOT REQUIRECUCU ADMISSION.
AND ALSO THE ADVERER E ENTS WERE
SIGNIFICANANY LOWER I INNHAT
GROUP.
ANDSE ARE SOME OF THE
IMPOPOANT BECAUSE THAT'S ONEF AE
THE T T TSHAT THE PATIENT IS
GOING TOTOAVE T LIVE WITH
SOMETIMES, BLADDER INJURY,Y, AND
AT W W ONES WHERE THEY WEREN'T
PLANNING ONNININ OUT P PT OF
THELADDDD, WHIHI DOES
VIOUOUY OCCCC WITH THE
ACENTATA PERCRCRAS...
BUT PROBLEM IS, W WH THE
BALLOON O OLUSION, THERE ARE
JUST E ERMOUS NUMBER OFFEPORTSTS
ON THIS.
MOSTSTF T TM RETROSPECTIVE.
MOSTF THEMM USING INTERNAL
IAC BALLOON CATHETERS BUTOME
OFOFHEM T TY'VEUT IN THE
UTERINE ARTERY, SOMETIMES
THEYEYEY IN THENTERIOR
DIVISION, S,ET,ET THE THE IN
E INTERNTLNT ILIAC, SOMETIMES
'REE USINGSI OCCLUSIONALLOONLOON
H ARE SOFTALLOONS,
S THEY'REY UNG
ANGIOPLASTY BAY OONS WHICHHI RM
AND THENHEHERE AHE PATIEATS
GETTINGG AORTIC BALLOON CATHE
THETTHS.
BENEFIT POT NTIALLY WITH THEL
AORTIC BALLOON CATHETERS,
CA
E AS I'M GNG TO SHOW
YOU, THEHE BIG PROBLEM
RTICULARLY W W THE PERCRETAS
IS THE FACT THAT YOU HAVE A N
MASSMASSUNT OF COLLATERALRALOWW
THAT'S GOING TO EVERY ARYAF
PLACENTA.
THIS IS WSRESEOPLEEALLY GET
INTO TRO TLE WITH THE BLEEDING
IN THE T PERCRETA PATIENTS.
SO THERE WAS A NICE STUDY THATT
YOU KNOW, THE STUDIES LOOKING AT
PUTTINGN AORTIC BALLOON
S, AND AHE QSTIOST IST
WHERE DO YOU PUT PHEM?
SO THEY ACTUALLY SRTED IN
THEIR INR ITUTIONIONTING THEM
JUST B B THE REN R ARTERIEER
HERE.
YOU CAN GET COLLATERALS FROMRO E
SUPESUPE MESENTERICRIRTERY THAT
ME AROUNDUNNTO THE INF IIOR
MESENTERIC ARTERYER AND THEN DOD
THESE COLLATERALS CANANEVELOP
REALLY QUITE QUICKLY.
THEYHANGEDNG-NG THEY FND
THOU THEIR SURGEONGEON WERE SAYG
THAT THEY WERE STILL HAVING A
LOT LO TROUBRO WITH BLEEDING, SO
THEYEY CHANGED TIR TEC TIQUEIQ A
APUT THE BALLOON DOWNOW JUST
ABOVE OVE AOR AC BIFURCATION AND
THAT IMPROVED THEIR OUTCOMES.
META-ANALYSIS OF A NUMBER OFF
PATIENTS WITH AORTIC BALLBAN
CATHCATHETERS, AND AGAIN, YOU YY
INTOTO REA R PROBLEM LOOKING AT
THIS INNERMS OF OAT WERE THEY
TRYING TO DO..
SO MOST OFHESE WERE COMING OUT
OF CHINA, AND THEY WEY REMOVING
THETH PLACENTA AND SAID THAT THS
WAS FOR PLACENTANTCCRETARE
SO THIS MAY BE A WHOLE DIFFERENT
GROUP OF PATIENTSHAN THEHE
PATIENTS WTSRE DEALINGITH
MOSTLY IN IR WHICH WE THE PRO
KREE TA PIENTS.
PERCRETA PATIENTS.
THE FIRST GROUPROSROHE ONE O WIH
THE HIGH BALLOONLO THE SECOND
WAS THE LOWER BAL BONS.
FAIRLY HIGH PERCENTAGNT OFA
RETASS AND INC ITAS IN BOTH
OFOF THOSE,ARTICULA TY IN THE
SECOND ONE, AND THEY FOUND TT
THEIR BODOD LOSSOSS WAS W ABO A-
ALMOST A 50% DECREASE IN TERMS
OF ESTIMATED BLOOD LOS L
DEPENDING ON WRE THEY PUT PUTHE
BALLOON.
SO CLEARLY,LYHIS IS REALLY GOING
TO BE IMPORTANT IN TERMS OF I I
YOU'YO GOINGOO USE A BALLOON
CATHETER, WHERE YOU'RE GOING TO
PUIT.
FUSIONON IN 22% AND 15% OF THEIH
PATIENTS.
SO MY BOTTBO LINE ON THIS ISOW
CRITCRAL THE T COLLATERAL PATHWS
ARE FOR PATIENTIEWITHTH PERCRERS
OR IRETAS.
TNK THIS IS PROBABLY NOT
GOING T BE ASASELEVANEV FOR
CRETA.TS WHO SIMPLY HAD AN
WHAT YOUANT TTDO IS YOU WANT
TO TREATAT ALL OF THOSESE
ATERALS, SO HERE IS A
PATIENT, AT, I'M GOINGO TALKK
ABOUT WHAT WE'VE BEEN DOING WITH
THIS, IS I HERE'S A PATIENT
AFTER DELIVERY,ER BUT BEFORE THE
HYSTERECTOMY, AND YOU Y C SEE S
HAVE BEEN RECRUITRU,, AND SONEHT
HE T TS T I TELL MYELLOWS
HYPEHYASCULAR TUMOR.IKE A
ITIT WILL SUCKN BOD FLOW FROM
ANYWHERE THAT IT CAN GET IT.
AND IN THE T PEL PS, THERE'S A T
OF PLACES THAT IT CAN GET BLOODO
FLOW.
SO TSOS ISHA IT LOO L LIKEE
AFTER YOU DO A SEL STIVE
EMBOLIZATIONTION
THIS, AGAINGA ISS BORE THE
HYSTERECTOMY.
AND NOW YOU CAN SEE S BASICALLYL
ALLAL OF THA T BLOOD FLOW HAS N
BEEN STO SED TO THE T UTERUSS.
SO WE KNOW A LOT ABOUT DOI D
POSTPARTUST -- ISSS BECAUSESEFFE
APNE, THAT'S A WHOLE DIFFEIFNTIF
BALL GAMEE THAN SON BODY WHO'S
GOTGONVASIVEIV PLACENTAACCRETA.
IT REQ RRES FLUOROSCOPY, IT
TAKETA SOMEE TIME IM DO BUT
ACTUALLY IT GIVES US A GD --
VES US A GOOD OUTCOME FOR
ESE PATIENTS.
AY.
SO THEREAS A PAPER THA T CAME
OUT A A UCSF, 2019, I THINKHITT
WAS, WHE W THEYY TKKATIEATS
O HAD AN INCRETA, AND AFTER
THEEE DELIVERY,HEY TNSPORTED
THE PAE ENT EN THE IR SUITE AND
EMBOLIZED THEM.EM
THEY COMPARED THAT TO PATIENTS
WHO THEYTHIDN'T EMB EIZE, AND
IMPORTANTLANTLN THIS, THEY ONLY
EMBOLIZED THE UTERINERTERIES.IE
THEYTHIDN'T EMBOLMBE ANYTHING
ELSE, JUST THE UTERINERTERIES.
BUT THEY DID SHOW THAT TY HAD H
DECREASE IN THE T BLOOD LOSS,
THEY HAD A DEC DASEEN THEIR
TRANSFUSSFN REN IREMENTS, AND A
EYEY DIDN'ID HAVE ANY ADVERDV
CT I THOSE SMALL NUMBER OF
ENTSTS
E PRE LEMM IS YOU HAVE TO
TRANSPORT SOMEBODY FYM THE
OPERATING ROOM T T IRRNDR OF
COURSE YOU KNOW THEY CAN'T B B B
BLEEDING TOO MOOH OR YOU DON'T
WANT TO TRA TPORTRT THEM.
ACTUALLY WHENHEHEY COMPAREDRE JT
THE INCRETAS, BECAUSEAUAU THEY'D
PERCRETAS AND -- ACCRETA, SRY,
IN THAT CON COLOL GRO G,HEY
STILL FOUND THAT THEY HAD HAD
DECREASED ADVEADE EVENTS,NT TY
D DREASEDLOODLO LOSS, AND
THEY HADECREASE IN THEHE NEED
FORFO TRANSFUSIFUS.S.
SO WE HAD THE UNFORTUORTETE
SITUATION WHERE WE HAD TWO
TIENTS WITHIN HI REALLY SHORT
PERIODRIF TIME F FONE ANOTHNO
HAD BAL BON CATHETERS PLACEDD
AND WHO DIED OFFEMORRHAGRH
AND ITIT WASN'T TOT TLY CLE C, E
PREGNANCY THAT WASN'T PICKED UP
EARLYRLN.
T WE'RE'ROT REALLY SURE WHAT
PPENED WITH THETHTHER ONE.
BUT THE THING WAS IS THATHA WE T
DOWN AS A GROUP AND SAID THIS IS
ACCEPTABLE, WE CANNOT HAV HAV
THESE PATIENTS DYI D D ON US.
AND SO WHAT WE DECIDED THAT WE
WOULDUL DO, ONE OF THE P PNTS
PARTPAULARLY WAS A PATIENT THAT
I GOT -- IENT UP TO THE
OPERATING ROOM TM SEE WHA WHA WS
GOING ON, AND AHEY COULDN'TT
ROL HER BLOODLOOD LS AND I
ID
GET HER DOWNO IR A
WE'LL EMBOLIZEIZ HER.
THEY COULDN'T KEEP HER STABLE
ENOUGH TO DO THAT,HA ANDHE DIED
SO WE SAID AFD R THAT, WE'RE NOT
ING IN DO THISTHIS ANYMORE.
WE'RE'R GOING TO HAVEAV FLUOROSY
ANDAN EMBOLIZATION AVAILABLE IN
SO WE BAE CALLY GOT IN A FIGHTHT
OUR CARDIOLOGISOG AND AOLAID, WE
ED TO HAVE A HRID ROOM
LABLEE TO US. U
AND THEY SAID OH, OH, WEL W WELE
I SAID,AI LOOK,K, YOU ARE TREATG
EAR-OLD PATIENTS WHO HAVE AE
PATIENTSHAT NEEDD THE LEADATREGG
REPLACEMENT, WHICH IS ELECTIVE,
ARE YOUNG, WHOAVE FAM FAMS, WHO
AND WHO HAVE HUSBANDS, AND
YOU'RE GOING TO LEA L THEM
WITHOUT A MOTHER AND A Y A'RE'R
GOG TO LEAVE THEMITHOUT AUT
WIFE.
AND SD THEY FINALLY AGREED.EE
AY, SO WANT WE'VEVEVENDED UP
DOINWA ALL OF OUR PATIENTS
GET MRIs AHEAD OFF TIME, SO
THAT WE CAN C REALLYYY STAGE WHS
GOING ON AND WE KNOW THAT
THERE'S GOING TO BO PROBLEMBL.
AND THIS IS WHATHA WE STARTED
DOING, WAS WE WOULDOUO THE
AORTOGRAMRA IN THN OPERATING R,
IN T HYBRID ROOM AFT A THE T
DELIDERED THE BABY, AY, WHAT W W
VESSELS THAT NEEDED -- THAT WERE
SUPPLYINGIN THISHI PLACENTA,ND
SOMETIMES WE COULDN'TT EVEN
FIGURE OUT WHAT THE VES VLS
WERE, BUT B WE KNEW THA THAEYHAE
SUPPLYING THEHE PLA PNTA SO WE
BOLIZED THEM.
AND THIS WAS W OUR PROTOCOL.
THIS IS ONE ONHE GYNECOLOGOLTS
PUT TETHER THIS PASTIME
PROTOCOL, OLACENTA, ACCRETA,
SPECTRUM, TREATMENT,T,
INTEROPERATIVE, MULTIVESSEL,
LIZATION.
SO WE HAVE AVEE HIISTORICAL GROO
D THIS IS TS NEW GROUPRO
ID LOT OF MAKING SURE THAT
ANESANESANLOGISTGITO THE FROM TE
INTERVTETIONAL RADIOLOGIST T T
THE GYN ONCOLOGOLT, YOU KNOW,
NEONATAL, EVERYBODY WAS INV IVED
IN KNOWING ABOUT THESEATIENTSS
AHEAAHOFIME, ANDATIENT SAW
ALL OF THE T T PEOPLEOAHEADEAEA
TIMETIO KIND OF TELL THEM WHAT'S
GOING TO HAPPEN AND AND THEY'RE
GOING TO DOAND THENR SC SNNING,O
THIS WAS PRETTYY MUCH THE SAME.
WE DID GENERAL ANESTHESIA BUT
W WE'VE'VEEN DON G MUCH MORE
IN THE WAY OFF REGIONAL
ANESTHESIA, AND THE T GYN
THE BEGINNING AND WE DID THISHIS
INTEROPERATIVETIMBOLIZATION.
THEHE THI T I I THINK THAT'S
IMPORTANRT AND I'M SURE A LOT OF
AT IT ADDSDD TIME TO THE, IS
PROCEDURE.
SO AS OOSEDO THE BAE OOE ,
WHICH ICS NOT N A BIG DL, TL,K
ABOUTOU A HF ANN HOUR, AND THEN
EY WOULD GO U U A AET T
FOR THESE PATIENTS, WE DOO PUT N
SOME SHEATHS WHICH TAKES US
ABOUTT 10 MINUTES TO T PUT IN I
SHEATH, AND WE U ULY DO IT
ILE THE ANE AHESIOLSIOLTSOLRE
PUING ININHEIR LINES AND
EVERYTHING ELSE.E.
AND THEN THEY DO THE CESAREAN.
WEWE DO THEO EMBOLIZATIOAT
OCEDURE.
AND THEN THEY GO AHEAD AND DO
THE HYSTERECTOMY.
WHAT WE'VEE' FOUND IS BASICALICE
HAD IN THIS PARTICRTAR STUDYTU
THERE HADEE SOM SIN THE
ST
WE H BASICALLY VERYY FEW
ADVERSE RCTIONS, N N
POSTPOERATIVE BLEEDING AND NO N
DEATHS.
AS YOU COU C IMAGINE, THE
HEME.RMOHIMO ARE PRE PYY MYH THE
MOST OF THEM WER W SCHEDULEDWO
OU
20 20% 2 WEREE EMERGENT.
VERY FEWEW NUMBER BER ACCRETAS,
BECAUSE WE MAD M THE DIAGNOSIS
AHEAD EA TIME AND WE KNEW WHAT
WE WERE UP AGAINSTINN THAT CASE.
>> ONE MINUTE LEFT.
>> OKAY,Y,ERY GOOD.
SO THE FLUOROSCOOS TIME IS A
LITTLE BITIT HEAI HIG HR OBVIOU,
LONGER, BUT WE' W FOUNDOUHAT WE
WERE EMBOLIZING ALL KINDS OF
ARTERIES.
TH UTERINE, THE SUPERIOER
VESICULAR, OTHER ONES.
AND T T MOST IMPORTANT THI T IS
WEOUNDHAT WE WERE EMBOLIZING
THE ROUNDND LIGAMENT,T, AND THAS
THE THING THAT YOU TON'T'TET
YOU INN BALLOALS,S
YOU'RE NOT N GOING TO BLOCK THEE
ROUND LIGALINT.NT
AND THAT MAY BEE WHY THE AORTICI
ONES DO WEL W
SO HE'S WHAT THE ROUNDOU
ANDT'S SUPPLYIPL THE PLACENTA
ANDOHAT IS A REALEAOURCE OF
PROBLEMS FOR FS.
AND I WON'T GO THROUGH -- THISHI
IS BAS BALLY VERY CY C TO WHA W
W W---- I WAS TALKINGKI ABOUT
JUST ANOTHER STUDY,UT W W HAVE
ALL OF THESE THINGHI THIT WE C
THE MOST IMPORTANT TNGNG IN
MY MIN M IS THA T WE PLAN IT OUT
AND GETGEGE EVERYBODYNVOLVED SD
THAT WE MAK M IT A AAFE
EXPERIENCEENCE THESE PATIENTS.
THANK YKERY MUCH..
>> WE'RE GOING TNG MOVEOV TO OUR
PANEL DISCUSSION,N, ANDND DR. F,
DR. HERRERA, DR. ROBERTS, INN
PEON, DR. CR.USI.I.
>> GEORGEAADE.
THANTHYOTH VERY MUCH.
GREAT TALKS,KSE DON'T N'ALN' GET
TO S S THE T TALKS HERE THATT
OFTEN.
OW THE TIME WAS SHORT, BUT
WE U UTO DO A LOT OT THINGS
HAVE MY OWN OPINIONNIBOUTHEM,I
BUT, LIKE, CAN YOUALK ABOUT
CELL SAVER, HEMODELUSION, ALL
THESE THINGS WE USE UTO DO
BEFORE?
>> YOU'RE TALKING TO DR. FARBER,
I'LL SLLAK TO T THAT.
I THINK SOMEOMOM OF U U UO STILE
CELL SAVER.
QUITE FREQUENTLY WE DIDN'TDNALK
ABOUT OURE SO MUCHMU
IT DEPENDS.
IT DEP DDS O O HOWOW EASY IT IO
GETGE TO YOUR UNIT, DT,FERENT
UNITS HAVE PEO PE ON SITE, SOME
PEOPLE HAVE TO CALLAL THEM IN.
EN I WAS DOWNTOWN INN HOUSTON,
WE FOUND EITHER YOU NEEDEDD MUCC
MUCHMUORE OE YOU Y Y DIDN'T COLT
ENOUGH TGHOCTUALLY TRANSFUSE
BACK, SO IT KITD OF DEPENEP ON
WHATWHR YOO UNIT IS.
COMMONLY.T IN IERY
THE LAST PATIENTS I HAD, WHEN
COLLECTED -- THE PATIENT LOST 2L
IT CAN CE EXTREMELY USEFUL.RS..
NOW AS FAS AS -- DELUSIONIO, THE
PROBLEM IS NOW IT'S HARDER TO
LL
T THE TYE OF BLOOD
COLLECTION BAGS TT ALLOW TO
YOU DO THAT BECAUSE A LOT OF THH
BLOOD BANKINGKIENTERS HAVE
CHANGED THE WAY W T WIR BAGS ARE
PRODUCED AND YOU CANNOT CONNECT
DEPEDEING ON WHAT YOUR SUPPLIES
ARE.
>> W W USE CELLER QTE A
BIT.
AND OFTEN WE'RE NOT REINFUSING,
SO THERE'S A A AUESTION AUT
URCE UTI UZATION, IF WE'RE
G TO STARTTAETTING IT UP AND
COLLECLLNG FNG ALL TLLSELL CASES
ANDD A MINORITORCTUALLY GET THE
BLOODOOACK.
SO I THINK THERE'S SOME TRIAGING
TO DO THERE.
AND THEN THE TSSUE THAT DR. FOX
OUGHTP THAT WE HAVE TO TELL
THETHIENTS,S, YOU MUST BE
WILLING TO ACCEPT ALLOGENIC
PRODUCTSUC BUCAUSE WE'REE' ONLY
VING RED BLOODLOLO CELLS, AND WE
CAN'T REPLAEPAGINALAL BLOOD
LOSS.
BUT I DO THINK FROM A RESOURCERC
PERSPECTIVE FOR SOMEOM OF THESE
HIGH BLO BLOOSS CASES, ITT DOES
DECREASE THE AMOUNTUN OF PRODUCT
THAT WE HAVE TO GET FRO FTHE
BLOOD BANK.
AND PATIENTS VERY ERCHERIKE THE
CONCEPT OF IT.
THEY OFTEN ARE ASKING ABOUT
ALLOGENICNIONATION DUR DG
PREGPRNCY WHICH WE DON D WANT
THEMTHO DO, DE'RE PUMPING THEM
WITH IRON, WE'T WANTO BE
KI
THE RED BLO B CELLS O
SO THE T T THEHE CONCEPT OF
IVING THEIR OWN BLOOD. O
>> AND TO ANS AR THAT, I TNK
THERE IS SOMEOM MOREPCOMING
RESEARCH, SOME PRELIMINAMI DATA,
A FEW SDIESES THAT HAVE BEEN
, MORE TO COME, ABOUT THEHE
USE OF WHOLE BLEOD.
GOING BACK TO WHAT WASWA OLD IS
NEW.
>> DR. ROBERTS.
YOU DIDN'T COMMENT ABOUT SOME OF
THEE COMPLICATIONS RELATED TO
DOING A LOT OF T PROCEDURES,
WHETWHR IT IS THE --
EMBOLIZATIONTI WHEREHE THE CASE-
BECAUSE SOMEOM OFF TSE WOMEN,
EY HAVE LIK L AN -- FISTULATU
THERE,ER AND --- TO EMB EIZE
ACTUALTU GOES TO THE LUNG.
REASON I HAVE PICTUREF
ABOUT 50 EMBOLIOL T THE LUNG
AFTER THR EMBOLIZATION.
AND -- CT SCAN MELF ---- BELIEVE
THIS IS SOM SHING THAT SHOWS
DAMAGES, SO I HAVE AVU SEENSEHI?
EMBOEMZAEMZA TO THE LUNG.
HAT ARE THE COMPLI KAIGS OF
EMBOLIZATION AND HAVE YOU SEEN
EMBOLIZATION OF THE MATERATLL TO
THE LUNGS.
>>ERE THE PATIENTS WE'VE BEEN
EMBOLIZING IN THE OR, WE'VE HAD
WE EMBOLIZE THEM WITH PARTICLES
ANDCCASIONALLYLL WE'RE GOING
TO HAVE -- IF THERE'S A ARTERY
THATTHOOKSKS LIK L IT'S I GOI
SO
EMBOLIZATION TO T GO, WE'LL PUTN
A COIL TO BLO IT SO THAT IT
GO
WHERE WHE WHEE WANT W IT.
THAT'S NOT TOOOMMON, BUT
TH
'S SOMETHING THAT WE CAN C DO.
HAVNOT SEEN ANYNNY KIND K O K
PR
LEMS WITH BTIK ISCHEMIAAA,,
ADDER ISSUE IE'VE NOTEEN
ANY OF THAT.
>> ZERO OUT OF 20, THAT'S A BIG
CONFIDENCE -- THIS IS WHAT I'M
SAYING.
I DON'T THINK WE HE HNOUGH
CASES WITH EMBOLIZATIONO SAYAY
WE DON HAVE THESE
COMPLICOMPONCO
MY SECOND POINT, FOR THE AORTIC
TO PUT -- OF TH O PATIENT WITH
TH
MRI A EVERYBODY THOUG T
SHE H -- SHE ENDED UP HAVING
A ---- THROMBUSOM AND - A A ANDE
TH
MBECTOMY.
THAT'S WHY I W SAY WG THESE
PROCEDURES UNLESS WE ARE -- THEY
ARE -- AND ONCE WE STA
PROMOTING THEM T -- A LOT OF ESE
COMPLICATILIS.
IN THEM.YBODY HAS THE EXPERTISEI
M.>>M. THERE'S NO QUESTION TN YY
KNOW,XPERIENCEERERND -- ISREAL E
CLRLY IT'S ONE OF THE RNS
THEY DO A DO OFF THIS.TERS WHEE
WE'VE NE HAD AROBLEMRO WITH
THROMBOSIS OF AN ARTERY.
IN OUR EERIENCENCOTOT BEEN BUT
VE COMMON.
IT'S -- WHER- WH WE'RE USING ---
TH WE'RE MAKING IN THE ARTERY.
AND -- WHICH I O OF THE
PROBLEMS POTENTIALLY YOU GET
CATHETERS, IS THA THERE'S A
LA
ERLAHEATH AND MOREE LEELY TO
HAVE A A COMPLICATION.IO
>> DR. WRIGHT, IGHURNO YOU,
EN I I DO VE AVEOMMENTOMME ALSO
THE ATIC BALLOONS.
>> JASONON WRIGHT FROM COLUMBIA.
THANK YOU YLL FOR YOUR YLKR
IT JUSIT STRIKES
THINGS ARE SOO HARD TO STUDY, AD
OCCLUSIONIO CATHETERS AND
EMBOLIEMTIONTIHE LAST 15 YEARS
AND LOONGOOT THE LITERATITE.
DOITH IT COMRED TO HISTORICWHATO
CONTROLS.
SO UNTILE REALLY CAN COME
ER AND STUDY THIS
PR
PEPRIVELY AND RCTs THAT
ARE CONTR CLED, I JUST DON'T'T
THINK WE'RE EVEREGOING TO AWERW.
IF CENTERS WOULD PROBLY A
PROACH OLUSI A -- IN
DIFFERENT ERNNERS AND IT JUST
REALLY SPEAKS TO I THINK THE ---
TO THE LITER LURE.
>> CANNOT LUMPN ILI
N WITH AITH AORTICTI BALON,
IT ISOT THE SAME OCCLUSION.
AND THERE ARE DIFFEREIF SIZE
THETERS.
THERE A N FOUR FNCH
AORTA, AND WHEN WE WERE W DOWNTW
USING THESEHE BALLOONS, WEAD --
I HAD THREE PATIENTS BACTO
BACK WHO HADAD VENOU THROMBOTIC
WITH T T 7 FRENCH.
WE SAID NO, WE HAVE TO RE- R
AT THIS, IT'S NOT BIGN.
AND WHEN WHEE W LOOKED ALSO ALS
ALL-COMER, THIS IS STILL
ISHED DATA, BUT WE ONLY
ACTUALLY FILLED T BALLOON WHEN
TTIN THE ACCESS THERE 20% OF
TH
THE.
SO THERERE REALLYEAS THE NEED FR
INTRAOPERATIVETAGINGTA
OKING AT OURR LOGISTICS,ND
EN OF COURSE WE HAD ZERO ZER
PROBLEMS WITH THE SMALLER
CATHETER, AND WEXPTED.
>> WELL, IT IS I DO THINK
IT'SIT REALLYLL IMPORTANT THAT E
NEED TO BE B ABLE TOO DIF DNT D
BEEEN AN ARETA,RE WHICH
PROBABLY YOU SHOULD BUL ABLEO
GET CONTROLOL OFF, WITHOUT HAVIG
TO USEALLOSR ANYTHINNY ELSE
AND JUST HAVE HNTERVENTIONALIO
RADIOLOGY AVAILABLE IN CASE YOU
GET INTONT TROUBLE WITH HEMORRHE
DOWN THEHE LINE,IN VSUS A
RETA, WHERE IT'S I GROWINGRO
INTO TINTOIN CERVIXX WHEREHE IT'
THE VAGIN V WHERE IT'S, YOUS,
KNOW, INTO THE BLADDER AND A
PELVIC SIDE WALLS.
II MEAN, THOSE ARE TRE PATNTS
RE GOING GO -- MAYBE
NOT UT ARE ANG TO REALLY
NEED, YOU KNOW, K EXPERTARE.
IMPORTANT ABOUT TS, IS TRYINGRYY
TO GET THOSE PATIENTS TRIAGED.
>> AOLUTELY.
>>
-- BROUGHT UP A REALLY
IMPORTANT POINT, YOU WERE
TALKING ABOUT THIS, JUS WITH
EXPERIENRI.
MEINGS WITH OBNN OENOME RESEARCH
ESIOLOGIIOS WHEN THEY'RE
TALKING ABOUT THESE ISSUES, AND
EY OFTENFTFT COMMENT AND THEY
LAUGH A LEE BIT WHEN THHE STH
IT BUT THE BIGGEST PREDICTOR OF
MORBIDITY IS WHO'SSTANDING ON
THE OTHER SIDE OFIDHEABLE.
AND I THINK WE TALE AUT THE AUT
INTERVENTIONS ANON PUT OUT
STUDIES FROM REALLY EXPERIENCED
CENTS, AND WE CAN'T ASSUMEE
THAT WE'RE GOING TOET THE SAME
TCOMES WHEN WE ADVOCATE FOR
IN.HINK WE NEED SOME WAY OF
MEURING ORCCOUNTING FOR
LEARNINGNIURVESVE AND EXPERIEXPE
D SKILL.
>> HEE HELENA FROM FUBLI FUB
COMMENT INT I JUST AROUND A LOT
THE STUDIES MAYBE ARE A
SUGGESTING THATT MORE TOWARDS
REGIONALAL ANESTHESIA AND MORE
AWAY FRO GENERAL ANESTHENEA AND
TH
SO I WLD JUST SAUSISAHINK IT'S
IMPORTANT TO ASKOMS
THAT HAVAT ACTUALLY BEEN TOUGH
TH
TH EXPERIEXPE SIXE ONTHE
LATER, DID THEY ACTUALLY UAINK
THAT THEY DHE HAVEAV BETTER
BONDING WITHHHEIR BABY BECAUSE
THEY WE AWAKE FOR PROCE PRE
THAT LOTAT OF PPLEPL WOU
CO
IDER QUITE TRAUMATIC AND
QUITE FRIGHTENING.IN
I
GET SOMEONE THROUGH THELWAYS
PR
EDURE EE E THROUGH REGIONALIO D
IT'S VERY SAFE FROM F A SURGICAL
LPOINT OF VIEW, VERY SAFE FROM A
ANESTHESIA POIIA OF VIEW, WHEREW
IT'S ACTUALLY MYY EXPERIENCEIEIH
SPEAKING WITNG LOTS ANDND LOT OF
MOMS FROM F ALL DIFFERENT
CENTERS LATES ATEOTTEF THEM DO
FIND IT REALLY FRIGHTERING TO BE
AW
E,E, SOEE HAVE AROUNDUN HALF
ET A MOM THA RRETS HAVINGI RARER
BEEN ASLEGEEP WHENHE WAS WELL
ED AND I DON'T BELIEVE
IS AWAKEWAFTER, THE PARTNER IS I
THEREE, MIDWIFEID SOMEONE IS ABL
SUPPORT HER WITH THE BY,
SKIN-TO-SK-T, THEYHE START
G, I DON'T THINK THAT
THERE IS LESSES BONDINGNG
NECESSARILY, BUT I TNK THE T
TIENT -- IS ZORAN IMPORTANT
ANDAN DON'T THINKHAT EVERYVE MOM
WANTS TO BE AWAKE AND I DON'T
TH
K -- IK THEY WANT TOANE
ASLEEP BECEPSEECHEY'RE AFRAIDAI
BECAUSE TUSY'RE NOT DOI ANY
HARM TO THEIR BABY B ORRR DOINGY
RM TO THEM AS MOMS MR
AN
HING,HI ANDND I THINK THI
NVERTION IF YOU'RE LEANING
MOARDS REGIONAL, THAT'S
GREAT, LESS COMPLICATION,ATESS
BLEEDING, THAT'SHAREAT, BUT, TAK
TO THESE MOMSE SIX MONTHS, ONE
YEARATER YOU Y MAYOUND FD
OUT YES, SHE DIDREFER, THAT'S
GREAT, BUT TAKE THAT INTO
COIDERATION BECAUSE IT'S
,ALEALLY IMPORTANT.
EMPHASIZE TOO TTOO T NEURAXIAL
ANESTHESIA AND BEING AWAKE
COCIOUS.CIATSAT
CI A PRETTY RE PATIENT THAT T
WE SEE WHO IS I ACTUALLY FULLY
CONSCICOS THROUGH THUG ENTIREOU
PROCEDURE.
MAYBE A GRADE I PAS WITH A
38-WEEK BABY WHO ISAVINGAV A
PRETTY EASY E E HYSTERECTOMY, BE
TY LIBERALLY USESE SEDATION,
D IT'S AT' REALLY IMPORTANTRT
POINT TO DISCUSS,O, BECAUSESE WN
THEY HEAR TY'RE N UNDERGOIN
GE ANESTHESIA, THEY'RE
AFRAID OFF BNG AWAKE DURING THIN
SURGERY ZOO IT IS REALLYEAY
IMPORTANT TO TALK TO THEMM AUT
THEIRIR CIOUSNESS I
D.
THE TAILORED APPROACH IS BEST,ES
WE NORMALIZE ITT BUT BE NEED TO
DO MORE M LONG-TERM FOLLOW-UP.
>> EXCELLENT.
REALLY QUILY Q, I'D LIKE TOAK
THE PREROGATIVE TO ASK YOU A
QU
TIQU.
CHRISTINRI
I THINK IT'S REALLYEAASCINATINGI
ULTRASOUND VERSUS MRI, WE KNOW
W THAT THHA PATHOLOGYHOLO ALO
COMBINATIONAT OFCAR, FIBROSIS,RI
AND VASCULATURE, AND WE CAN SEEE
MYOMETRIUM, WE CAN SEEETHE
PLACENTA, WEE CANEE VASLAR
REALLY WELL WITBOTH.
AT WE REALLY STRUGGLE TGL SEE,
I THK, I THE FIBROSIS.
YOU OFTTIMES CAN'T SEE THAT
UNTIL YOU GET INTO THE O.R.
Y FOREE ANYNY ROLE OF MRIRI
ON THAT PATHWAY ATLL?
>> I INOWNOOR SUREURHAT WE'RE
CE
AICEY ON THE M NOTING THAT
THEREER IS FIBRIN DEPOSITION THT
I'M GOING TO HAVTO RECALL TO
STUDYY BY ONE OF MYY CLEAGUES,U,
DIANEE TERKL T, BUT WHEN WHEY
OKED AT THE FIBRIN, THERE
WASN'T AS'TLEAR OF
ATION BUT CLEARLY YOULYAN
SEE SOME OF THAT EVIDENCEE O O .
>> BRIANANNDERSON.
>> BRIAN ANDERSON, UNIVERSITY OF
.
I THINK IT'S IMPOR INT THAT WE
TRY TO CE TO ANO AGREEMEGR ON
WHAT WE'RE TRYING TO PODICT IN
OUR PLANNING.
E OF THEOFHEHEENTRAL FRUSTRATIOS
OF READINGDI LITERATURE IN PAS S
JU TO KNOW THASOMEEOPL
LOONGOOT PRESENCE ORR
ABSENCE OF DEASE, SOME PEOPLE
ARE LOOKING AT HISTOPAISOLOGIC
CONFIRMATION, SOME PEOPLE ARE
OKING AT DIFFE DNTFEGINGGI
SYSTEMS, PEOPLE ARE A AING TO T
DIFFERENT BASET BA YOUR APPRO
APPROACH.
PEOPLE ARE TRYING TO PREDICT
IR INTER INTION OR ANY OTHER
INTERVENTION OR REFERRAL TO
PAS CENTER.
T MAYBE ABE OF THOSE THING THI
IMPORTANT, TAT DO YOU HAVE A
SENSE FOR WHAT WULD BE HELPF HF
TARGET IN OUR STUDIES MOVING
FORWARFOAR?
SENSITIVITY ATYEING ABLE TOO
PREDICPR TIC PRESENCE.
I THINKHI WE' MORE REMOVED IN
TERMS OF CLEAR PREDICTION OF
SE
THINK WKN IT' NORMAL, WE CAN
TALK.
AND I THINK WHEN IT'S REALLY
BAD, WE CAN TELL. TL.
ANDANDL. TNK IT'S THAT GREY
INTERMEDIATE ZONE WHEREE'RE
BETTER DISCRIMINCRION, AND THAT
GOES INTO THE MTHEEMENE OF WHO
>> I'M GOING TO ADD TON THAT.
I THII WE HIT ON THAT A LITTLE
BITT EARLIER TODER TOO,, I,
UNTRY FULL OF MATERNALRN CARE
SERTS, IT REALLY IS I I IETTING
THE PATIENTS TO THE RIGHT SIGE.
I MEAN,N, AGAIN, IF PEOPLE ARE
GETTING THEIR CAREAR ATT THEIRHE
LOCAL GENERAL LIS CLINIC, IT
MAYE A VERYIFNT
TRASOUND IMAGE, A GETTA GEIT
IS IN THE EYEF THEE BEHOLDER
RD WHAT PEOPLE ARE BEING
LOOKING FORS OPPOSED TO GOING
TO A CENTER WHERE PEOPLE KNOW
AT, HEY, THI, IS WT WE
NEED TO LOOK FOR.OR
SO I THINK TT'S A LITTLE BIT OFT
ALL OF THE ABOVE A
I
GREE WITHHOU,T'SEALLY
CH
LENGG WHEN WE'RE LOOKING
AT THE L TERATURE.
BOB SILVER.
MORE GREAT G PRESENTATIONS.NS
SEM JUST GOING TO THROW OUT
ANOTHER PROVOCATIVO COMMENT TONT
THE GROUP.
I THINKHE IR STUFF STU HAS
TREMENDOUSUS POTENTIAL, AND THE
TECHNOLOGY KEEPSETTINGETTER.
AND WE KEEPAVING SUCH S DEBATES
ABOUT IT, RIGHTLY SO, PEOPLE
WILL SAY I'VE GOT A NEWROVEDME
TECHNIQUE THAT'S EVEVE BETTER AD
DON'T HAVE COMPLICATIONS.
THERE'SER CERTAINLY A LOT OF
OPERATOR DEPENDENCE AND THIS AND
THAT BUT IHINK TO REALLY
REQUE RCTs, ANDNE OF THETO
BE
IS WE HAVE A BUN OFEOPLETINGTT
WITH A BUNCH OF PATIENTS WHO
MIGHT BE WILNG TO PTICIPATE
IN
RCTs AND IS THERE AATHAT
FORWARDRWOR RCT TO REALLY ASSESS
TH IN A PROPERLY SCIENTIFIC
WAY, BECAUSE I THINK THAT'S THE
WAY TO MOVEOV THINGS FORWARD.RD
BUT IT'S VERY, VERY HARD TO DO
FOR ALFOHE REANS THAT YOHAT L
KNOW.
I THINK HONESTLY IT'S GOING
TO BE B TOUGH TOUGH BECAUSE I TS
SMUCH AS WE W WLDLD SAY RANDOMID
CONTROCOTRROL IRO REALL R THE TL
STANDARD,,DA IHINKHINK AT OUR
INSTITUTION, I'M NOT SURE H
WELL OUR GYNECOLOGICOL CLEAGUELE
ULDAKE TOHE IA,A, WELL,
YOVE GOT A PLACENTA PCRETACR
THAT'S GROWING IWIO GIGINA AND
LET'S GET THOSE AND RANDOMIZE
THERY.ETWEEN NANENMI TRAPY AND
I DON'TW.
THEYEY FEEL ABOUT THAT BUT I HAE
A FEELING THAT THEY WILL SAY,G
NOT RANDOMIZING TT
PATIENT TO BALLOONS, TO
EMBOLIZATION, TO WHATEVER AND
NO
SO I GUESS G IT WOULD DULEND WHW
KIND OF RANDOMIZATION YOU W YEE
GOING TO T
WITH THE EMBOLIZATION OF
MULTI-ARTERY EMBOLIZATION THAT
WE'RE DOING,, THERERE HAVE H BEO
MA
BEEN NO -- THERE'S BASICALLYE
BEEN MORE M PAT MNTS THA HAVE
BEEN TRANSFUSED AT ALL AND MOST
OF THEM,M,NE UNIT, NON OF THEM
HA
GONEO THECU.CU
I DON'T KNO'T'T
I THINK WE MI WT BE W A LITTL W
HARDHAREED TO DO THAT, BUTUT IF
WE -- IF THERE'S A CENTE C TT
DOESN'T DO THAT NOW, ANDND MAYBE
WILLING TOO GO FM NOT N DOI
IT T NOWOW DOING IT,T,T, THAT MT
BE ONENE WAY TO GO AO UTO UTT.
BU
I DON'T KNOW K.
I DON'T KNONO WHAT THE ANSWER I.
QUESTIONESS,ES DO YOU PUT WOMAN
THROUGHHO PROCEDURE WITH THE
POTENTIAL REALLY BAD OUTCOMEUT
>> I THINK T TT'S A TRIFIC
POINT, AND IT'S LIKE THIS WITH A
LOT OF THINGS THAT T ARE
CONTROVERSIAL.
YOU' GOT SOME PEOEE THAT
ALREADY DECIDED AND TANY DON'TON
HA EQUIPOISE.
I THINK IF YOU DON'T,ONT'SONS
DEPENDS UPON HOW MANW AND IT
PE
LE HAVE EQUIPOISE.
YOU DON'T D WANT W DO
RANDOMIZED TRIAL OF DOING A
PA
UTE JPING OUT OF AN
AIRPLANE THINE TG IT WORKS, BUTT
DON'TN' KNOW THAT -- I THINK T
TSTST CENTERS DON'T DO THI
ROUTINELY AND STILL HAVE
EQPOISE.
IT ALMOST SEEMS LIKE YOU NEED
TO R RZE TO A CENTER.
KE -- TO - CHA -E THE WAY W THAT
THEY MANAGE THE PATIENTS SEEMS
LIKELI YOU'RE ASKING FOR TROUBLE
IF PEOPLE HAVE, OVER TIME,
EVOLVED INTO I A SAFE SAF WAY WE
CARE OF THEIR PATIENTS.IE
BUT I DON'T KNOW IF THERE'S A
WAY TO RANDOMIZE TO LOCATION OF
RE.
ISSUE.HT HELP GET AROUND THE T
>> WE'VE GOT A LOT OF HANDSOT UU
I'D LIKE TOO GO FIRSO TO -- T N
BEHIND CISTINA, AND THEDID
HAND UP.RISTCHASTOU HAD YOUR
>> THANK YOUNK VERY MUERY
IT'S VERY INTERESTING AND THANK
YOU FOR ALL THE GREATALKS.
JUST AOMMENTNT FROM THE --
RANDOMRAED CONTROLRIALS.
IT'S A SITUATION THE'SHE SOUCH
MORBIDITY, IITS SOO HIGH, SO ITS
SO DIFFICULT T PERFORM
RNIZ CONTROLON TRIAL B YOU
LITTLELE TM BECAU B A FERN
DOESN'T WANT TO TESS SOMETHING
BECAUSE THEY DO NOT BELIEVE IT
COULD BE INTER ITIER, AND
ANOTHER POINT IS P WHEN YOU
PE
ORM THEM AS CONTROLONTR TRIAL
THE TEAM HAS THEHE SAME EXPERIEE
FOR THE TWO GROUPS, FORS, EXAMP,
IF PERFORM CONTR C TRIAL -RI S -
IF I DISCOVER THAT FINALLY THE
RESULT IS NOTN FAVOR F OF -- YOU
WOULDULAY YESOU HAVE NO --
WHY YOU PARTICIPATEN
CONTROLLED TRIALS,RI SO --ACCRE.
>> AND IT MAY BE THAT MAYBE MT
NOT RANDOMIZE CZETROL TRIALS BUT
CERTAINLYROSPECTIVETIVE TALSALS.
LISA?
I'M SORRY S.
>>>> HI.
JENN GELLA G
I THINK THE -- I AGREEGR WE WILL
NOT BE TO SOLVE TS ISSUE,SS
AND I COME FROMRO ANN ITITUTITI
WHEREE'VE EMULATEMED MANY OF THE
SAMESA THIS, HAVEHE SAME KINDIN
OF OUTCO OS, NOBODYOD IN E I IC,
VERY LITTLE TRANSFUSION OVER
RMANY YEARS TE,HE DEVIL DIL
BECOS IN THE DETAILS.
I THINK THIS TS WHAT IS MRING
THE CURRENTLY AVAILABLELITERALIL
IS
CREED E PARTICULARLY
WITHINWIHEWI PELVIS, SO THERE'T'
MA TMANGS THATHAORACAC OF
TIME TO GO INTO ANT THEHE DETAI,
I THINK, DR. ROBERTSON, YOU
DIDN'T HAVE A CHANCE TO GET
INTO, ADAPTING THEHEE,
TREMENDOUSLY DECREASE THE NUMBER
OR NON-TARGET
EMBOLIZATION COMPLICATIONSAT
HERE'S SO MANY OF THESE
DETAILS THAT WITH PROSPECTIVEEC
RANDOMRAND ORA NOT, PROSPECTIVE
STUDY WILL ALLOW US TO NARROW
DOWN THE MIXF THE DATA THAT
WE'R LOOKING AT.
SO WE'RE NOT JUST TRYING
COMPARE, OH, THERE WAS W
LLED O IR BECAUSE IT'SE WE
LEADINGADO A MASS M M OF DATA TT
CONCLUSIONS TO.TANDARDIZED
SO THERE IS THATT NEENG A
PROSPEPRIVEIV APPROACH.
EVEN THOUGH THEH AHE MANY OF US
WHO, I AGREE, I'M HAVING A HARD
TIME BEINGNGILLING TO T WITHO W
THE MULTIVESSEL EMBOLIZATION
THAT WE'RE DOING, BUT AUT
WILLINGLLO THINK THROUGHOUOU HAG
THE STANDARDIZED APPROACH TOPP
DOING TO DETERMINENE WHICH PIECP
IS REAISY MAKING T BIGGEST
IMPACT.
>>OU'RE SAYING WE NEED REAY
GOOD ENDND STAGE DIGN IS WHAT
I'M HEARING ALSO.
II SEE BABA B AND --
->> GO AHEAD.
>>>> USC.
TRANSFURAON.RA
A CONVE CATION WITH MY
SHORT TERM T CMLE CUE AND THEYND
TALK ABOUT THEIR ONGOING
RANDOMIZED -- MULTICOMPONENT --
PATIENTS, AND THENN BASED ON O R
THINKINKIN THIS --S IN THIS TC
WOULD THAT BE THEHE CASEAS TO TS
SAMEAM THING --
>> I THINK SO.
IN A LOT OF OUR DATAAVEVEEXTRAPA
TRAUMA LAUERATURE, WHICH IS
WH
E THIS WHOLE W BLOOD ALOOD
WALKINGLOOD TRANS TSION -- ORR
WALKING BLOOL BLOOD BANK
LITERATURE COMES FROM, FHERE ARE
SOME SSOLLTUDIES LOOKING
SPECIFICECLYEC APLACTA ACCRE A
SPECTRUMTR WITHIT WHOLE BLO OUTF
TONIO THAT HAVE HAD
SITISIESULSI WITH LESS W
TR
SFUSIOSF
JUSTUS NEED LARGERGEGE SDIES, D
THAT'S A VERY EASY LEAP TO MAKE,
AND THED ARE SOMEOM SDIESDI THAT
E ONGOING A PLANNED.
>> SEE>>NE OF BIGGE B
TH A PAIN AMOUNT OF PAIN THE T T
HAS.
S.WHETHER YOHEGO OUT AND SURVEY
TIENTS,ENENHAT WAS THE WORST
THING YOU HAD IN THEOSPITAL,
THE EMBOLIZATION.ATN.
THEY HAVE EXTREME PAIN AFTER THE
THIS IS ANOTHER ONEER OF THESE
OBLEMSOBLET REALLY WE'RE
FACING.
LIZATION, YOU DOU'T DOUAVE THE
SKIN CHANGES AND IT'S VERY
PAINL.
ELL, ALL OFF OUR PATIENTS ARE
GO
GGON TO CESAREAN
HYSTERECTOMY.
THAN TANY WOULD HAVE WITHITHHPAI
HYSTERECTOMY.
SO THEY DON'T D HAVE ISCHEMISC
I MEAN, OBVIOUSLYUS IF THERE WAS
NON-TARGETTAMBOLIZATION, WE
ULD ES PECT SOME ISCHEMIA, BUT
YOU COULD HAVE LEG ISCMIA,A,
BOWEL ISCHEMIA, BLADDER
BUT WE HAVEN'T SEENN THAT IN ANY
OF OUR PATIENTS.
SO AGAIN, WE'RE A CENTER THAT'S
SBEEN DOING THISEN FOR 30 YEARSW
IN O W O O ANOTHERND
THAT'S NOT TYPICAL OF EVERYER
PLACE.PL
>> THISSS W WE NEE TO
LLECT THIS DATA PROSPECTIVELY,,
DE
NITELY.LY
>> I THINK THIS MIGHT B OUR
NAL QUESL ON, DR.QU DDE.
>> GEORGE SAADE.
MY QUEION IABOUT THE AORTICOR
BALLOON.
AND I'M NOT ABLE A T RONCILECICI
WHAT IEAD ABOUT IT IN THE
TRAUMA LITER LURE WITH THE
HOITAL APPLICATIONCA AND
THEN WITHOUTXPERIENCE HAS BEEN
AN ACCRETA WITH WHEN TAKIN T SO
LONG TO PUT THE SHEET O THEHE
CATHETER, AND IONRING
WHETHER THEHE ELIBILITYLITYFTY W
WE USE IT IS IIS WRONG,RO VSUS W
THE TRAA USES IT, WHICH IS
TEMPORALLIZATION UNTIL THE
PATIENT CAN BE TAKENN CARE.
I'M WONDM ING IF I THERE IS A RE
FORR IT IN CASN WRE YOU NEED
THAT TIME IN ORDIN TO GET YOUR
TEAM TOGETHER, IF R,UF EPARTMENT
DIDN'THAVE TO ST TT WITH,H, OR U
CAN CONTROLOMOFOM THE T BLEEDING
RATHER THANSINGNG IT
PROPHYLACTICALLY.
>> JUST SAY THAT ONE OFONHE
THINGS THAGSS REALLY IMPORTANT,
THIS GOES TO COMICATIONS AND
AT KIND OF THING, IS IF YOU,
ONE, ARE AUTTING IN BALLO B IN
NOT BEING ABLE TO SEE WHERECOPYY
YO
RE GOING,, AND JUST PUSHING
THIS FAIRLY LARGEGE DEVIC D INTO
THE AORTA AOR WITHOUTHO ANY KINF
GUIDANCECE,OU CAN C GET INTO
TROUBLE.
S WHERE I THINKEOPLE
HAVE PROBLEMS WITH ISCHEMIC LEGS
AND THATD IND OF THING.
SO THERE'S -- I THINK THERE'S A
SE TO BE MADE, AND THIS
ASSUMEAS YOUHINK YOU'REOUOINGOIS
TO HAVE THAT DITAL -IT IF
U'RE GU'RE TU'OO UO THAT DEVE,
HAVE IT PUT IN USING
FLUOROSCOPY, CHECKING TOAKEE
SURE HOWOW BIG THE T BALON NEEDS
TO BE INFLATED LA ORDER TO STOP
E BLOOD FLOW GOING G INTO THEE
PELVIS, AND THAT ISONE MUCH
BETTER WHEN YOU'RE NOT IN AN
EMERNT SUATION WHERE
SOMEBODY IS BLEEDING.
>> YEAH, AND I THINK ALSO --
2 MINU2 , OK2 .
SO FROM FY PERSO PL EXPERIENCERI
USING THE BALLOONS AS WELL, TOO,
AGAIN, OFTENTIFTS THESE ARE
PLACED WITH ULTRASOUND GUIDA GE
C
SEE THE VESSEL REALLY
WELL
WE'RE VERYERSED ISE THAT.
IT'S NICE TO HAVE HE
FLUOROSCUOIC RADIATION, THEY'RE
H, I CAN HARY SEE THE
MRI YOU'VE DONE DRE - DRE BUT IN
SEE EXACTLY WHERE THIS IS, I'LLI
LGOO T WHATEVER AND YOU CAN
JUST SHOOT A QUICK FILM RHER
ALTERNATIVELY WHEN I HAD H TO VE
SEE EXACTLY WHERE ITT IN ANDLD
THAT WAS GREAT,, HAD RLTIME
CON CONFIRMATION, BUT I DOHINK
THERE'S SE'ETHING TO SAYBOUT
INTEROPERATIVETITANGPE AND
LO
ING AT THE TOP OG FEE O F F
WHAT YOU SEE.
THERE'S ER VERY NICE N PER PROM
COLUMBIA WHERE THERE STARTEDTART
PUTTING A BALLOON IN EVERYBODY
BALLOON IF NEEDED, AND WHEN
WE
OUR DATA WAS OASY -- ONLNL
FILLED IT I
20% 2F CASES, SO,
YOU'RE RIGHT, TO WE USEHIS
PURELY PROYLROTICALLY, BUT IT
JUST THAT, IT IS TO BUY TIME
TO GET CTROL OF O THEURGICAL
NG.E
IT'S NOT INTENDED TO LEAVE IT
THERE FOR LONG TERM,M, WHEN IT'S
AORTIC BALLOON.
>> KARIN KJUST OUT OF CURIOSITY.
IN THE T PATIENTSNT WRE YOU DIDT
INFLATEE IT, WHAT WAS THE
PATHOLOGY IN THOSE PATIENTS?
>> IT I DEPENDED.
SOME WERE TRUE, LIKE BIC BMESIG
TENSE WHAT WE'D CALL
RCRETARCN THE PAS, BUT THERE
WE
INVOLVINVOED, LOTS OFF BLADD B
INVOLVEMENT, HUMONGOUS VSELS
WHERE -- I HAD TO FILL AND
UNFILL TREE TIMES, CERTAINLY HAD
HAND ON THE AORTA A BUT THAT
TA
TO WORK WO W A LITTL L MORERE
CHALLECHING.
NO EASY ANSWERS.RS
OR THERE ARERE OTHERS WHOS HAVE
REPORTED VERYY CLELY ABOUT A JUT
CROSS-CLAMPING TPI ATA, BUTT
A MATTER OF HAVIN H H CONTROLON
STILL NOTLLBLE TO
CONCILE HOW THE TRAUMA PEOE
CAN DO IT ON THE HIGHWAYIG OR IN
THE EERGENCY ROOM AND WE CANNOT
DO IT IN THE OPETING ROOM. R
TH
'S ALL.
>> AND I IHI YOU'R Y EXACTLY
RIGHT.
NOW THNOW WAS ONE MORE RECEN R
STUDY THAT SHOWED THAT T
EMERGENTER CASESON IN THE
TRAUMA, THEY ARE I ATHE
OPERATING ROOM, DIDN'TT
NECESSARILY HAVE A LOWEROW
MORTALITY, BUT AGAIN A HAD THEY
YPUT THE BALLOON IN THAT EARLY E
THEN THEY T PROBABLYBAEREER THET
SEVERESERAREA CREES TOO.
>> I AEE.
>> I'M GOING TO TAKE THEE CHA'S
UP.ROGATIVE HERE THE WRAP THAT
WITH THE KNOWLEDGE THAT IT WAN
GO BACO B TO WHAT GEOTE SAID, ,
WHICH IS THAT EVERYTHINRY THAT'S
OLD IS NEW AGAIN.
WH
I'M HEARING MOSY FROM
THIS GROUPS IS DO THIS BECAUSE
I HAD PATIE PSIEHO HAD THATT..
WE AREWE ALL THE COLLECTIVEUM OF
OUR INDIVIDU TRAUMAS, AND THATT
DOES NOT DATA D MAKE, TT
ANECDOTEECDOES.
SO TME, T RL TEAWAY FROM F
TH SESSIONESS H CANAN WEAKE
WITH DR. HERRERA ISONE AND
TRANSLATE IT INTOIN WHO NEEDS WT
DR. ROBERTS BERT AND WHAT
DR. FARB. DOES, AND HOW C W
PRE-SPECIFY THAT 'S NOT BASED B
ON OUR OLD INDIVIDUAL BIAS AND
OUTCOMES BUT BASED ON ACTUAL
DATA.
MENU OF OPTIONS FOR US TSS THE T
CONSIDER WHAT WE WILLL GO FORWAD
WI
>> WE'RE GOING TO TAKO TAKREAK
,>> GOOD AFTERNOON.
IS IT POSSIBLE TO SEE MY
PRESENTATION?
TH
K YOU VERY MUCH.
SO WRE GOING TO DISCUSS
UTERINE SPANG FREETMENT FOR
PAS.
CARE IN U.S. U COMPAREOM WITH W
FRANCE.
WE HAVEANY EXPERIENCEE WH
CONSERVATIVE MAGEMENAG WITAG
SO I HAV TO DISCLOSE OF THIS.
CONSULTINGNGEES BUT I HAVE NO
DISCLOSURE FOR PAS.
SO THE GOALS OF MY PRESENTATSEN
IS TOO DEFINE UTENEPARRING
TREATMENTS FOR PAS INCLUDINGDI
IN SITUU EXPECT TANAN MANAGEMENT
AN
MMETRIAL RESECTION AND
EATMENTSTMO TRYO AID OUTCOMEUT F
STERECTOMYECTOND TO CONSIDEONDE
Y INNATION GAPS RELPSED TO
EDERINEIN SPARRING TREATMENT AND
POTENTIAL STUDY DESIGN TO
ADDRESS THESE GAPS.
SO
HASO IS CONSERVATSEE
MANAGEMENT?ME
'S DESCRIBEDCR WHERE
HYSTERECTOMY TO DECREASE --
COMPARED TO --F CRSE IF
SUESSFUL, WEWE CAN AVOID UTERINE
PR
ERVATION, FIRST AIMT A AS TO
DECREASE --SE-- ASSOC ATED A TO
CESAREAN HYSRECTOMY.OM
SOSO THERE ARE THREE UTERINE
G OPTIONS.
IX TIRPTIVIR METHOD, NO LONGER
MYOME MIAL RESECTION A
REPAIRN TU EXPECTANT
MANAGEMENT.ME
SO EX-TI EX-TIRPTIVEETHOD --
NSERVATIER MANAGEMENT IN
SECOND PERIOD.
AS YOU CAN SEE,EE CONRVATIVE
MANAGEMENT, LOWW RAT O MASSIVE
PPH A I THINK NOBODY TRIED TO T
HAVE A - TO TRY T HE ----
UTERUS.
SO TH THE T TRIPLEPL P PROCEDURI
EXCISE THEE E MYOMETRIUM WITH
PAS DISDER TISSUE AND TO
RECONSTITUTETITERINE DEFNET.
INCLUDECL ULTRASOUNDSOUN LOCALIN
OF THEHE SUPERIOR EDGE OFDG THE
PLACENPLAC PELVIC DAS
INAARTERIALERALLOER CATHERS,
AND NO ATTEMPT TO REMOV R THE RV
RE PLACENTA AND HAVE H THE
CILITY TO U LOCAL AGENTSGE.
INTRAOPERATIVETI DETAILS OF 50
WOMEN AND A FILIESITH BOD
LOSSSS MORE M THAN
2,000 MILLIMETERS,ER EACHOMAN
WHO HAD A TRI OF RESORPTION PT
UTERUSUT WAS SUCSSFUL TO AVOID A
HIS RECTHYSTERECTOMY.
EXPERIENCEEN WH COMPARISON
BETWEEN --N WITH OTHER SURE
TOURS, IS, DON KNOW WHAT THIS IS
EXACTLY, AND THEY FIND THAT
SUTURE PROCE PRECE WIT-- T T
LOWER BLOODOO LOSS,VERUMEF
TRANSFUSIONS.
TO READ AND AS YOU CANAN SEELT
BETWEEN 300 WOMEN THAT HAHABEEN
INCLUDIN IN THE STUDY S -- OY
IN
- CASEAS PUBLISHED, THE SAME
TEAMUBSEENT OUTCOMES CO
PREGNANCEG, KZs.
IT WASASAS MAY TPL T P
PROCEDURE, AS YOU CAN SEE, THEY
HA
ONLY LESSES THAN 2%FF WOMEN HAD
HYSTERECTOMY, THAT IS I VER
RPRISING, SID FINDLYIN THEY
THEY HAD DESCRIBED -- S S THAT 2
NANCYNA - AND ONLYY 22 --
PREGNAPRYNA DESCRIBEE RISK OF
CURRENCEF PLACENTA ACCRETA
UM OF ABOUT 20% OF 2ASES.
-- - - WORKING IN ADJUNCT -- IN
BAY NUFOOWED BY THE INVADED
UTERINUT-- TO PERFORM THIS T KD
OF
SURGERY,HEY -- VCULAR
DI
ONNEION OF NEWOF FORMED
SSELS AND THE SEPARATIONAT OF
INVADED UTERINE TISSUESSS FROM F
INVADED VESD CAL C TISSUESIS --E
ENTIREEN PLACENTA.NT
TY T PERFORM --RMHE MAIN
ST
IES INCLUDED 3,02626 W26EN, AS
YOU CAN SEE, THE RATE OF
HYSTERECTOMYEC 30% O 3 CASES
ANDAN THE RISK OF FAILUREAIF THT
PR
EDPRE INCREASEDRE WITH
SEVERITY OF DISEASE SO THEY SAID
URINE CONSE CATION HAS
BEEN --- BE IN ALMOSTOS 80% OF
CAS.
EY ALSO AS WE CAN SEE
DESCRIBED OUTMES, SOO BOT B B
1,000 -- OCCURRED IN 30% 3 OF
CASES THEEED TO -- IN 15%
CASES, IN ONLY 4% OF CASES
AND -- WAS A VERY, VER LOWER
WEIG WITH ONLY 2% OF CASESES,
AG
N I THINK QUITE SURPRISING,
AND THE RATE OF PCEDURES
S -- AND SO PUBLISHED 202
BSEQUENT PREGNANCIES AFT ONE
STEP CONSERVATIVE SGERY AND
THERE'S -- NO CASE OF PLACENTA
APREVIAR ACENTA ACCRETACC
SPECTRUM AFTER THISHI KIN KFF
SO AGAIN, I THINK IT'S
QU
PERIENCES. WITH W OTH W
SO I FIN THIS PAPER INTER ITING
BECAUSEE FEASIBILITY -- TRIALS Y
NIETO-CAETACHE WORKINGLOSELY,
ERFORM THIS STUDY IN T
CENTERS, ONES, O IN COLOMBIA ANE
IN AENTINA, EGIBLE WOMEE
WERE WEN WITHITLACENTA PREVIA
IAWI
SAREAN SECTIONECO WE CAN SEE
WOMEN TRIEN TO HAVE -- SUSPECTE
EDPAS ON ULTRASULNDASUL THE AIM
WA
TOO ASSESSS THESSEASIBILISISI
RCT, NOT,T, SAMPLEIZE CALCULATIU
WA
FUNDING.RF THERE WAS NO
RANDOMIZATION TO TYSRECTOMRE OF
ONE STEP CONSERVATIVRV SURGERYWD
IT WAS W T FIRST TIME TAT I'VEE
SE
SE I'VE READEA THISORMULAMU,
R ONE STEP CONSERVATIVRVAT
SURGERY.RV
AS AS YOU CANOU SEE, - UTERUSR,
THE WOME HAD TO HAVE
2 CENTIMETERS OF SC MIAMI
TREUM -- SHOULD BE LER LER TN
% OF THE AXIALAL CIRCUMFERENCE,
SO YOU CAN SEE THATTT IT'S NOT N
RY --CE -- SPECTRUM.
THE PRIMARYY OBJECTIBJEC WAS W
PROPORTIOPOR OF ELIBLE PBLIENTS
OO AEEDEE TO PARTI PPATI IN THE
UDY, FREQU FCY O FALSEAL
POSITIPOS, NUMBER OF PATIENTS
ASSIGNED TGNO EACH E ARM OF THE
STUDY.
SO THEY HAD 64 ELIGIBLE WOMEN,
TH
WERE ABLE TOOO ENROLLNROLOL 60
WOMEN, THE SAME POSBILITY
OF -- IN IN FRANCE,RAND ARAS YON
STEP CONSERVATIVE SURGE S,GEGE D
ONG THIS GROUP, Y, CAN S
ONLY 18 WOMEN RECEIVEDEI
ASSIGNEDNTERNTION AND 9 DID
NOT MEET THEUIREMENTS TO T
HAVE ONE STEPP CONSERVATSEE
SURGERY.
Y.AND FOR THE HTERECTOMY GROUP,D
ASGNED INTERVENTION BUTUT7 WOMEP
CONSERVANSVEVEGERY BGEAU B WE
FOUND THAT THERERE WAS ULTRASOUD
FALSE POSIVE.
-THISIS MORNG - PERFORM A
SURGERY AND TO PERFORMOR ONE STP
NSERVATIVE SURGERY AND NOT S S A
STERECTOMY.
SO YOU C SEE --EE - CHANGE -- 2%
OFASES OFFHE -- GROUP, YOU
CANCA S THE WASAS NOOO --
SIAG IN IN ABOUT 25% OFASESA
CASES -- FS SE POSITIVEIV CASESO
THEE FIGOO CLASSIFICSSIOIC NO P
DURINGNG SURGERY, SURPRISING DNR
HYSTERECSTMY IST A FORM NO PAS -
RING THE SURGERY.
AND SO YOUOAN SEE T SRE WAS NO
DIFFERENCES FOR BEN
STERECTOMY OTOTHE ONE S OP
CONSERVATIVE SURGERY VERSUS --
FOR MORE TNN -- UNIT BETEN
THE TWOEROWOS AND FOR F THE
SURGICALIC REINTEREINTIONS AND -
ADVERSE EVENTS WAS QUITE LOWER
IN THE HYSTERECTOMY GOMUP BUTUPT
WAS NOT NIGNIFICANT, AND YOU CAO
SEESE THE ADVERSE EVENTS WAS
DEFINED BY BLE BG OF MOREHAN
2,000 MILLILITERS OR OTHER
SITUATION THIO PROLONGED
HOSPITALIZATION.
THEE PROPORTION OF FAILED ONE
STEPONEPRVATIVE SURGERY
REQUIRING HIS RECT ME WAS NOT
REPORTED INHIS PAPER
UNFORTUNATELY.Y.Y.
SO THE IUE RELATED TO T RCT ----
THE TIMING OF TANZATION,
AS
ISHAOTOTOTOF USE.ME THATHA
DETERMININGIN THE T T CLASSIFICN
SO SSOE,SO CLI CL E LY IS NOTOT
EQUIPOEQE ISSUE AND WONDE W IF
ITT ANALYSIS IS APPPRIATEPRIA
NOTNOTPR ABLE TO -- ANALYSES,LY
BLINDING WAS IMPSIBL AND
WH
H HOSPITALS SHOULD
PARTICIPATE BECAUSE AS YOU KNOW,
TH
ISSUE RELAT R TO VUM V
AVAILABLE RESOURCES.ONS,IO AND
SO I WILL DISCUSS NOW THE T
CONSERVANSVEVA TREATMENT.
I TOLD YOUE NO
PERIENCE WITH --H AND SO
CONSERVATIVE MANVEEMENT, WE --
OPENED THE ABDOMENE CONFIRM
TH
SPECTRUM -- IN TERMS OFMSHEF
PLACENTA, CUT CORD C ASTS
PLACENTAL INSERTION, AND A FINAN
AND DISAPPEISANCE OAN THEECASE
PLACENTAND ITT TAKES -- MORE NOE
THAN SIX MONTHS IN THE MAJORITY
OF CASES.
AS YOU CAN SEE S IN 2010 ANDAN ,
IT WAS NOT CONSIDERED AN OPTIONN
FOR WOMAN WITH PAS, FINALLY --
ENCOURAGCO-- OBVIOUSLY FOR THE
IT WAS W POSSIBLE FOR -- CES FOR
WOMEN WHO ARE PROPERLY MOTATEDED
TORY TO CONSERVE TTERUS,
AND ASD A -- I LIKE --- SAFET T
AND IEREST O CONSERVATIVRV
MENA INASEFAS
COMPARED WITH --.
FINALLY -- GROUP SAID
APPROPRIATE MANAGEMENT STRATEGTR
FOR WOMENOM WISHING TO PRESERVE
THEIR FERTILITY, AND I I HE
ACENTA -- UTERUS AND
SO W HAVEAVAV THEREFOHE.
RETROSPECTIVE -- IN FRANC F IN
2010, IT HAS HEEN IDINGDIDI 40
CENTERS, ENCOURAGING 5GI OF
CASES WE'VE WAD INCLUDED ONE OF
16
AFTER AF OF CASES AND4 HOUT
FIRST 24 HOURS -- OF CASES
CONSERVE THE T UTERUS --YS, D
80, -- 8 OFASES --
ED IN -- I IERESTING TOO
2% OF WOMOF HADHAT ONLY
ANSFUSIOSFUSND ONLY5% OF
WOMEN HAD -- MOREEHA FIVE
UNITS.
S.
DEATHH THAT WAS RELED -- WHOERNR
HAD - AFTER INJECTIONONON OFF
METHOTREXAOT WITH ORGAN FLURE,
PLACENTA AENRETA WAS CONFIRMED
ON HISTOLOGICALXAMINATION,ON AN
EM
SPONTANEOUSLY INN 75% 75% O CASS
AF
DELIVERY. M OF 14 WEEKS AFTERFT
.AND W HAVE -- WE WERE ABLE T
CONTACTNLY 70% OF THE WOMEN
AS YOUAS CAN SEE, WE H
DESCRIBED --BE FOR 2ATIENTS --
PREGNANCEG SO 18 WOMEN W GAVE
BIRTHO 21 HEALTHY DURING THE
THIRD TRIMESTER OF PGNANCY BUTCY
PPHHCCURRED IN 19% OF CASESESND
RECOMMDED FOR CSERVIVESIDEOND --
MA
GEMENT,,FFICACY FOR THIS
AS NEVER BEEN
NDEMONSTRATED, ONL, CNLE RNLORTE
CESAREAN HIS RECT ME OR
LEAVING THE PLACENTA INU.S.NU IU
I THINK IT'S --S TRIAL THATHA S
, VY VY IMPORTANT AND
INSTRUCTIVRU--IVIFFICULT TO
PERFORM THIS KINDD OF -- BF AUSE
A
T OF -- BELIEVES
CONSERVATIVE MANAGEMENT IS A
VE
AND SO WEEE PERFORM PRO SPEC SIE
STUDIES TO TRY TODD ADDIT ANAL
CREDENCE TO T T LITERATURE..
-- STUDY, THE - T T WAS -- WITT
IN FOR OF THE CONSERVATIVELL
TREATMENT COMPARED WITHD ESAREAN
HYSTERECTOMY, ALL AAVEASURED
LIMITATIONS SO POPULATION-BASED
COHORT STUDIES PROVIDE AVI UNIQE
OP
RTUNITY TOO ASSS MATERNALNA
TCOME ASSOCIATED WITHE O
SURGICAL MANAGEMANT IN AN
UNSELECTED POPULATION OF WOMEN
WITH PAS.
SO
E COMPAREDPA SEVERE MATERNAL
OUTCES IN WOMENOM WITH P
BETWEEN THOSE WHO W HAD CESAREAN
HYSTERECTOMY AND ALSO WHO HAD H
CONSERVATIVE MANAGEMANT,AN AND O
LIMIT THE IND IIONN BARRIERS,
WE USE A PROPENSROYNSRO SCORE
ANALYSIS.
STUDYDY HAD -- WHOHO HAD H HVAN
E, THE -- WAS 520,000,0
DELIVERIESRI FROM 176 M 1ERNITIS
IN EIGHT FRENCH REGIONS.
INCIDENCE OF WEN TRANSFUSEDFU OF
MORE THAN 4 UTS UFF PACKED RED
BLD CELLS UNTIL 6 MONTHS
POSTPARTUM.
AS I TOLDOLDOL YOU, THE TIME T S
VERY LONG,ORE THAN SIX MONS
SIN SOMIN CASES,ES SO WE TRY TO
ASSESS ALL THE PRIMARY AND A A
SECONDSECOOUTCOMES AFTER SEVERAL
MO
HS.
SO AS YOU CAN SEE, THE RATEAT OF
WHO HAD PLA PA PREVI PRE
WAS THE SAME BETWEEN THE TWO
GROUPS ANDNDND MORE THAN OF
CASES ANDS HE RAT RAT R OFLACELA
PREVIA WEV PROCERO INT
SECTION WAS ALMOST --% O CASES C
BETWEEN THE TWO GROUPS AND --
SU
ION OFAS -- I -THE CASE
OF WOMEN WITH W CONSERVATIVEAT
TR
ALSO THE POINT THAT T IS
IMPORTIMT, AS YOU CAN SEE,
REFERRAL CENTE C MANAGE THESE
SES INN ONLYY 70% OFF CASES
EE IN SOME TIMES, THERE WAS
NO -- O PAS P SO -- THE STUDY,
THESEESES WE MANAGED BY B
FERRALFEENTEFE.
-- WITLADDER IASIONN WAS --
CONSERVATIVE GROUP COMPARED WITH
S RECT ME GRP.
SO THE PRIMARYRI OUTCOME WAS WON
IN CONSERVATIVE MIVAGEMENT
GROUP, YOU CAN SEE IN 16% OF O
CASES, -- WITH RESPECTCTO THESE
AND SOME PEOPLEEOEO CAN CANAN ST
THIS WAY IS HIGHER AND --
CE
REAN HIS R HT H HYSTE HCTTEYCTT-
CENTERCE MANAGEAG HIS R HIS HRY
CASES.
THE OTHER OUTCOMES WERE LOWER II
TO BLOODLO LOSS, AOSS YOU CAN S-
IN 20% OF CASESN CONSERVATIVE
MANAGEMENTNTNT GROUP, IT W AGAIN
CONSISTENS WITH OUR --- RESULT,
WHEN COMPARED W W
RETROSPECTIVEE STUDY, 30 WOMENWO
NO TRANSFUSIONFU IN
CONSVATIVE MTIVEEMENT GROT
ED WITH ALMOST 90% OF
WOMEN WHO HAD TRAFUSION ---
MEN WITH WIT CONRVATIVE
MANAGEMENT RUIRED READMISEAONS
CASES S IT'SS A REALI ITI ALMTT
PROBLEM FOR F THE POSAROSM
PERIODOD BECAUSE -- WOMEN NEED -
TO MUCH --SOSO THE STRENGTH OF T
WAS AROSPECTIVE MULREGIONALGI
DESIGN, LARGE POPUL PION OF O
WOMEN WITH PAS, WE HAVE H SOME
EXHAUSTIVENETI OF THEF
RECRUITMENT THAT WTH CHECKED,
THE TH CASES WERE FOLWEDDP
SIX MTHS -- P AND AND
TCOMESES WERE PDEFINED, WOMEN
WE FOLLOWED UNT SIX MONTHS
STPARTUM, AND CONTROL
INDICATIDI BIADI
WE
E HAD NO N HISTOLOGIC
CONFIRMATION OF P O FOR THE
SES WITHOUTHOUT HYSTERECTOMIES,
AND SO SOME S MAY ADVISE -- SOM-
MAY WONYR IF IF ALLLLASES -- WEE
I HAVE TVEO SAYAY THAT THET RAF
PAS CASES WAS ONE FOR 5,000
DE
VERY SO I BELIEVE THAT YES
BECAUSE THE RATE OF IF S NOT
OTOTTOO MUCH, BUCH WE DON'T'T KW
BE
USE WE HO -- WE VE
NOT -- BETWEENEN THE TWO GROUP G
AND -- SO T MAIN LIMITATION OF
PARTICULARLY INDICATNDN BIAS
THAT MAY PERSIST EVEN EITH E
USE OFF PROPENSROYROY SCORE
ANALYSAN..
SOSOUR RESULTS SHOULD BE
INTERPRETED WITD CAUTION.
AN
WE E ARE THAT THE
MANAGEMENT OF PAS IS HIGHLYY
DENDENTNDEN O -- CONSERVATIVE
MANAGEMENT FOR A A VERY LONG TIE
RESULTSLT CAN BE EXTRAPOLATED FR
OTHER CENTE C, C OTHER COUNT C.
U ONE MINUTE.
>> OKAY.KA
THE LEVEL OF EVIDENCE FOR
CHOOSING THE BEST TREATMENT AND
MANAGING WOMENITH PAS P REMAINSM
SEEMS REASONABLSO TO PROPOSE
IN THE PRESE P STATE OF
ELI THAT -- FOR SOMEOMANCE WE
WOMEN -- FOROMEN WHO WANT THE T
F FUTURE PREGNANCY AND
MONITORINI.NI CLOSE FOLLO FUP
IN CENTERS WITDEQUATE
EQUIPMEQT ANDND RESOURCES --
AND I BELVE ADDIT ANAL
IDENCE IS R IUIRED FOROR TOR T
TRIPLE P PROCEDURE.
YOU VERY MUCH FOR Y FR
>> OKAY, OKA THANK YOU FOR TT.
NEXT TALKAL ISY DR. HOBSO H WHOO
HYSTERECTOMY FOR PAS..EDCESAREAN
>> HI, EVERYONE.
E.PLEASE TELL ME YOU CAN SEE.
>> YES.
>> O I LOVEOV THAT.HAHA
ICM HUMBLED TLE T T PSE P AFTERT
WE
TEND T PRESE P ONE AFTERFT THE
OTHER ANDT'ST' LUCKY THAT T
MOST NON-CONFRONTATIONTA PEOPLE
THAT YOU CANAN FIND.
SOSO HELLO,LO AS YR UGLY COUSIN
FROM THE TORTH, I'MM JOINING YOU
FROM EDMONTON FM MY HOTELOT ROOM
WHERE WERVEEEN RUNNING OUR
CANADIAN NATIONAL CONFERENCFE AD
FOR THE LT THREE TAYS.
I'MI' BIT SEP-DOUGH PRIEVEDRIED.
IT'S OUR FIRST ADVANCED SURGICAL
SURGICAL SKILLSN OBSTETRICTE
COURSE WHISEHI HAS BEEASA LOT OF
N BUT TODN I'MN OING T TALK
TO YOU ABOUTUT CESAREANEAEA
HYSTERECTOMY ANDELAYED
INTERVAL HYSTEREYSOMY.
SO IN TERMS OF OY DECLARATIONS,
S,WORK IN A CENTER THAT DOES A
LOT OF CESAREANAR HYSTERECTOMY
WRITING OUT CANADIANIA GUIDE GNS
AND THE THE FIGO GUILINES.
SO
ORSOY GOALS OF TOD, I I WANT
TO TALK ABOUT ABO EXPECTED
SHORT-TERM OUTCOMES ANDANAN
LIMITATIONS OF C-HYST ANDT A
ECTRUM.TRYSTYS FOR ACCRETA
ECIAY AND NON-SPECIALTY IN
KNOWLEDGE GAPS THAT TE HAVE ANDE
WHAT ARE THE SORHE O
INTRAOPERATIPE TECHNIQUESS AND
INTERVENTIONENTIHAT WE CAN C DOO
WE'VE'VEARD A LOTOT OF AP OES AD
THERE'S A LOT OF ORANGES AND
ARS IN THE ROOM TODAY.
ANDAN TT'S WHAT MAHAS PRESENTING
ON
HIS SO DIFFICUIF O EVERY
SINGLE TOPLE THAT WE'VE HE'RD SO
FA
.
IN TERMS OF THEF RADITIONALTI
APPROAAPPRMOST OF THE TIME IN
MOST OF O OUR OLDER GUIDELIUIS,
IMMEDIIME CESAREAN HYSTERECTTEY
HAS BEENECOMMENDED.
NOW THE OPERATIPE RTIPE ISS
AN INSANE PLACE WITH SOMETIMESET
MOREMO THANHA 20 PEOP0 OP IN THM
WITH T MOST IMPORTANT PERSON
THE CENTER SURUNURD BY B A
ARE NAREUSNDNDND EITED, AND A A
E VY CARING TO GET THE BEST
PO OUTPOOME FOMEHEE
PATIENT AND TIRABY.
WHEN WE GENERALIZE ITHE
LARGEST WAYTHE ORATIVE
WILL UNDERGO SOME FORM OMATIENTT
ANESTHESIA, OURS UNDERGUN
REGIONAL FORALHE VASAJORITY
OF CES.
A URINARYRIATHETEAT ILACED
MOST OFT O HOOKED UP TO
ME
D DEFREIGHT THE DEFLATE THE T BH
GHTHE PROCEDURECE
OUND TOUIDE OUR SKIPERATIVE
INCISION AND UTE U IISION
LL AWARIY FROM TOM PLANTA.
WE DO A SURGICALCACA TE OUT
BECAUSECA WE'REREUSUSUS GD SURGS
TRYING TO FO TOW THE RULES, AND
THEN SOME GROUPSUP WILLIL PROCEN
TO CYSTO COPY C AND UROTAIRK
STENTIST, WE, DON AND A THEN --
EE LAPAROTOMY OT AOT HUGE POINT
OF CONTE CION.
DO WE DO A MIDLINE, A WIDE, WIDE
FIN AND STEEL, TEL OPTIONS ARERE
EN
ESS.
WE ENTER THE T UTERUS, DOS, YOU
US
A AUTO STAPLER FOR THEHEHE
PLACENTA PREVIA CASES OR DON'TOT
YOU.
BE THEN THE BEAUTIFULUT BABY IS
BO
, BUTUT THE PLACENTA IS LEFT
U AND THE UTERUS I
CLOSED.
AND MOST OF USF WHO W USE U CELL
SALVAGELVILLUCTION T
NIOTIC FLUID OUT OF THE WAY
AND THEN STAN S USING A CELL
SAVER BUVE WITHODERN LKO LTE
DPEE PLEETIONIO FILTERS THE'S
O MUCH OF A NEED TO DO THAT
AN BELIEVE IT REMNSNS AN A A
UNANSWERED QUESTIOUE ANDUE
CERTAINLY WE SUCTIONTI ALL OF TE
VAGINAL BLOODLO AND USE TOIVE
BACK TO THE PATIENT WITH A CELL
SA
INTER INTIONAL RADIOLOGY,
,WE
E HEARD A LOT ABOUT THAT
TODAY.
OUR GROUP ABA ABA THAT ABOUTUT
SEVEN YEARSYEGOSECAUSE OF OUR
HIGH COMPLICATION RATESES WITH ,
11%, AND WE DO SURGICAL LIGATION
ONLY IF WE ENCOUNTNCNT BLEEDING.
D THEND EN PROENED ON WITH THE
HYSTERECTOMY.TO
SO IN TERMS TER THE CRITICAL
STEPS OF GETTI G INTO HEMOR HAGH
FOR IMMIATE CESAREAN
CRITICAL POINT P PVE GOT A FEWEW
SO FIRSTLY WE'VE GOT DELIVERY OF
TH
WE CAN GET G INTO I MORELEEDING
ERE AND MNDBEBE THINGS LIK ANN
AU
STAPLERTAPLL HELP, HEL AS
SUPER THICK, AICNUTOTAPLER
CAN'T EVEN COME CLOSE TO CUTTING
THITSECOND PLACE WE CAN RUN INTT
DING IS WTHER WEER W TAKE THE
UTERO OVARIAN LIGAM LT.
LUCKILY MOIL OF THE F ME THAT
ELL, BUT I'VE GOT A FEW
POINTS I WANT WOO TALK ABOUT AIH
THAT..
DISSECTION OF THE BLADDER DOWNIS
OFF THE FRONT WALL OF THE T
UTUS, AND TRE'S TWO
INSTAYS ST AROACHES T THIS,S,
THE SO OF SLASH AND ARAB
APPROACH AND THE SLOWW AND STEAY
PROACH.
I MEAN SLASHLASH AND GRA IN I
ANY NEG NE WAY, BUT IT'S A
MUCH QUICKER, MORE RAPIDD
PROACH TO BLADDER DISSE DION
WITH MORE IENTIONALONYST TO
THE ME, ANDND MAYBE THAT' TA GD
ING RHER THAN THE PNFUL
ULSLOW AND STEAD S S DISSECTIOSA
WE DO THA CAN TAKE AN HOUR AND
HF, TWOF,OURS TOU G TOU THE
BLADDEROWN.
E NEXT NPOT WE CAN RUN INTO I
BLEEDING IS WN WE TAKE T THE
VASCULARAR PEDICLES FOR T
HYSTERECTOMYECNDMYHENMYH A RLLYL
CHALLENGING PART FOR A LOT OF US
STILL IIL HOWS DO WE ENTER E E E
T AND HOW DO WE W CLOSEHE
VAULT IN A WAY TTINIMIZESES
OOD LOSS THE BHET AND THERE'S
A NUMBERBE OF ARO AHES, A
STERIOR APPRR CH USINGNG A
BRASKE RETRACTOR AND THERE T A
LOT OF OPPORTUNITY TNI RESEARCH
TH
TH.
REMEMBER I SAID I WANTEDANO TAL
ABOUT THE UTERO OVARIAN LIGAMENT
TAKING THE BLOOD YOU ISLYLY
THERE.
IINK IT'S IMPORTANT TO
UNDERSTANDTA SOME SOM THE NEW
STUDIESN 1.5 TESLA, WE'VEONEE
OUR CENTERHAT'S BET'
TED BUT NOT PUBLISHED YET,
JUST IN THE PROCE P, WHERE WE'VE
GOT EARLY DAYS D OF RECRU RMENTF
FOUR PATIENTS WITHS LACENTA
AAC
NTROLSNT IGNORE THE DATA WITHAH
PLACENTALEN INSUFFINSENFI BUT IS
IN THERE, A WE'RERE DOINGSE
O DO NON-C NTRASTAS
ANGIOGANPHY TO TY AND A QUANTIY
USINGG TIMEF FLIGHT SEQUENCESUEE
AND THEND TH CIN PHASESE CONTRAO
WORK O HOWUC BLOOD FLOW IS
GOING WHEG.
D WHAD IT BASICALLYLY SHOWS, IF
CAN SUMMARIZE, IS TH I IN
PL
ENTA ACCRETA COMPARED PA
INCREASECREA DOUBLING,BLBL IN BD
AORT THROU T THE DESHENDING
HAVE A SIGNI SCANT INCRE IE
IN UTERINE ARIER A FLOW AND
OVARIAN ARTERY FLOW, BUT , E
PLACE WHERE THE BLOOD ISEAVING
THETERUS IS NOT DOWN THE
BOTTOM, IT'S RIGHT AT THEOP
THROUGH THE OVARIAN VEINS.
HUGE INCASE IN BLOOD FLOW
THROUGHHE OVARI O VEINS.
SO IT'S IMING IN NGROUGH ROE
BOTTOM AND HEADING OUTNG THROUGH
THE TOP, AND THAT'S WHY W I THII
WEWE SHOULDHOXPLORE A LITTLE BIT
TFU
HER THE CONCEPTONPT OF O PUTTING
SOME LONG STRAIGHTAIT CLAMPS OVR
THE UTERO UVARIANAN PEDICLES,
S,BECAUSE CA ARE THEN T EFFECTIY
OCKING OFF T VENOUS DRAINAGE
FOR OUR UTERUSS AND POTTIALTI
INCREASING THE PRESSURESUR AND
MORRHAGIRRSEQUELAE FOR SOM
PATIENTS.
.SO I THINK WE SHOULD EXPLORE
THIS.TH
NOW, VERY BRIEF B, I, WANTED TO
RT OF TALK ABOUT SOMOF THE
ORT RM CONQUONCES OF AN
IMMEDIATE HYSTERECTOMY, AND A I
HAVEHA TO DO THIS WITHINIT THE
CANADA.DADATHE T U AND OF OF
SO THESE ARE A COUPLE OF PAPERS
QUITEIT HIGH VOLUMEENTERSISH IN
SHOWING THE OUTCOMES OF
IM
DIATE CESAREAN HYSTERECTOMREOMY,
SO
I'VE MUSHED THEM TLL TLLET TR
AND IT'S'S THE CTEMPORARY
OUTCOME, IT'S NOT THE 10-AR
HIORY, IT'SS THE RECENTEN
OUTCOMES AFTER WE'VE HAD A FAI
TIME ON OURUR SURGI SLGIEARNING
CURVE.
SO OFSO OURATIENTS, THES, VASTAS
MAJORITY, 70 TO T 90% THEM ARE
STAGE II TO OR INCRETA
PERCRETA, WERE DELIVERING AT THT
APPRECIAPR THE PROROND LOWTO
IN CENTERS TTET DO THIS ALLSHELL
TIME, AND THIS ITHRETH FOLDDD
LOWER THAN MANY OFHE OTHER
OUTCOMES THAT WE'VE SVEN TAL T
ABOUT TODAYOD.
EE BLADDER DISSECTION AS N
MENTIONED, THEHE FAST APPROACPP
VERSUS THE SLOW AND STEADY
APPROACH NEEDS TO BE EXPLORED
MUCH MORE IN DAIL, AND I GUESS
IF YOU ARE HAVIN H GOOD OCOMEME
WI
JUST DO WHAT YHA'RE USE TO, BUT,
I THINI THE CENERS WHICH WCH ARE
LEARNING A TECHNIQUE, I THINK
THEY SHOULD TUL AND STICK S TO E
AND DO IT ALL THE TIME.TIME
TERMS OFF THEHEROLOGICAL
OU
OMES IN OUR T O GROUPS, WHEN
WENKNK ABOUTBO CYSTOSCOPYND
UR
ERIC STENTING, WIN HARY
EV
DO IT, 1% 1R LES
FOR THE HUGHES TOOES GROUP, THEY
YDO IT ABOUT 65 TO 6 70% OF THE
TIME.
BUT IF YOU LOOK DOWNN THE BTOM,
OUR ADVERSEEROLOGIROLGI OCOMES
ARE ALMOSTOS IDENTICAL INN TERMF
AAOTAL NUMBE N OF CYSTOTOMIES,
URETERIC INJURIESS AND FISTULAS.
IF YIF DON'T -- BUT YOU DO DO
DOTHISDOLL THE TIME, ACTUALLY HE
THE SAME RESULT.T.
SO NOWN TO DAYED INTVAL
PUBLISHED ON THIS.EEN A FEW PAPS
THAT'S'S THAT INITIAL C-SECTI-S
AWAY FROAY THE PLACENTA, THE
DECISION WHAT YOU'REOUOING TONGO
TRAOPERATIVELY, THEE UTERUSS AND
ABDON ARE THERE CLOSE C AND
SOME PATIENTS WILS GOO FOR IR O
EMBOLIZATION.
TH HAVE ANTIBIOTICS AWEWE
KNOW, METHOTREXATESS NOT GIVEN,
THE PATIE P SYS FOR A SHORT
TIME IN THE HOSPITALPI IF THEY'E
WELL AND A THEN THEYY HEAOFF HOE
AS LONAS AS THEYON'TON LIVE TOO
FAR AWAY.
EY'RE MONITORED WITHH LHS AND
ULTRASOUND FOROR REGRESSION, AIO
IO
HEYY EVEUALLYYY HAVEE A
HYSTERHYTOMY FOUR T S WEEKS
LATER IFTE EIFRYTHING GOES WELL,
WE ALSO NEED TO DO SOME
IMPORTANT MEASURING OFF
PSYCHOSOCIAL IMPACTS WITH THISH
APPROACH BECAUSE LIVING UNDER UA
EAT OF A BADD OCOME
UNTIL YOUUT WAIT F YOUR D-DAYS
IS A B BHING TOO THROUGHOU.
NOW CALLED IAIP AIP P HEHE
POTENTIAL COMPLICAMPONS OF DOIFI
A SECOND INTENTIONAL SURGICALL
PROCEDURE POTEE IALLY OUTWEIGHED
PUBLISHED THEIR PAPER AFTER TFTY
GUIDELINES WERES RELEASED.
A RETSPECTIVE STUDYVER AT A
SIX-YEAR PERIOD IN NASHVILLE
WH
E 34 PATIENTS HAD HNTIPARTUM
DIAGNODIS OF STAGE IIGE TOO
3 DIASE.
314 HAD
DELAYEDEL HYSTERECTOMY COMPARED
C-SECTION HYSTEREYSOMY.YS
I THINK IF WE LOOK AT THEEL
IMMEDIATE GROUPS, THE
SURGICALRGIMESERE VERY
FFERENFFFF INITIALLYLY FOR THE
DELAYED AND A IMMEDIATE GROUP, D
IMPORTANTLY, THEY, ESTIMATED BLD
LOSS THA THEY REPOR RED WAS
OFOUNDLY LOWORHEESAREAN,EA
0 MLS, AND HYSTERECTOMY, 750Y,
MLS FOR A CBINED TOT OF 13000
UT THE IMMED ITEROUP HAD
3 LITERS OTEVERAGE OF BLOODOD
LOSS, VERY DFERENT TO WHAT WE
HADHAD W1,000 TO 1500 MLS,LS
RY, VERY DIFFERENT.
SO ISO THINKHI THE VOLUME OF CAS
ISIS VER IMPORTANT IN YOUR
DECISION-MAKING, SO JUST TO BE
NTROVERSIAL, IN DETERMINING
WHICH OPTIONOP PERHAPS IT'S TT'T
CASELOADND EXPERIENCE WHICH
MIGHT HELP YECIDE WHERE CAN
I SUGST THAT LOW OR MID VOLUME
DELAYED HYSTERECTOMYEC BUT FOR F
VERY HIGH VOL VOLOL CTERS,
IMMEDIATE HYST CHYST BE TH BWAYA
GO
TH
CAN BE FURTE R DISCUSSED
BEAUTIFULLAPL WHICH CHAED MY K
WORLD IN THEINAY THAAY I CAN TAK
ABOUT THIS.
I REALLY ENJOYED THIS PHIS P OFA
INDIVIINALS INO HAD A C-H AT F
PL
CENTERS, AND T BASE OF THIS T
WAS OUTS F CALIFORNIA.
AND THEY FOUND FOR SURGICAL
MORBITY THE TURNING POINT PTHE
REFLECTION POINT WHERE THEY
STARTED TO HAVE H A SIGNIFICANT
DIFFERENCE DEPENDING ON NG O
NUMBERNUF CASES WASES W 25 CASER
YEAR, AND AS SOON ASYEYE YOU DID
MORE THAN T 25 OR5 E ME M CASESR
BETTERBE THAN T THE T MEDIU M OW
VOLUMEVO CENTERSEN.
ANDANHINK ABOUT VOLUMES.RWARD
SO F HYSTERECTOMY, I'M
WRAPNG UPOON,VER ALL THE
IDEALEA CDI CTE IN I IYPIYON
WI OR CIRCUMFERCUTIAL DISSE,SE
YO
PRESERVATIER SURRY YOU'RE
ES
E CORES OFF THE CERVIX.THE
WH
THERE'S BLAER CERVIX OR
IR ME TREEL INVASION, WHEN
THERE'S A MASSIVE AREAA OF O
DEHYDRATIODR WITH A REALLY LOW
INFERIOR BORDEROR THAT YOU CAN
GET DOWN TO STITCH UP, EMERGENCY
LO I I THINK ARE GOODS O BLOODLO
CANDIDATES.ES
PATIENT PREFERENCFE ISFE VERY
PLEIR FAMILY.HEN THEYN E COMPLEL
WHEN THERE T A CONCURRENT
INDICATION FOR F A HYST WITH A
HISTORYOR OF HYPERPLASIA O
FIBROIDS, WDSVE DONVE THAT A FEW
FMES, AME WHEN THE
MULTIDISCIPLINARY TEAMY REFERS
IT.
SO IN SO IIDERING DELAYED
HYSTERECTOMY, WE HAVEE O BE SUR
THATHE TEAMEA ANDNDIENT
SUPPORTS ARE ALL ON THE SAME
GE.
THAT THE SURGICAUR TEAM IS
AVAIBLAI 24/7 FOR7 7 THESE
PATIENTS WHO DON'T GETET TETOO R
PLAND HYSTERECTOMY DATE, AND
M CARE CS C SO
IMPORTANT.ANT.SO FOR T ONTARIO N
CONTEXT, FORT,OWN TORONTO,
I ALL THE TIMIM HAVE PASAS PATIS
FROM TWOOURSOU AWAY IN ORILIA,
4
2 HOURS AWA IN SUDDE S SUDPURN,8
HOURS A WAY IN I THUNDER BAY A
WHATSOEVER.'T HAVE ANY RHODESDE
SO OUR KNOWLEDGEED GAPS AND
SEARCH DIRECTIONEC TO DISCUSS
MORE TOMORROW, DOW, D DO
CYSTOSCOPYPY AND A YOU'R Y TAIRK
STENTING,, DO WE W ENGAGE WITHIA
HYBRID OBR THE RATINGAT ROOM AND
RECOMMEND IT, WHA D WE DO WITH
OH YOUH SOU AND HOW DOUGH
WITH DO THAO THA IN A SYSTEMATIY
BEFORE WE START.
WHAT IS THE BEST SKI INCISIONCNC
OR WHAT SKI INCISION SUITS WHATA
PATIENT.
I DO TXA -- DON'T WAI UNTIL
ANSWERED THAT QUESTION.NOBODY'SS
DO WE GIVEIVIV UROTONICS OR NOT,
NOBODY KNONO.
WH
DO WE DWITH THE INTERNAL
ILIAC ARTERY SURGICALLGI ANDND D
WE DISSECTCTT OUT AND OY CLIP C
THEMTHF WE RUN INT BLEING?
WE DO SSH AND GB, DO WEE
DO SLOW AND STEADY?TE
WHAT'S T'S BT WAY TO T ENTER TNT
VA
T AND AVOID THAT BLEEDING?
ARIANOUS DRAINAGE DURINGRVESERV
THE SURGERY AND NOT BLOCK IT O
SO THAWE C MOVE THE UTERUS
AROUND?
WHAT ARE THE BESTPWISE
APPROACHES TO THE HYSTERECTOMRE
OULD WLDLDOMMENDOM TOTAL OR
SUBTOTAL?
HOW DO W ENGAGE WITH MACHINEAC
LEARNILE AND A.I. TOOELP UN
PREDICTION?
WHAT ARE THE BEST WAYS T
EDUCATE IN SURGERY, PRODUCING
VIDEOS ODE SIMULATION?IO
ANDANFE GOO DOWN A PATH OF
DUCINGDU PRIMARY C-SECTION
STERECTOMYEC ARE OURUR NUMBERS
GOING TO PLUMMET AND THEN WE
LOSE OUR SURGICAL SKILLS AND
S LITERATURE IUR TRICKYRI TO
INTERPRET.
BUT AT THE MOMENT, C-HYST
MAINS A PREFERRED APPROACHRO BYC
MANYMA AMERICAN CENTERSENND
GUIDELGUID.
LUME IS VERY, V VERYMPORTANT,
OPPORTUNITY TOITY LOREY HIS.
AND THERERE ARE A SEVERAL KEY
OWLEDGE GAPS AND TECIQUES
THAT WTHATEED TO EXPLORE
TOGETHER.
AS WE M WEORWARD.
W HAVEE TO COME C C WH OPEN
MINDS TO LOOK ATTHAT WE W CAN
ARN FROM EACH OTHER TO REFINENE
THE OPTIMAL RESULT, WHATEVER
THAT MAY BE FOR F EH INDIVIDUAIV
PERSON.
.SO THANK YOU,OU THANK YOU, THAK
YOU.
>>
HANKS,S, DR.OBSON.
PRECTE YOU JOININGNI REMOTELY.
WE'RE GOING TO MOVE ONOVO T
ALTERNATIVRNO CAREAN SIBAI,
ECTOMY IN THE UNITEDUN
EDSTATES.ATES
>> THANK YOU EVERYBODY.
MY TALKK IS GOING TCOMPLEMENT
THETH PREVIOURE ONES, PROBABLY E
CO
AND QUESTIONSNS ABOUT A
WHAT WOULD WLD W THE NEXTTEP?
SO FOR HISTORICAL BACROUN
TRADITIONALLY TREATMENT OF PAS
IN T UNITED STATES HAS BEENN
CESAREANSAYSTERECTOMY THAT WAS
ED FIRST IN 1937.
HOWEVER,WEINCE THE THE HHEE
EN AEN LOT OF QUESTIONS WHETHERH
IT SHOULD BE THE PRORAPPROACHPR
IN 1951, COMMENTED IN I THE NEWE
GLAND JOANNAL OFL MEDICINE,IC
WITH THE GHEERAL OPINION THATT
HYSTERECTOMY ITO THE TREATMENT F
CHOICEN PLACENTA ACCRETA.
IS IMMEDIATETECTOMY TOM
BEST APPROACH, PARTICULARLY --
RE'S AN EXAMPLE OF A PATNT
LOSS WAS 29 LITERS.ATIVE BLOOD
I WAS WAS INVOLVEDOLVED THIS PA.
AB
T ABX OR EIGR EEEKSEEGO
D YOU LOOK AT ALL OF THESEHE
CENTERS AND SO ONNN, MORBIDITY S
I HIGHLIGHTED FOR YOU IN RHE
NUMBER OF PACKEDD RED BLOODLO
NIGMS TO THE ICU.OLISM, ADD
SHOULD ITE -- MANEMENT FOR
ALL PATIENTS WITTS ACCRETA.
HO
ABOUT WHEN YOU HAVEOUOU REALLYY
SEVERE INVOLVEMENTVEF THE
BLADDER?
THE IDEA ISSS ACTUALLY TO DO
CONSERVATIVE MANAGEMENT, LEAVE
PLACENTA IN SITU.
SO HOWSO DO WE COUNSELUR
PATIENTS?
STARTED THIS IN 2015,OORY
TO
ENTA IN SITU.TS IE LEAVE THEVE E
SO FIRSO QUESTION WHEN WE TALK
THE P P, FUTUREUR
FERTILITY, PRESERVE THE UTERUS.
THEYTHTILL WANT THE URUS EVEN
THOUGH THEYHE DON'T WANT CHILDR.
SO WE TIE THE TUBES AND LEAVE
THE PLANTA INS SITU. S IT'S NOE
UTERUS FOR FERTILITY.
TH
ARE OTHER REASONS THEYHE
WANT TO KEEP IT.
TO HAVE ADEQUATE FOLLO FUP WITLA
US, AND THEN WN W HAVE TO TAKE
INTO CONSIDERATION IURANCECE
STATUSSTAT, -- THEN EXTT OF
PLACENTALEN INVASIONIO TODJACENC
GANS.
AFTER THAT, YOUAVE FOUR
OPTIONS.
S.YOU CAN DO CESAREANEA
LAYED HYSTERECTOMY, UTERINERINES
RESECTION AND RECONSTRUCTION,
ANI'M GOING TO T SW SU THEY
ACTUALLYTUALAL DO PLANTAL RESEC.
THIS ISOW A PARTIAL RESECTION
DONE.ON
EY DO A- THEN THE UTERUS IS
T BTK TOGETHER.
NOW I'M GOING TO SHOW YOU WH
WHAT -- SO S WHAT THEYO, TYY
START DIARECTING -- OF THE T
BL
DER.
THE -- THE VESSE VESF VHE
BLADDER, THEN AFTER YOUR O
DISSECDION, DIVAS
OF -- AFTEROINGHIS -- AS YOUN
N SEE, S THEY PULL THE PCENTA
T.T.
--HEREHE THE T PLACENTA
ACTUALLY -- THEE -- THE PLACENTA
REMOVED COMPLETELY.
AND THEN YOU CAN S T T
ACCOUNT CUT ALL OFTHATFF AREA.RE
ANDD THIS IS -- YOU CAN SEEOW
THE PLACE PA ACCRETA WAS TWO
ACTUALLY INCISIONSIS ONE AT THEE
TOP ---- AND ONENE BELOW.
SOMETHING NEING HE ANSWER IS NO.
FOR SOME OF OOU -- WHEN WESED
TO OPERATE WITH ABDOM ABD
USED TO LEAVEHE PLACENTA INO, E
NSITU.
WHEN YOUOUO DELERY OFERHE
SEND TWIN, MOST PEOPLE DON'T
REALIZE WE ARE LEAVI LEA THE
TA IN SITU.
SO LEAVI L PLACENTA IN SITU ISUY
YEARS - THIS IS WT ARE
AV
LEAVINGVIHE PLACENTA
AIN SITU, EVERYTHING THAT TT
EVERYBODY HAS BEEN TALKING
ABOUT.
IN 2015. IS I MY PROTOCOLTOLL ST
WE DO SURGERY INN LABOR/DABIVER,
DO MIDLINE INCISIONC WE EXTENDX
THEMBILICMB.
I DO A FUNDALDAYSTETOMY,,
TRANSVERSE.
WE LIGATE T T CORD IN PROXIMITY
TYTO INSTION.
WE
THESE WOMENRE GIVEN GIVTAMICIN
AND CLINDAMYCIN.
WE EVALUATVATHEM FOREM BLEING.
EY ARE KEPAT THE HOSPITAOSTA
FORFO SIX DAYS.
THEN WEOLLOW THEM WITH
ULTRASOUND EVERY TWO TO FOUR
WEEKS AND WE MONITOR FOR
THIS WILLE THEHE -- PL -ENTA
PREV -- - AT 21 WEEKS.
TO HAVE MORE CHILDREN.D SHE WANE
THIS IS WHY I DECIDEDID TO OER O
RHAT.T.
-- THREE MONTHS LATER,OT
PREGNANT AGAIN AND --- SO NOW I
ABOUT TOUO SHOW I YOU, THOU IS E
OF
HE MOST RECENT CASES C I DID
NEED HELP HERE.
OKAY.
HERE ITT I
SO YOUOUAN SEE S THE -- GET THE
TAKES TAS TO 40 MINUTES --RE
EVERYBODY IS HAPPY.
THIS ISS SOMSOF THE CASES C WE'W
REABOUT TO SOW SOU, GDU GLY G --
UTERUS THROUGHHRHE ABDOMINALAL
IN
SION, WON DO THERANSVERSNS
CISION.
THIS IS ONE PATIENTNTHO HAD THE
PLACENTA PERCRETA, YOU SEE
IT IS, DETACHED FROM THE --
AN WE DECIDED TO DOO THE DAYED
ERECTOMY ON HER.
THIS IS WHAT IT LOOKED BEFOREOR
THE CESAREAN WAS DONE.
OOD LOSS WAS 300CC.
THISIS IS -- BYAITING FOR
VASCULARITY TO GO GOY ANDY YOU
HAVE LESS BLOOD SUPPLY.
THIS ISSOW UTERUSTE LOOKED AFTER
YOUU DO THE DELAYED HYSTERECTOM.
THIS LAST PATIENT, YOU CAN SEE,
IT WAS DONE R ROBOTIC ANDND TNDT
BLOOD LOSS WAS W 50CC.
TH IS THE DIFFERENCE --
TRANSFUSION WHETHER YOU DO
IM
DIATELY OR WITH THE DELAY.
AND THE PATIE T DEE VERETHRE.
THERE IS ABOUT FOUUT DAYUT LATE,
THAT ONENE TKBOUT SEVEN WEEKS,
ANDD ONE WAS 16 WE 1S.
SO ONE O O MY FLOWS WHO'S HER
>> CANAN Y REMOVE THE RINER?
?>> I DON'T D SEE IT HERE.
IT'S NOT ON MY SCREEN.
SO - THE BLOOD LOS650 AND
E -- 200 2 1,000.
.E UTERUS WAS PRESERVED IN SIX,
FOUR HAD H SUBSEQUENT PREANCI.
-- AND A ONLY ONE REQUIRED
ABDOMINAL HYSTERECTOMY.
TH
NUMBERS -- BY --S IS -- I
WE CONTINUE TO COLLECT DATA D OD
THIS
AN
PLACENTA LOO BEFEURGERY.
.THIS IS HOW THE PLACENTA CE WEW
FOLLOWED THE PLACENTA, T
VOLUMEVOFVO PLACENTA,CEHEA,ROP N
BLOOD SOOPLY TO THE PLACENTA.
AND YOU CAN SEE THIS PATIENT
HERE WITH W PLACENTA COMING --I
WE WENWE W AHEAD AND REMOVED THE
PLACENTA.
SO
WHAT ARE POTENTIOTOT
THETHE IMMEDIAMM HEMORRHAGE FROM
HAPPENS ONE W OHIN TO THREE
YS.
THIS ISHILE WE KE W THEM IN
TH
HOSPITAL FORALBOUTALIXUT DAYS.
ABDOMINAL PAIN, P CRAMPINGIN AND
NESS.
-- SOM-- S OF THEM.HEHE
LAYED DIC TAKES ABOUT THREE T
SIX WEEKS.
HEEEN PATIENTS
- VET NONE N N OF O THEM HADADAD
TO CONSERVONIVE MANAGEMENT.T.OMY
ABDOMIABL PAIN ONEO TWO WEE,,
ONE OF THEM PREGNANCY ISIS
POSSIBLE, THE OTHERTHS
IBLE.
FOLLOW-UP ISNEO TWOWO TES,
EVERY TWO TO FOUR WEEKS FOR THE
OTHERHENE.NE.
BOTH CANTH C HAVE H INTCOURSE SX
WEEKS LATER.R.
HOW ABOUTBO RECURRENCESES OF -
U CAN SEE THE -- IS I PROBABLY
SO
SUBSEQSUBS PREGNANRE.TA IN A
THESE ARE DATA FDAM VARIOUS
CO
TRIES.
SO WHATHA ARE DELIVERY OPTIONS R
PLACENPL ACCRETA?IN THE PASAS
ACENTA -- - IMMEDIATE
HY
ERECMY SHOULD BE T B
OPTI FOR EVERYONE.
I THINK THEREHE IS A PLACE NOW O
DO DELAY -- PLU- OR MINUS
EMBOLIZATILI, LEAVINGVI PLACENTA
INITU ANDU DOINGU U U PLACENTL
RESECTION.CT
>> THANK Y, SIBAI.H.
NEXT IS DR. KOJI MATSUO, MULTI-SPECIAL SURGICALRGICERTISE
>> I MADE THIS VIDEO TO KEEP THE
20 MINUTES TIMELINE BUT IT LOO
KE --
>> I HAVEE NO DI NLOSURE.SUSU
PRESENTATIONRERE T DISCUSS THE
SURGEON'S ROLE AT PAS
HYSTERECTOMYECANDAN TOO IRODUCE
HYERECTOMY.ECHNIQUEHNIQ FOR PASP
THE FITHT PART ISHE SURGEON'SONS
WHOERRMS THE T HYSTERECTTEYTE
FOR P P HAS BEEN THE ACTIVEIV AA
OF RESRCH INTEREST.
LTIPLE SOCIETIES AND --
EXPERIENCED SURGEONS SUCH AS
GYNECOLOGICOL ONCOGNCTTS
SU
ORTINGTI AGENCIES FOR THIS
SRECOSENDATIONDA
IS IS A 2015 PAS CENTER OF
EXCEENCE CTERIA, SURGEON IS
SHOWN IN RED BOX.
2018 STATEMENT --COG --
SURGEONS ARE UERLINED.
THIS ISS 2019IS-AIP SPECI S
SURGEON RGOWN IN RED BOX.
THIS IS I 2024 PANAM PANAN SOCIY
REVIEW, THEW DO N SPEFICALLY
ATEYN-ONCYNS REC RNDED
SURGEON.
OUR SDI SDIECOMMEECING --
PRIMARILYIL FOCUSED ON
GYNECOLOGICAL ONCALOGIST.
IS RETSPECTIVETI STUDYROM UC
FETAL CSORTIUM COMPARED THE
SURGICAL OUT COM C BETEN GYN
THIS WAS STATISTICTI DIFFERENCEC
WASWA NOT CONNE CED TO CRITICALA
DIFFERENCE OF 2.2 VERSUS 25 --
SAMPLEMP SIZE W 122ASES.
DATA SUGGESTED GYN G O N
INVOLVEMENTENS INCREASING AIN
THEY ARE MORE LIKELY TO BE
INVOLVIN IN SE FORM OF PAS.
IS SINE CENTE CRETRO SPEO
STUDY INCDING 98 CASES
OF PAS P HYSTERECTOMY EXAMINEXA
TIMINGTI OF GYN ONC INVVEMENT
ST
TING WITH GYN ONC, AS NEEDED
ANDO INVOLVEMENT.NT
-- FROM BEGINNING ONIASES ISSAE
RGICAL OUT COME COMPARED TO
NC CALLED AS NEEDED.
IN 2024,ESEARCESRS IN U.S.
EX THEEXREMIERE DATABASEASE
TO ASSESS CHARACTERISTICS --
IMMEDIATE DI PAS BASED ON
SURGEON -- INCLUDINGDIENAL
LIST, GYN ONC AND MFM.
AAOTAL OF WITH IT THOANDAN 240
40SES WERE EVAATED.
PA
JORT JOR O PAS HYSTERECTOMYERE
PERFORPED BY GENERAL LISTS --
TH
ION INCREASED TASEE FOLDT --
T20.% TOO8% BETWE B 2016 TO T
THETILIZATIONZA OF EU RECEIPTPT
RAL STE AND A EO ARTERIAL
PR
EDURES GRADUALLY INCREASED
DURING THE S TDY PERIOD OF TIMOF
PERIOD.
THIS TABLE SHOWS TARGET
PROCEDUROC INCLUDING TXA
INDUCTION, UTE RAL STENT
INSERTIONIO AND A END ARTERIAL
OCCLUSION.
AS SHOWN IN THE RED BOX, THE --
S -- ME LIKELY TO PREPAREFMFM
AN - PASYSTERECTOMY IN
SWS THE SURGICAL
MORBIDITRBRB FOR PAS HYSTERECTOY
ACROSS THE SURGEON'SGE SPEALTY.
RATE OF HEMORRHAGE, INJURY,
SHOCK AND COALOPATHY WERE ALSOOO
SUBSTASUIAL AIAOSS THE THREE
THEPS.OU
SGEONON EXPERIENCE MAY
MORE MMPORTANT THAN SURGEON'S
SPECIALTY ALONE.
HOWEVER,HERE'S TOO LIMITED
DATA -- SURGEON'S'S EXPERIENCEIN
THE OUTCE OU OF PASF HYSTEREYSM
BASEDSE O-- CENTER STU DINED
THAT P SPECI SIST IS SURGEON
IN PAS ANDNDIGHH LEVEL OFIECAE
KNOWLEDGE AND SKILLS RELATING TO
S.
IN
AS HYSRECTOMY --Y SPECIALTY
SURGEON RGS ASSOCIATED WITHITH
INCREASEEED -- BOD LOSS. L
HOW DOW W GYNEC GOGIC G ONCOLOS
VI THEIR PAS HYSTERECTOMRE
THE RECENTEC SOCIETY -- T-
XTTENDING SURGEONSN SGO.
TH
FIGURE SHOWS ANNUAL
HYSTERECTOMY CASE VOLUME FOR F S
R SURGEONUR
INAJORY OF GYNEC GOGY
OF PAS HYSTERECTOMY CTY CT YEARY
YEAR ONE --F MORERE TN 10N
CASES CA YEA
E RESPONSE RATE --
N-RESPONRERS MAY --AY WHERE
THERE'S NO OBB PRACTICE.
-- PAS IS INCASNCG IN RECENT
YEARS.AR
NEARLY HALLYLY HAVE EXPERIENCER
CONSERVATIVEVAANAGEMENT, ABOUT
HALF ARE A INVOLVED FROM THE --F
THETH CAS.
IMPORTANTLY, THREE QUARTERS HAVE
EX
RIENCED MORE THANAN
FIVE LITERSITER BLOOD LOSS, AND
NEARLYAR ONE-THIRD-T HAV
EXPERIENCED MORE THAN 10 LITERS
OF BLOOD LOSS.
NE
LY 50% OF RESPONDENT ARE
INTERESTED IN PAS -- AND THIS
POSITIVE VIEW WAIE QWATED IN IN
2023, SGO -- SUMMIT.MI
HOW ABOUT -- OF PAS
HYSTERECTOMY?TOTO
ACGME PROVIDES THE --- FOR
GRADUATE MEDICALALDUCATION IN
FLTED STATES.
SPECIALIST 20, IT SPECIFIES FOR
HYSTERECTOMYMYMY BUT NOTOR --
SURGICAL EXPERIENCE.IENCE.ALAL
IN A VIEW OF -- 20, SEV0,AL --
RAISE A CONCERNCE FOR INCASING
LEX
LELE OFF SURGERY- IN 2020N
PROPOSEDOP A FUTURE DIRECTION
IN -- GAIN EXPERIENCER WITPAS
MANAGEMENTGEMEME
MFMM SURY SHOWS MAJORITY O MFM 2
LLOW ARE NOT COMFORTABFO TO T
PERFORM C-HYSTEREYSOMRE WITHOUTT
GYN ONC.
SHOW SATISFACTIONCT FOR P -- ISI
LOWER THAN --HA INCREASING PASAS
CASES AND DECREASE IN I SURGICAA
EXPERIENCE OF COMPLEX PELVICVI
SURGERY WAS W ALSO --LS---- TAKN
THER
THESE T DATA CALL FOR
PORTUNPOY TO PROPOSE --
--SPECIFIC TO PAS ACROSSOS THE
SOCIETY GENERALEN LIST, GYNYN OC
AND MFM.
SUCH AREA MAY INCLUDE
ESTABLISHING A FOUNDATION
PATIENTAT CAN OBSERVE CENTERTE
EXPERIENCED PASURONS
TENIQUE USING THIS ----
E SECONDALF OF THE
PRESENTATION IS TO -- OPERATIPE
TECHNIQUE FOR PAS HYSTERECTTEY.
-- PLACENTA CONTA CING --
SEGMENT OR -- AND A INCREASEDED-
MAKE SURGERY COMPLEX AND MORBID.
POSSIBLESS CONSEQUONSE OF ORDINL
HYSTERECTOMY APPROACPP FOR PAS Y
APPLYINGYI THE SURGICALCA CLAMPT
THE LOWER SEGMENT ABOVE THE T
TISSUE RESULTED IN HE IRRHAGING.
EXTENSEXEEXE NEOVASCULARIZATION
BE
EEN THE LUS AND BDDER
IS -- CHALLENGE INN PAS
HYSTERECSTMY..
DRUPTEDPT LUS IS I SEEN IN
PAS, ONCE WALL IS DISRUPTED --
BLEEDIBLEEAPPLYING THEHE FIBRIN
PAH TO THE STIONITE CAN
INUR HPITAL, WE RENTLYNG.
HARMONIZRM THE CO CONSENSON OF -
APPROACHPR AND INTERPRETIVE
FINDINGS- GS THE --HE
EVIDENCE -- - CONCERN FOR
HYSTERECSTMY -- OR KNOWN
HYSTERECSTEREC AROACH.H.H.
TIMING OF O O COMPLICATION AT TO
WEEKS TOS ONE WEEK AND 7 T
WEEKSS -- BE REANABLE TO SET
ON FR WEEKS.
HERE -- TECHNIQUE IS PPOSEO
ADDRESS THE UNIQUE CHALLENGELLGN
PA HYSTERECTOMY, I SHOWW A VIDEO
FOR TWO-HAND TECHN TUE.
>> AIQ TWO-HAND TECHNIQUE IN
CESAREAN HYSTERECTOMY FOR
PLACENTA ACCRETA SPECTRUM.CT
E NO DOSUR.
THERE HAS BEEN A RIDING
INCIDENCE OF PLACENTA ACCRE A
WELL DESCRIBED IIBEDHEHE LERATET
LIKELY DKE TO INCREASE IN
CESAREAN DREANERY RATES,ESLDER
MATERNAL AGE, PLACENTA PRETAA.
THE'S A 74.5% MORBIDITY
INCLUDING HIGHH VOLE BLOOD
LOSS,SSCU LCU OF CARE, BLOOD
4 UNITS, ANDND PROLO PED HOSPITL
STAYS.
S.WHEN THERE'S A PERCRETA PRESE,
THERE'S A MORTALITY RLIEE O O
1.4%, IN, OTHER WORDS W1 IN1 I.
A CENT SURVE S OF THE
GY
COLOGIC ONCOLOGISOLOL SHOWE S
THEY HAVE ALSO NOTICEDIC INCREAS
IN PLACENTA ACCRETA CASES INES
PRACTICE.
82
%AVE A MULTIDISCIPLINARY
TEAM APPROACH.
78.7 HAVE EXPERIENCEDNCASES WITH
EATEEA THA 5 LIT 5S 5 OF BLOOD B
LOSS.
CASE FROM THE T T BEGIN BNG, BND
ABOUT HALF H OFESPONDENTS
EXPRESSED INTED ST IN ACCRETA
SURGERIES FOR FUTURE PRACTICE.
CONSIDERATIONS IN I PREPARATIPA
FOR PLFOENPL ACCRETACCASES ARE
SUMMARSUED IN THE TABLE
DISPLADID.LA
PREPARPRIONS TAKNS TOR OURUR CAE
TEAM, CELL SAVER, CYSSCOPY, WE W
WILL REVIEW SURGICAL APPRO AH
SHORTLY, A URINE ARTERY
EMBOLIZATIONZAZA W UTILIZED.
ALSOALOORDINATED WITH OUR
SURE WE WAD AN EXPERIENCED TEAM
MFORTAMFE WITH MASSIVE
TRANUSANN PROTOCOLOTOT
THEOT BLOOD BANAS AWARE,
ADDITIONAL ANESTHESIA BACKUP WAS
ADDITIONAL, ADDITIONALIONA ACCES
WAS ESTABLISHED ALONG A WITH --
SIA WAS AWARE OF THE
TIMELINE AND AND AEADY TO AD%IR
TXA.
THE CASEASE'LL USEOODEL
TWO-HAND THAHNIQUE IS A
5 DAYS WDAH AIS ARY OF TWOD
CESARE DELIVERIES, AND
UL
ASOUND FINDINGS CONCERNINCEG
FO
R PLACENTLACECRETA SPECTRUM
WIWITH A PLACENTA PREVIA AND HIH
SUSPICION FOR -- INV-ION AN
HIGH VASCULARITY IN THTHE CERVI.
FIRST, THE SNOWMAN CONFIRMONS TE
CL
AGNOSIS OF PLACENTA ACCRETA
ECTR..
YOU CAN C SEE HERE THAT LOWER
SEGMENSE - - AFTER DELIVERY OF -
TXA IS ADMISTEREDTEND THE
ACENTA IENEN LEFT IN SIGH TEU DE
TO LACK OF D DENT. D
ONCE IONCE I CLOSED, ATEXT IS
TU
ED TO THE CYSTS C CYSTOSCOPTO
THE BLADDERLA SURVEYED TO RULE T
ANY EVIDENCENCE O PLACENTAL
INVASION.
ALT STENTS ARE PLACED LAD'REE
DATTENTATNN IS TURNED BACKK TOOE
ANDDOMEN.
IN OUR CASE THERE WAS HIGH
SPICION FOR HYPERVASCULARITY
IN THEERICERVICAL ANDNDVICAL
AREAS SEA THE FASCIA WAS CLOASD,
AL
ERINE ARINRY EMBOLIZATIONAT WAT
PERFORMERFRF
EXTENSIVE PARASITIRAESSELS THERS
NOTED BETWEEN THE UTERUS AND T
BLADDER.DE
WE NEXT PROCEED TO DEMONSTRATE
3, 2, 1 APPROACH FAC COMPLETING
CESAREAN HYSTERECTOMYOM FOR
PLACENTA ACCRETA F SPECTRUM WHIH
IS IMPISMENTED AFTER.
WE FIRST BEGAN IN SEQUENTIAL
ORDER WITH W THE POSTERIOR CUL E
ASPE, AND ANTER AR ASPECT BYL
THE END PELVIC FASCIA ACTION TO
CERVIX.
BLEEDING WERE TO OCCUR, IT IS
OFTEN FROM THE BLAHEER
DISSECTION.
DUE TOTO ENGORGED VASCULAASRE AD
DISRUPTION OFONHIF UTERI U WALL
WHICH IS ALMOST POSSIBLESS TO IO
REPAIRPANCE DRUPTED.
SPECIAL ATIANTIOIANTOULD BE
KEN IN THE PCENTACCRETAA
SURGERIES.
WE THEN T PROCEED DISCTING
TOWARDS THETH LIGAMENT, A
POTENTIAL STEP WITHH A HIGH RISK
OF BLOOD LOSS.
IT IS UFULL TOO DIVOE THIS INTO
TWO PEDICLESDIONE BNG
OMINANTLY FIBROUSIB T TEE
ENTERG TTE SPACE AND EXTENDINGN.
IT LAT RAYLY, COMPLETOMYETOM
DETACHES THE T PERITONEUM FREU E
WHERE THE PLACENTA CAN C BE NOTD
TO BE BULGING.
TH
STEP EASILY ALLOWS
LATERALIZATION OF THE URETERS.
TH
ZATION OF THEF UTERUSRU,ORER
THEREFORER FACILITATING THE NEXT
EP, WHI, IS THELADDER
DISSECDION TO THE ENDO PELVIC
FASCIA OF THE CERVIX.
IS ELEVATEDD WH A DRYTHETERUS
LAPAROTOMY STONG INSTE I OF --
TRADITIONALLY SELL IN TOTALOT
ABDOMINAL HYSTERECTTEIES.
THISTH IS TO AVOID PROULINGS,IN
NING.ETE TO THE DELICATELTERINE
SO IDENT IY IHE END PELVIC
SCIA FIRST BECAUSE THIS AREARE
RARELYRA HAS -- THEATHOLOGY AGYA
AAT THE VERY END.
IN THIS STEP,TE BACKFILLIKF THE
BLADDERRITRDE 100DEs OF SALINE
CILITATESTATA THE IDENTITY OF TE
R EDGE.
NOT STARTINTA ANTERIORLY WRLRE
THE YELLOW Xs ARE A MARKED, YOU
AVOID ENCOUNTEROUGER THOSE
ADHESIONSON A PROGRESSINGES INNA
MEDIAL DIREC DON..
THISIS PISTION OTHEE DISSECTION
N TE ANYWHERE BETWEEN 30 TO
45 MINUTES DUE TOO THE
SIGNIFICANT DEVELOPMENTNT OFF
BETWEEBETWBE THE LOWER -OWSEGMED
E BLE BL WHICH NEEDS TO BE
TIFIEDTIFI ISOLATEDLA AND
DISSECTED MICULOUICY.ICY.IT IS T
THESEESSELS SHOD STAY WITH
THE UTERUS AND A THE BLADDER
OULD BE DISSECTED OFF O OTHEM.
ONCE YOU ARE CONFIDENT YOU ARE
BELOWHE PLACENTA AND
IDENTIFIEN THEEN FASCIA ON THE
CERVIX, THE TECHE TUE CAN BE
THIS ULTIMATELY HELY H SECURE TE
UTERINE VESSELS.
YOU CAN SEE HEREE NE THIS
SCHEMATICCHAT AN ORDIN OY O
PLACED IN T LOWER UTERINETERIE
SEGMENT FAR AWAY FROM THEHE
UTERINE VESSELS.
HOWEVER, IN IN PLANTA KREE T,
THE SURGEON RGNDS ARND PLACED
ANTERIORLY POST POSTERIOSLY BLYE
PLACENTAL BED.
TH
LIGAMELI, ME, THIS POI THE TWOO
HANDS ARES E GENERALLY MOVED
UPWARDS, THIS STEPNABLES
CREATION OFF SAFE ANATOMICAL
DISTANDISTROM SURROUNDING
STRUCTURES AND ISOLATIONLA OF
FTHE --E ALIGNMENT BETWEEN THEE
TERIOR AND POSTERIOR FIGURES.
HERE IS A DEMONSTRAONONONON OF W
ADITIONALLY WOLLD YOLL TRAMP
AND TRANSECRA UTE WIN VESSELSESN
WHAT APPEARSPPO BE THE LOWER
SE
ENT THEHE UTERUS.
IFIF THEY'RE TAKENAK UP AT THIHI
IGHT YOU WOULD HOUE TO T
SEQUENTIALLY LATLYALIZE THE
VESSELS ALL T A WAY DOWN TN T
SER FIX, INCREASING YOUR RISK OF
TRANSECTING ORETTING INTNY
NEOVASCULARIZATION, INCREASING
YOUR RISUR OF HEMORRHAGE.
HERE NHE WE'RE G TO
DEMONSTRMOE THE TWO-H TD
TECHNIQUENIND SAFELYEL CTURE THE
UTERINE VESSELS.
E SURGEON HANDS ARE PCED
AN POSTERIORLY AT THE
LOWER UTERINE SEGMENTEGELOW THE
PLACENTAL BED..
THE FINGERTIPS OF BOTH HANDSDS
ME
AT A THE T CARNAL LIGENT
BELOW THE PLACENTA AT THE LEVEL
OF THE UPPER U CERVI C OR VAGIN.
AT THIS POINTT THE TWO HANWO ARE
GENTLY MOVED UPWARDS CARRYINGIN
THEEE PLACENTA CONTAINING LOWERW
TERNALEGMENT.
THISTEPSTE ENABLESHE CREATION
SURROUND STRUCTURES AND FROMM
OLATIONAT BETWEEN ANTERIOR AND
PO
ERIOR FINGERS, ALLOWINGGAFE
PLACEMENT OF THEF F ACCEPT LIN
AMP.
FORHE -- FOLLOWED BY SH BPLY B
TELITED ASTEHEY WOULD IN A
TRADITIONAL ABDOM AALAL
HYSTERECTOMY.
THE SAME IS RE IATED ONN THEHE
CONTRALATERAL SIDE, ADE,HE
THROUGHORO THE REMAINDER OF THE
PROCEDURE.
SURGICAL TECHNIQUEIQ FOR PLANTA
ACCRETA SPECTRUM CTRTINUES TO
EVOLVE.
THISROPOSERO TWO-HAND TECHNIQUE
IS EASYAS TO PERRM ANDND
REPRODUCIBOD AND CAN ULTRAMAY
WITH FIGO F FA. PATHO PGY
EES ANDREW VALLEJO,
CALIFORNIA.RF SERFERNER
KE TO THANK ALL
MYCOAUTHORS ANDHE DEPARTMENT
DEPARTMENT -- FOR THEIR SUPPORT
WITH THIS T PROJECT.
AN
ON BEHALF OF O TEAM, I
WOULD LIKE TO THANK TOU ALL FOR
YOUR ATTENTION HERE TODAY.
>> THANK TOU, DR. MATSUO.
DISCUSSION.V30 MINUTES OFF
SO WE WILL GO THROUGH0.
AN
NEXT BREAK SINCEIN WEE TOOK TE
BREAK, AND WE'LL MAKE UP TIME TT
TH
END E WITH LESS TIME SPENT ON
CHARGECHO WORKING GROUP G
>> JUST KIN MIND THAT YOU'RE
STILL GOING TO HAVE DR. HOBR.N
ON THE TOOMM AVAILABLE.
>>
I THINK T BIG ISSUE WE'RE
IDENTIFYING ACROSS THE BOARD IS
THE NEED FOR STAARDIZATION IN
TERMS OF ULTRASOUNRA AND -- BUTT
DEFINIDELY IN YR CATEGORAT
WHO'S THE CONSERVATIVE
CA
IDATE, AND F WHICHHI
PROCEDURE ARE THEY CANDIDATES
FOR AND CAN WE AN W TO CONSENSUS
WHOMHO WEE SHOULD EVEN BE
COIDERING THIS IN.
II KNO DR. -- WILL TALK ABO
2 CENTIMETERS BELOW THERE
LESS THAN 50% OF THE
CIRCUMFERENCE IVE
I'
I'URUS, DO YOU O REE WITH
THAT, ARE THEE OTHER CAVEATS?>>E
CONSERVANSVE MANAGEMENT IS WHAT
THE PATENT WNTTS.
FOTHETH PATIENT.,NGNG THE SITUAN
ORSESE WHO HAVE VISION -- WE
HAVE GOT A HUGE BULGE,
PARTICPAARLY AT THE -- SID ANDND
WHERE YOU SEEEE THESESESE BRIDGG
VESSELS, ALL THESE PATNTAT THE
HINGOR YOU SO TO LEAVE
PCENTA AND FOLLOW YOUB
MAKE DECISION SIX TOSIIGHT
WEEKSATER, WHETHER WE CONTINUE
THE SE PROCESSCE O IF YOU WANT
YOUR UTERUS TORU BE REMOVED, THN
WE CAN DO THE -- SO THIS IS
REALLY BASED ONED THE MRI,
ULTRASOUND, ALL,F THESE
NDINGS.
>> YES, I SEE -- THE WOM AND I
ITOLDLDLDOU IN FRANCE, WE DO NT
CON FEND CONSERVATIVE -TIVE FOR
WOMEN.
SO IT DEPENDS ON THE SITUATION.I
THE MAIN MAIT WHENHE WE DISCUSS
WITH A WOMAN IS T FOLLOW-UPLO
TH
FOR THE WOMAN TO HAVE H A LITTLE
BUMP INMP THE ABDOMEN THAT COULD
AT ANY WAY A ANY
TIME.
IT'S NOT SO EASY FOR THE WOMAN.
I'M NOT TOO -- I JUST JUST TOE
N.
D R CIVIC CASES,ES WE BELVEVE
FRANCE, IT DEPENDS ONDSHE
ORGANIZATION OF KAI IT'S NOT
KE CANADA OR I THINKHI IT'S NOT
LIKE U.S. WHERE WHEAVE A LOT OFO
CENTS VERY NEAR FROM THE H THE
OF THEOF TOMAN.AN
SO WE HAVE NOAV WOMAN WHO LIVE T
8 -- FROM THE CENTERS -- SOME
EMOST FAR AWAY IS LES THANHA
100 MILES.
SO WHEN WE RECVE CASES IT'S
T DIFFICDIT TO PERFORM
CONSERVATIVE MAGEMENT.
WHATWH DIFFICULT IS AFTER, THE T
POSTPARTUM PERIO THE TIME TO
TALK ABOUT IT DURING MY TALK,
BU
TO KNOW WHEN W HAVE T-- THE
WOMAN, WHEN WE HE TO GIVE SOME
ANTIBIOTIC, WHEN, E HAVE TO T
PERFORM -- WHEN WEN HAVE TO DO
AG
NAG SURGERYUR SETIMES IN
EM
GENCY.
SO FOR SERIOUSUS CAS, PLACENTA
ACCRETA, IT'S NOT DIFCULT TO
RFORM CONSERVONIVE MANAGEMENT,
SO WE CAN OFFER FOR THEM.M.
AN
W BELVEEL IN FRANCE IF WEF
HAVE THE ABILITYO AVOID A
RY -- FOR ME IS BETTER FOR
THESEE CASES.
GUESS IN US ., IT'S THE
RY, W,RERE YOU CONSIDER
THAT WHEN WE HAVE H VERYER SERUS
CASES,CAT'S T DANGEROAN TO
LEAVE THE WOMAN W AT HOME, THATT
CAN BNE BE VERY DANGEROUS AND YU
NEED TO HAVE THE THEROCESSESSS
TO MANAGE WAN --AN SO IT'S QUITE
DIFFERENT -- BETWEEN OUR TWO
COUNTRIES.IE
DO NOT SAY S'M RIGHT RHT I JUSTI
SAY HOW DO IN FRANCE AND
HOW -- SO WE WO HAVE -- IT'SS NN
LIKE -- - I I ASSURE YOU -- SURY
WRI THE PAPER FOR -- I
THOUGHT THAT IT WAS POSSIBLE FOL
ANY WOMAN AND I THINK IT WAS - W
E WHEN WE HAVE -- ME SURE
AND VISION, I DON KNOW HOW TO
REMOVE THE PLACENTA ANDHE
ERUS AT THE SAME TIME,TIOR, ME
IT'S LIK'S HYSTERECTOMRE
FINALLFI, -- SO THE WOMAN HAS TO
AGREE, SHEE, HAS TO WANT IT, AND
SHE HAS TO HAVE THE POSBILITYBI
TO UNDERSTANER WHAT'S INVOLVED
ER AND FOROR HERAMILY,AMT
CETERA.
>> -- THE ORG,HE WANT TO
SPEND TWO YEARS WITH THEM -- AND
THEN SHE WTE A A PAPERER I
EN
AGE ERYBODYBOBO TO READ,
E CHALLENGE WE'RE FACING, BUTC .
HI TO COMPARE OURREESULTS TO
THEM, BECAUSE THEY HAVE A
NATIONNA - HEALTH SYSM, T
DON'T HAVE A LOT L O L TS -- OUR
BIGGEST CHAENGE -- WE SEE A
LOT OFT WOM W A W
UNDOCUMENTED.
IMMIGRANT.
AND WE HAVE TO -- SO MA SO S
THIN, A LOT OF TIMES IANTO
TO -- SHE'SE' AFRAIDD IILL ----O
TR
EL AND A THEY MUST --EPORT
TH
SOSO WE W WE HE A L OF CLLENGES
IN WHAT WOULD BE THE BEST
TOP
ON.
IT MIGHT NOT BE THE BEST MEDICAC
ONN MY OPINIONPI BUT I I
STILL GO AHEAD AND DO TO PROTECT
HER.
>> WONDERFUL PRESENTATIONS
NSAGAIN.
ORANGES TOGEEARS ANALOGY,ES TOO
SEBASTIAN, THAT YOU GAV
ONE OF THE THINGS THAT IT THI T
IS REALLY CHALLENGING WITH THIS
F RESEARCH, TCHUGH, TOO,OO
IS IT'S HARDO COMPARE
SOMETHING THA LASTS FOR SIX
THAT IS COMPLETED AT ONENGHI
SURGERY.
I THINK IT'S EASIER TO COMPARE
CONSERVATIVE SURGICAL MANAGEMENE
NT
TH CONSE CATIVE LEAVE THE
ACENTANSEED SURGICAL
MANAGEMENT OR TO COMPARE
TIME WHAT W IS THE BESTD ALL THT
MANAGEMENAGENA
THAT'STHUMBER ONE.
NUMBER TWO, HAVE YOU ALL THOUGHH
ABOUT FOR THEONSERVATIVE
DELAYEDLAYEDYE HYSTERECTY, IS TE
AN OPTIMAL TIME?
I THINK T THAT' TONE OF THEHE
BIGGEST UNANSWERED QUESTIONS, IS
SHOULDT BE ONE WEEKFT,,
SHOULD ITT BE TWO WEEKS AFTER A
OULD ITLD BE SI BWEEKS AEKER?
>> AGAIN, I DIDT HAVE TIME T TOT
SHARE, WHEN WESHTARTED TS,
THEN WETHAIDD SINCE INSURANCE DD
NOT COVER THE THE ONE AFTER SIX
WEEKS, AND N CNGE -- WE
STARTED DOING THEM WHILE THEY
ARE INARHE HOSPITAL.
BECAUSEE WE FOUND --O WE DON'T D
KN ABOUT THIS.
BUT NOW SINCEIN NOW N THEY CAN T
INSURAINE COVERED IN TEXAS -- -I
DON'T BELIEVE THERE IS A PLACE
FOR -- 11 --EK1
OUR EXPERIENCE HASE EEN VERY VAD
AND WE STOPPED DOING IT.
>> SOSOSO I -- SC- MA IN MY
PRESENTAESON OVER WHICH WE
DISCUSSEDHIS POTENTIAL
PROPOSAL AT OUR INSTITUTION
INGR. WRIR.T UNDET
SUPERVISION, MY COLLEAGUE FROM
JAPAN JAPA PREVIOUSLY PUBLICATIN
PUBLISHED IN -- IN WCH HE
PUBLISHEDISHEDATABL FOR THE
PLACENTA ACCRETA UNDER
CONSERVANSVE MNSAGEMENT AND THEN
THE PEAKE FF THE COMPLICATIONIO
OCCURCU AFTER - ANDND TOPICS, OE
IN THE SIR S TOO WEEKS,EE THEN
FOLLOWED BY KIND OF A PTEAU
ASE, THEN AFTER SEVENEN WEEKS,
EN PEA P OCCUR AECONDON O,
IMPRESSION THAT THERE MAY BE
HYPO -- WDOW --DO THE OTH
PPORTINGORTI SO --O WE DECIDEID
>> -- DOES NOT HAPPEN FORBOUT
FOUR WEEKS AKS BEYOND BECAUSE WE
HA
BEEN FOLLOWING -- DATA ON
THIS, AND AS OF TODAY I DIDED
NOT TO MONITOR THA ANYMORE
BECAUSE WHAT TWHY'RE GOING TO DO
WITH THAT INFOR ITION?
I HAVE SEEN THEEE--ROP- AS LOWOW
7
-
BEDING,ING,O -- WE DIDWEHIS
AIN A LON A TIME AGO, WE USED
TO HAVEABIES WHO WHO DIED IN
UTERO, AND A WE KEPT K DEBATE WH
FO WKS, WE USED T GIVE THEM
SUBCUTANBCUS HEPARIN WHICH WE
DON'T DO ANYMORE, BUTUT WE STARD
DOING IT BECAUSE -- - -
>> IOULDN'T AGREE WH YOU
MORET THE T PATIENTS' WISHS
ARE THE NBER O PRIOR PY, BUT
I DO TNK WE OWE THEM A
COMMDATI..
.WE DO NEED TOECOMMEND TO THE
PATIENTTIPA THAT IF THE'S
SOMETHING ON IMAGI I THAT YOU
WOULD RECMEND O APPROACH
VERSUSVE ANOTHER.
I THINK THE MANAGEMANT NEEDS TO
DOVETAIL TO OUR VERSI V OF THE
BIOLOGY.
IF YOU KIND OF PUT P THISND
THAT TOGETHER, MAYBE THE MORE
W ADHERENCE MAYBE AROUND AREN' A
THE BEST OPTIONS F
CONSERVATIVE MANAGEMENT, MAYBE
E THEY'RE N'R'R DEEPL D INTOVE
THE WALL,AL THE FIBRIN DEPOSITIN
ISN'T AN' GREAT, INFLAMMATORY
OCESS ISN'T ASS GREAT,, THEN
MAYBE THAT DOVETAILS, THERE'S A
>>>> THIS T IS WHY WE CALL IT --
AGAIN, I AGREE WITH YOU, TO
THOSEOSOS WHO DON'T HAVE THE - N
MRI, A MAJOR -- UNLESS SHE
WANTED TO KEEP HER H UTERUS, THE
WEWEAN'T ARGUE WITH THAT.
WE'LL GIVE THE RECOMMENDATION,
N,BUT FOBU SOME WOMEN YOU HAVE O
SAY, IS IT BETTER TO DOHISS
OR --HE WHOLE COULERY.
IS IS THE PROEM SOMETIMESE
. FA
>> -- TO MAKE --
ENCOTIONS OF -- BECAUSE IT
S ON FACTORS.
-- THE- OUTCOMES, YOU WILL HE
WOMEN --EN - THE THE MAIHEPOINT
IS TO TRY TRY KEEPHE UTERUS
BECAUSECAUSE IMPORTANT FOR HER.
.YOU HAVE OTHER O WOMEN YOU SAYI
WANT WHEN I LEAVE THE HOS HTAL
FINISH TO HAVE H SOME PROBLEMS.
OF COURS CYOU CAN HAVE SOME --
SOME LIMITATIONS OF THE RISK, I
N'T WANT TO LEAVE THE HOSPITAL
TH MAJOR RAJOR I DON'T'T CAROL
IF I HAVE THE MAJ RIS OF
BLEEDING DURING SURGERY, GET DO
E THIE THAT I
REALLY ----O IO
VERY, VER-- ANDND IT ALSO -- I I
DON'TT- IT'S THE TM T SHOULD
AG
E, ANY- SHOULD AGREE,
EVERYBODY SHOULD BE AGREED, YOU
KNOW, WHEN W YOU HAVEE ONE CONCN
THAT IS NOTOT OKAY FOR
CONSERVATIVE MANAGEMENAG, SO I
OULD BOU B SHARE S SY ALS MEMBES
OF THE T TEAM.
M. I THINK DR. HOB SOBOB WANTS O
COMMENT ASO WELL.
OH, THANK YOU.
I'LL BE BRIEF. B
WE ALL AGREE AGRT WE NEED TO
TAKE INTO AOUNT THEATIENT
PR
ERENCESCE, WE ALL AGREE WE
NEED TO WORKK ON EDICVE
VEMODELS AND PATIE P DEMOGRAPHIH
AND ULTRASOUND FINDINGS, MRIRI
FINDINGS, TO T AND AND HELP US
FIND A PATHW P THW THE SOLUTION
WHICH SUITS THATT INDIDUAL
LSO DON THINKHI WE CAN
DISCOUNTSCROMRO THIS CONVERSATIN
IN
VIDUAL INSTITUTIONTI OUTCOMES
ANDANHAT THEY'RE ACTUALLY VERY,
VERY DIFFERENT, AND CERINLY
IT'S LINKED TO VOLUME IN A VERY
STRONG WAYAY BUT B WE STILL HAVE
CASES THAT DO LESS TN 25 CASES
SA YEAR THAT HAVE OUTANUTNG
OUTCOMES BUT THE CNS CNS HAS
TO BE B TAI BREAI WITHIN THE
CO
ES ARE FOR THOSESEURGICAL
IN
VIINAL SURGEONS AND SURGICAL
TEAM
AND SO I THINK THAT'S AS A RY
IMPORTANTRTARTRT OF
DECISION-MAKING.
>> MY QYSTION RELATES TO THE
AL TEAM.
AGREEING, EVERYONE IN E ROOM,
NE HAS A PLAN AND WE KNOW
HOW MULTIDISCIPDINAIP TEAMS
WORK.
T AS A POINT OF TH O WORKSHOP,
CAN WE SAY THAT THE SURGICALL
TEAM NEE SDS TO BE ITHE
OPERATING ROOAT THE START OF
FIS CASE, AND I ASK THAT ONLY
YBECAUSE I DON'T KNOW HOW -- I
TRY TO LOOK L AT AHIS LITERATUR.
THE DATH IN GYN AND ONCOLOGY,
ARE THEY THERE -- IF THEY'RE
GO
G TO BE THE ONES DOING THE
CALLED IN TO CHAOS WHEN Y'VE
ALADY LOST 10 LI 1RS OF BLO,
SHOULD THEYE THERE AT THE
START OF THE CASHE C
HE CM USING GYN ANDOLOGY AS AN
AMPLE, BUTE, B FEEL FIKE THIS IS
A CASE THAT WEHAEED TO MAKE THAT
CLEAR IF IFHE POINT IS TSM PROVE
SO MAY IT BE THEFM WHO'S DOING
STMY OST THE UROGYN OR
E GYN ONCOLOGY DO WE HAVE
ENOUGH DAY TOOAY THE SURGICAL
TEAM NEEAM TO BEE THERE T
INTRAOPERATIVELY AND NOT NO
>> JUST ARIEF SMALL DATA D
E -- GYN ONC IOLVEMENT
BEGINNING -- ACCTA O COME
IMPROVED.ED
AND ALSO GYN GYNNC'S VIEW BASEDN
O, AREO,NVOLVING -- BEGNING,
NEARLY HALF OF THOSEHO RESPONDED
EN MANY ARE ACTIVELY
EXPRES INTEREST.
AND IF SO, MY HBLEED BEGINNINGI
RECOMMENDATION TO THEM WOULD BEE
AT,, PROBABLYBA MOREORMPORTANT O
BE ALSO INVOLVING IVITHE -- IN
TERM OF MANAGEMENAGEMHAT TY'RE
INCLUDING MAYBEIAGNOSISA
MADE -- CASE SCENARIO-NASED NOT
JUSTST BNG B- IS NOTOT PROBABLYY
THE BEST UTILIZATIONTI - TO BE -
DISCUSSION -- THAT'S HOWOWOW WE
I DON'T KNOW IF THAS
NO GOOD --
>> ARE>> GOI>> TO BE INVOLVEDOLN
R AFFAIRS, THEY'RE GNGO
ATTEMPT THE MULTIDISCIPLINARY
DISCUSSION, THEY GO AND VEEE THE
THEY WANT TO BE IN THE OPERATING
ROOM AND SEE THE PATIENTS OR O
STAFF AFTERWARTE
>> ONE MORE.
NATION NUMBER O DREASING
CASES, WSEKING CAS AND THEN
THETH SURGEON TO -- CHEMO CEY
CHEMOTHERAPY -- POINT OFF VIEWIE
AND THEN TYPICALLY THEHE MIs --s
SO MORE EXPERIENCED SURGE SS
ARE --AR LOTS OF GYN ONC IS --S
INSTEAD OFD ASKING QSTIONS.
BASED ON THE -- PROSPECTIVE DATA
WHICH --H THE DATASE, BUT TT
TTHEY HAVE SPECIFIC INFOR ITION
AND IT SHOWS OUT COME OF
IALLY SAYING THE SUR
Y -- OB GYN -- YNYBE
CALLED FOR -- CASE OR -- O
ING BUIN TO ME GYN ONCN ONCES --
LAST 10 YEA I THINK IT'S
NOT -- C-- AND NEED T BE
SOMEONE WHO HAS EXPERIENCED
SURGEON REALLY HAVENOWLGEWL
SKILL -- UNIQUE -- CHANGE TO
THE -- NEED TEE BEAISING HAND
SOCIETSOCIPPACH IS MYIZE A CLO
OPINION.
>> THANK YOU.
I'M GOINGOING TOUSTT ADDT TO WHT
YALDA HAD SAID HERE.
I THINK PART OF THE DISCUSSIONS
WE'RE HAVG IS,HICH IS THE
BEST APPROACH, WITH CONSERVATIVE
MANAGEMANT VERSUSSU HYSTEREYSOM,
AND WE'RE BIASED, I THINK T
BECAUSE WE'RE TAKIN T OUR OWN
'S EXPERTISE INTSE THIS THI
DECISIONCIAKONG.ON
I THINK THI TOST OF THE MORBIDIY
FROM THIS DISEASESE HAPPENS IN
UNDIAGNODID PATIENTS THAT SHOW
UP TO THE COMMUNITY HOSPITALS,,
AND THEIN THE T T MDLE OF THE
TRYING TO DEAL WITH THIS.N ICI I
I THINK IT'S A OORTUNIOR FOR
US TO USE U THENOWLEDGEWL WE HAE
FROMOM CONSERVATIVE MANAGEMENTEN
BECAUSE THAT'S -- THE
CONSERVATIVETI MANAGEMENT CT SAE
LIVES.
AND WHERE WE AS A GROUP SHOULDUL
MAKE SOME RECOMMENDATIONS, HOW
ABDOMEN AND SEE THA THE --HEHE
FIRST WE NEED TO INFORM NFAT
IS AN ACCRETA POTEN PALLY
AND TOD T PROVIDERO SOME INFORMN
ON THE APPROACH USING ULTRA UUND
TO AVOID THE PLACENTA, GET G THE
BABYBY OUT, -- FORHE LOWOWOW HAG
FRUIT THAT CAN HAVE TREMENDOUS
BENEFIT AND REDUCE MORTALITY
RELATED TO TS CONDITION.
>> JUST JUS J TO FOLLOW OL THE
CONSERVATIVE MANAGEMENT
DI
USSION, TOTALLYAL AGREE BUT
BABA IN, AND SEND THE P TIENTHE
ELSEWHERE.
BUT I THINK WHAT WE'RE TALKING
ABOUT HERET EAREYRELL CALLS FORA
REGISTRY.RY
I THINK IT'S A GAA
OF CONSERVATSEE MANAGEMENT AST
YOU SAID S S THE UNITED STATES
ANDD OUR OUTCOMES ARE S
DIFFERDIT.
I THINK WE NEED MORE M
PUBLICATBLNS ON THE PATIENTS FOR
WHOM IT FA IS,FAND IN
DIFFERDICEER BETEREN SOMEBODY WO
S PREVIA PRO PRO KREE TA AND
PLACENTA STILLTI IN.LL
IF TIFT GETS ALL LUMPEDUM
TOGETHER, I I THINK T TT'S VERY
DIFFICULT IC KNOIC KW TO COUNSEL
A PATIENTENAD S SAYS I WANT MY
AND AFTERFT HAVG THE
RISK, SHE MAY N M WANT ITAN
IIEA SCO'S COMMENT THAT I
THINK WE OWE TO THE PATIENTSS TO
MAKE A RECOMMENDATION AS WELL,
AND IS IS ONE AREA WHERE I
THINKIN IT'S PRETTYY CHALLENGINN
IF YOU LOOK AKTHE DATA.
>>
SO I WANT TOOCKNOWLEDNO
CAUSE I'M NOT GOING TO BE IN
THIS WORKING GRO TOMORROWRO BUT
THE QEION I HAVEEOR Y IS,
S,ONE OFOF THE DIFFICULTIES I IU
WHEN YOU ASK --E HAVE ONEE E
WHERE IT'S READILY AVAILABLE,
TH
HAVTO B ONNITNI WE'RENOT THATTE
GOINGINO ND THEM, BUT THEY'RE
STILL HAVING TO HOLD THEIR T O.R
TIME.
SO JUSTIFICATIONTI FTIOW WE MAKM
RE THERE'S COMNSATION FOR F
THIS VALUA VEUAIME THAT WE'RE
BOOKING OKT THEY DON END UP
SENT AY. AEING BNGNG NEEDEDD ANA
THESE CES?ME TOE TERMSER WITH
THEY'RE INCREDIBLY COSTLY T
GYNECOLOGICHE
EXPERTISE WN WE'RERE ASKING TO
BE
BE T.
>> THAT' T EXACTLYCTCTHEEBAT
ERE W -- EARLY 2000,00 ACCRETA D
A HUGE DEBATE.
AT WAS ONE PRESENTATION FROM
JOHNS HOPKINSNDHEY ARE --
DON'TN' CAL-- WANT TOO FOCUS ON
NCER SURGERY, SO WHAT THHA ARE
DOING ISIS SHIFTING, GIVING THE-
ED -- TEACHING THNIQUE
D -- TECHNIQEC, ---- THE CENTER.
I THINK THIS IS A BIG
DISCUSDION NATIONAATY.
I THINK DIFFE DNTFEFE HOSPITALSE
PROVIDING THIS IHIS DIFFERENT
WAYS, YOU HEHE PUBLIC
SURGEON WHO'S GOING TO BE TO RE
EV
IEV THEY' T JUST ONTANDBY,ND
BUT CLEARLY, WT DO YOU THINK
ABOUTABATIONAL SOLUTIONS, I
THINKBOUT THE SURGICAL
EXPERIEXCE, HOW TO COMPENSOME,OE
AVAILABLE I THINK NEEDS TO BE A
PART OFBEBE IT.
I HAVE A FOLLOW-UP QUESTION
S. T
MOST COMPETENT SURGEON ORO HAVTR
WHATEVER IT BE, GYNON GS GISTISR
WHATEVER PRESENT FROM THE
BEGINNINGI WHAT ARE THE OTHER
SURGEONS DOING THEN?
WHY ARE THEY THERE?HE
>> IN MY CASE, GYN ONC STANDING
BEHIND THE LEGS AND THEY SUPPORT
C-SECTIONEC AND -- - GO HIGR,
YEAH, GO -- AID ADHION,
DON'T WORRY ABOUT THAT ADHESION,
KIND OF NUANCE.NCNC
EN AFTER THE BABY IYY OUT, THEN
FROM THE PATIENT'S RIGHT SIDE
ANDAN THEN -- HYSTERECTOMY.
MAYBE THAT'S WHERE THE COST
SAVINGS SHOULD HAPPD IS THE
OTHER SURONS DON'T NEED TO BE
TH
>>
I AGREE WGRHH GEORGE, ALL
GYNONICS GGYNONCOLOGISTS D CESAN
SO THESO DONSO NEED TO BE THERE.
>> DANIEL -- I HAVE TOOME BACK
SHIFT FOR US.K IS AN IORTANT PAG
I TNK T IT'S HARD TO IGNORE ONOO
REFUSE, I THINK THEARDEST PART
AS
OU'VEAID IS MANAGINAN THESE
PATIENTSEELS LIKE THE E LD,
WILD WESLD.
THERE'THA LOT OF DESCRIPTION OUT
THERE, THERE'S NOT REALLY ANY
EVIDENCEIDASEDIDED GUIDELINES, D
LO
, YOUR COUNTRY, YOU HAVE
BE
SO HELPF H IN GIVING USG THE
DECADESCA WORTH OF DA O, BUT ARE
YOU HONINGG IN ONATIE
FFERENCES ANDS ANAGEMANT
DIFFERENCES AND WHO NEEDS
EMBOLIZATION, WHO CAN BEAFELY
ONCE ION A WHILE, WHOAN ORTSLE
SHOU BE INSTRUMENTEDMET SOME
POINT POR THE PLANTA, THESE
ARE ALLE REALLY IMPORTANT THINS
TO HAVE A HANDLE ON AND I
JUST WONDERONHEREREE'RE AT WITH
UNDERSTANDING IT.
>> Y, THANKK YOU FOR YOUR
ESTION.
I GIVE SE DETAILS AAIUT ALL
DETAILS OF CONSERVATIVE
MANAGEMENT, WE HAVE NOT ED ASOU
DO IT'S IT'OSSIBLE TO RESPOND TO
ALL THE QUESTIONSST THAT'S WHY I
DO NOT BELIEVE IN RCT FOR FOR AL
BECAUSE WE -- TOSE OXYTOCINCI R
-- FOR THE DURATION -- FOR
IMPOSSIBLE. FST -- IT'SS
.SO I SONGLY BELIEVE THAT GOOD
OSPECTIVE --E ESTABLISH -LISH
WO
D BEE INTERESTINGESO TRY T
OHEHEHE DIFFERENT
NTQUESTIONS.S.
VE NO -- RESPONSE.NS
CLEAR RESPONSES
>> ALL THE TIMESIM BUT I KNOW K
DO LIKEEE THAT AND SOMETIMES I Y
TO NOT DIRECT THAT FOR MORE
CASES CATH NO MRH A IF YOUU HAV
SOMESO TROUBLES AND IAN-- YOU HE
SEEN, WE DO NOT PERFORM -- SOME
DINGSO IT'S VERY DIFFICULT
TO CHANGE CULTURE OF A TEAM SO
THAT'S WHY BELIEVE THAT
PROSPECTIVE -- WOULD BE B
INTERESTING ANDUST RESPONDES
TO KARIN, THE T CLINICAL SITUATI
IS VERY DFICULT, VERY V
DIFFERENT BETWEEN THE FST TWO
WEEKS, THE FIRST TWO WEEKS YOU
CAN HAVN MASSIVEVE BLEEDINGS AND
TO PERFORMURGERY EMERGENCY ATT
TWOTWO HOURS -- WEEKEND.KE
BUT AFBUR AFE FIRST TWO WEEKS,
IT'S MORE LITTLE IECTIONS TIS
SMALL -- - OR -- IT'SS NOT
MASSIVE BLIVDING SO YOU HYOE
MO
TIME TO TORGIZEE TO PLANO
RATIONS.
IT'S NOT THE SAM CLINICALL
SITUATIOTUATIO
I THINK ALL OF YOU IN THEN
AVE TO BE PREPA PD TO
ART OFFERING THIS. T
MANYMANY WOMEN NOW ARE AWARE OF.
I ASSURE YOU THATOW WE'
DOING ONENE TO TWO EVERY WEEK, D
O US-- WOMEN ARE COMING T
BECAUSBE THEY ARE REFUSING WHAT
I HAVE PATIENTS OM ALL OF THEN .
NOT ONLY FROM TEXAS T
I GET EMAILS EVERY ETHER DAY,,
ECES, SHEENT ME -- SAYINGVE
MY -- WANT TO DO D ONL
THIS IS THE ONLY OPTION..
SO THIS IS BECOMING VERY COM COC
YOU ED TO PPARE,PA MANY WOMEN
NOW ARERE RLIZING THIS IS AN
TIONND THEY'RE GOING TO
DEMAND IT.
-HEN THEY DO T ULTRA UUND
ON THE TATIENT.
THE LASTE PATIENT -- NTMILY --
REFUSED FU LET US DO I..
WHETHER IT IS I A ACCRETA OR NO,
THAT WAS THE OPTION.
SO WE NEED TEEO START PRERING
FOR IT.
>> CAN YOU COMMENT, THOUG T ON
MEASURES A PATIENT EXPERIEXPE
AFTER AS WELL, BECAUSE I THINK
THAT'S KEY PIECE.
EE MEDICALUTCOMESS
IMPORTANT AND THATHASHANE AS
WELL.WE
>> --HE ONE W O CUT THEIRUTERUT
AGN.
THEY LTHVE THE HOSPITAL,
ME OF THEM,THHEY COME BACK
BLEEDING.EE
THE BIGGEST --T FT THEM IS THE
SCHARGE.
E.SOME OF THEM SAY I HE THE
SMELL OF DISCHARIS THAT'S
MING.
.SOME OF THEM, THEY TON'T HAVE
ANYTHING.
IT'S GOINGO VARYASED ON OLLLL
OF IT. I I
NOW, DO IO HAVE H ENOUGH NUMBERO
SAY I -- EXPERIENCE RIGHTHT NOW
SO AS WE'RE WOLRECTING DATA, D
WE'LL START TO T COLLECT ALLF
>>T WANT TANO T FOLLOW ULO ON
THIS.
SO WE'REALKING ABOUT I IN
DIFFERENT WAYS OF DOI IT BY
DIERENTT CENTERS AND CONTINUETI
ING ATOU'RE US'R TO IN
YOUR CENTEREN OR WE'LL SEE WHA
THE PATIENT WANTS OR THE
IMMIGRATION ISSUE IS DETERMINING
THIS.
I DON'T THIT THIS SHOULD BE THEE
WAY WE PRACTICE MEDICINE.
BECAUSE IF IE BELIEVE WHATT YOU
SAID THAT THIS IS LESS MORBID
THAN THE HYSTERECTOMY, THEN WE
SHOULD PROVE THAT.
NOT JUST SAY,H, IT INDSNDSON TI
DISCUSSION.THIS IS AS WONDERFUL
YOU'RE GOING TOE ALLLL TOGETHER
ANDITH FEW OTHERS, SO YOU CGROUP
CONTUE THAT AFTER.
THANK YOU, DR. HOBSON,OBOON,
>> I ALSO THINK THAKWASK A
NTASTIC SEG NA OUR NEXT
N 4.
WE ARE GOING TO BE SKIPPING THE
BREAK, SO IF ANYBODYBO DOES NSD
TO TAKE TAK AAK, PLEASE FEELL
FREE TO DO SO.
SOESSION 4 IS GOING TO BE
MODERATED BY DR. CARUSI,
EAKING OF W OT THE PATIENTS
LY WAN WANANE'RERE REALLYEA
HONORED TODAY TO HAVE THE
PATIENTEN PERSPECTIVE GIVEN TO S
KRISTIN TERLY SEE FOR THE
NATIONALON ACCRETA FRENDATION.
THANK YOU SO MUCH FORH COMING.
KR
N TERLIZZI.LI
>> SO MY TALK IS GSNG TO BE
MORE RELEVANT TODAY THAN I EVENE
EXPECTED.
I'MRISTINERLIZZI,I,NDI,ND I'M
O TALK TO T YOU ABO THE
TIENTT EXPERIENCE OF PLACENTA
ETA SPETA UM..
RIEXCED PLACENTA ACCRETA
IN
MY SECOND PREGNANCY.CY
TODAY WITH AWIUOTE.UO MY TT MYT
ANDANDT'AN A QUOTE FROMRONE
BROWN.
WHAT ELSE IS A STORY SIF NOT N
DATA WITTA A SOUL?I AM A CHAMPIT
STORIES, AND THE DATA THAT THEY
AND AS CO-FOUNDEFOF NATIONAAT
ACCRETA FOUNDATIOND I'VE HEARDEA
HUNDREDS OF ORIES.OR
I SPENT THE PAS SEVEN YEARS OR
AT THIS COLLECTOR, THIS
CURATOR OF ACCRE A PIENT
ORIES.
ANDD PATIENT STOESTO HAVE AEE WY
GETTINGNG US NEW INSIGHTS.
THEY CAN HELAN US TO SEE ASPECTS
OF CARE THAT MAYBE M WE DIDN'TID
REALIZE OR NOTICE BEFORE.
AN
FOR US THINGS THAT WE MAY
ALREADY KNOW, BUT WE C'T QUI'T
FIND THE WORDS W W FOR.OR
I'VE FOUND WHENE SPEAK IN AKE
LANGUAGE OF PATIENT STORIES, WE
ARE AAR OF SUDDEN ARMEDRM WITH
THESE SPECIFICC EXAMPLES AND
ILLUSTRATIONS OF DATA.
AND WHEN THAT HAPPENS, O
UNRSTAING GAINS A DEPTH D TO
A NUMBER OR SR TISTIC
DOESN'TESN' CESRY ASSS EASILY OS
MY STU OF PATIENT STORIESTO
I'VE NOTICED THAT T SOME WAYS,
ONE PATIENTAT STORYAN
T'S STORY.LTLY BE ERY
CARRYCAY THE SOUL O MANY.
ANDD I'MLWAYS STRUCKTR HOW HISOA
PREGNAPRY FEELS, YET HOWOW
UNERSAANDONSISTENT SOT MANY
DEITE CETY DIFRENT ARE.RERE
CLINICAL CASES.
THISTH FASCINATES ME.
D I HOPEOP IF ITE DOESN'TLREADYY
Y ATE END OF THAT TLK,
THAT ITASCINATES YOUOO.OO
SO
THE YEARS SINCE I'VE
EXPEENCECE PCENTA ACCRETA, I
SHAREDSHARSTORY A LOT.
KE A LOT.
AND THAT'S ME STANDING ON MY O O
PEONALOUNTAIN BECNSE ITTT
FEELS LIKES LIT SOMETIMES,IM
G OUTHERE'S'S THIS THING T
CALLED PAS AND IT'S A DEAL!
RIGHT?
AND I'MOING TO KEEPO ELLINGY
STORY UNTIL WE REACH RY GL,
WHICH IS FOR F ACCRETACCARE AND
PERIENCE TO ADVANCE SO MUCH
THAT MY STORY IS NO N N LONGEIS
RELEVANT.VA
SO I HOPEOP THAT T HEARING MY SY
TO GROUNDDDOUN W WE
AREAR HERE. H
ANDANHEAN WORK TORK W NEED TO D.
OF THE HUMAN ASPECT OF THIS HY
WORK, A THE MOST IMPORTANT PAR
PATIENT STORIESP RECONFIRM
YOUOW IORTANT THIS WORK
AND THE T TREMENDOUS IMPACT
THAT YOUATAVE.AV
ALONG WITIT ME ON PATNTYOU Y
EXPERIENCE JOURNEY.
I'M GOING TO TAKE YOU Y YHROUGH
SOME OMY STORY WITH PLACENTA
ACCRETA, AND I A AOEO
BRING IN SE OF THE WORDS AND
OF OTH WOMEN WHO'VE
EXPERIENCED IT AS WELL.L.
I'LL SRT MY STORYTO AT ONE OF MY
SO USUALLY, MY ULTRASOUNDT
APPOINTMENTS HAD BEEN HAPPY.
DOCTORS WOULD W SAY THINGSS LIK,
LO
T THAT CE NOSE,ND
POINT TO THESE PICTURES THAT
STLY I CLYLD NEVER REALLY
UN
RSTAND.TA
BUT NOWAT MYY 30-WEEK
APINTMT AT A NEW PRACTICE,
NO
NE WASAS SAYING ANYTHING LIKE L
THAT
AND IN FAC MOST M OF MY
OUTR WASN'T EVEN SPENT
OKING OK MY BABY. B
IT WAS SPENT HOVERING OVERVE THT
THEY TELL ME TL T IT LT KS L
LIKE MY PLACENTA HAS GROWN
AND PROBABLY YOUR BLADDERER TOO,
THEY ADDED.
I HADI NOWN AUT T UTERUS
PART FOR A FEWAYS,S, BUT THE
AND THAT WAS SOMETHINGET BEGANIT
WONDERING ABOUT 10 MINUTESIN
EARLIEEAINHE APPNTMENT, WHE
THE COMPLETELYELILENT ULTRASOUND
TECH WAS SPENDINPEINPE WAY TOO G
GOING BACK AND FORTHVER MY
BL
DER.
AND SO THEY TOLD MEO COME IN
FULL F BER. OINTMENT THAT DAY D
SOMETHING THINTH MY M PRE PS
PRACTICE HAD NEVER TOLD ME TO
Y THE WAY.
AND I'M A VERYER COMIANT
PATIENT, SO I DRANK THISIKE
ORMOUS COFFEE ON THE WAY
THERE.TH
D I CAN TELL YOUOU THATHA IT'
ONFUSION TODD OUT THAT
MY BLADDER, DDE ONLY ONE I IET,
ALTHOUGH AT THE MOMEN MOMT
BECAUSE WHILE I'M PCE PING ALL
OF THISNFORMATION, I ALSI WAS
HOLDING MY BREATH BECAUSE I HAD
ADTO
EEO BAD BAD FADM THATT ENORMOUS
COFFEE...
SO THEY SWHECH THE ULTRASOUND
INTO VASCU VRITY MODE, A A NOW
IT LOOKS LIKE A WEATHEREREPORT.
AND ITT DOESN D RLLY MATTER
I DON'T KNOW HOW TO
AD IT BECAUSE LOGIC AND
CONTEXT ARE REALLYLL ALLLL IT TS
TO THINK THANKALL OFALHESE
BRIGHTLYOLORED ILLUMINATIONS
TWISTITW AROUNDRONTO WHAT I CAN
BLADDER, THAT IHAS NOT A N G ADD
THING.TH
AND THESE ARERE ALL THINGS I'VEE
BEENBE SURING THE INTERNET OVER
S WEEK.
MY PVIOUS PRACTICE IICIC
DIAGNOSED ME WITH PLACENTA
PREVIA AT MYA ANAMY ULTRASOLTD,
I HAD LEARNED ORN THEI
KIPEDIA PAGE, YESON THEHE
WIKIPEWIA PAGE, YOU GUYSUY LOVE
THAT, RIGHT, WHE, PATIENTS GO TO
WIKIPEDIA, -->> I THINK WE LOST.
>> ALL THE ELECTROLECS ARE
FAILG.
I LEARNED TT PLACENTA PREVIA
PLUS A PRIOR CESAREAN CAN BE THE
PEECT STORM FOR A SEVE
COMPLICATILI THAT I HAD NEVER
HEARD OF CALD PLACD TA
ACCRETA.
MY PRACTICE ABOUT THAT AND THEY
SAID, OH, NO, NO, YOU'RE GOING
TO BE FINEIN
TH
SAID THED WOMENOM WHO GET
THAT, THEY'VTHHAD LIKE MANY,
MANY, MANY C-SECTIONS.
EY SAID YOUDE ONLYNL HAD ONE
C-SECTC-N, YOU'R YGOING TO BE
FINE.
AND THEDT ON TREATINGAT ME
LIKELIKE A RTINE PREGNANRE FOROR
ANOTHER TWO M TTHS OFTHS FLAGS
UN
L I GOT CONCERNEDED ENOUGH TO T
MAKE MY OWN SECONDEC OPINIONPI
HOSPHO -- OH OR APPOINTMENT.TM
SO AT THIPOINININ THE
APPOINTMENT, DOCTORS ARE STILLLL
TA
ING, I'M JUS'M CATCHING
SNPPETS OF INFORMATION,ON
ADMITTEDLYTTROBABLRO THE WORST
ES.
HEAR 99% CHANCEHA OF MASSIVE
HEMORRHAGE AND HYSTERECTOMRE
I HR 9R CNCE OF ICU TIME TN
ILATOR.
I DON'T WN'T TO DIE FROM
CHILDBIRTH.
OUNDS LIKEE SOMEE 19TH9T
CENTURYNT OREGON TRAIL TYPE OF
FDE
F A LIVE IN I
SAN FRANCISCO.
I HAVE GAT HEALTHCARE.
I TAKE PRENATALL VITAMINS.
I FLOSS ALMOST EVET E DAY.
I HAV BEEN DOING D ERYTHG
THAT I AM SUPSED TO DO.
AND SO AT THIS POINT, TNTRE'S'S
TEARSTREAMINGGOWN MY FES
JUSTHIINGINBOUT HOW MUCH
GI HAVEE TE LOSE.OSOS
ERE'SE'LL THIS SWEAT
PO
CK PLUS PAPERAP BEDED COV THAT'S
MAKING ALLLLFLLHIS WORSE.
WHAT AWHI SUPPOSEDPPO DO? D
SO FOR THEEN LIKEYSELF WHO
ARE LUCKY ENOUGH T BEE DIAGNOSI,
HOW DO WE LEA TOOPE WH
THIS DIAGNOSIS?
IT ISHE I WEIRDESEIRD FEELING IN
THE WORLD TDO NOT BEOTXCITED
ARE ALSO TERRI TED OF DYING.U YY
ACCRETA MOM MOM SAYS, I RESEARD
AND READ ACCRETA STOESTO EVERYRY
NIGHT WGHLE IAIDN BED NOTOT
SLEEPING.
I EVEN WATCHED VIDEOS OF O
CESAREAN HTERECTOMIES.
THE FEAR OF DYING CONSUMED ALL
MY THOUGHTS.
PLACENTA ACCRETA OFTEN SEPARATEP
WOMEN FROM THEIR FAMIES,ND
IT CHANGES EVERY FAMILY DYNAMICM
I WAS CEO A ORGAN OER OF MY
HOME, AND WHE I WASASAS ADMIT A,
MY HUSBAND BECAME AAMINGLE DAD
OVNIGHT.
ALL OF A SUDDEN, EVEN,THINGIN IS
GOING WRONG FNG TNGOMEN..
AN
MANY ARERERE ACULYCULY AWARE OF
A ACCRETA MOMAY I'M'M AONTROL.
PLANNER AT HEART AND SOMEWHAT OF
CONTROL FREAK, AND THIS
CONDITIOND WENT AGAT A
EVERYTHING I HAVE
EVER E KNOWN.
I WAS W ADMITTED SHORT S AFTER A
THAT ULTRA UUND APPOINTPPNT.
I W TD T THAT T WOM WITH
WELL IN THE ONSIDE WORLD IFDO
ING WEREG O HAPPEN.
TH
CHANGE INNGHE LEVEL O CARE
WAS IMMEDIATELY AELARENT.
AND THERE WAS A PIECE AND A A
FINALLY FEELING LIKE MY
NDITION WASN BEING TAKEN T
SERIOUSLY.
AND ONCE I GOT INT THE
HOSPITAL, ITIT WAS W SREALAL TOL
ELCOMPLETELY HEALTHY AND FE
WHILE THIS TEAM OF PEOPLE THAT I
HAD J MET MET WAS W BEING ASSEMD
TO
EM PN OUTN THE DETHELSETF WHAT
WAS EENTIALLYHISHI LIKE
TERRIBLE ACCIDENT THAT MEE AE MY
UN
RN SON WERE ABOUT TO TO BE
AND ONE OF THE THIHES THATOF
BOTHERED ME MOST WAS TT I I I WS
GO
G TO T BE THE LT ONE TO KNOW
ABEVERYTHING.
I WAS GOING UNDER U AND I HAD N
IDEA WHEN I WOULDOULDOU WEP OR
WHAT IOULD WAKE UP .
AND THATEVEL OF SUSPENSE IS
PRETTY HAR TO TO MATCH.
AN UNDIAGNOSED ACCRE A MRE SAYS,
MY HUSMYND WATCHED ME WHEELED EE
WHEELED IN TO THE NICU, NOTSONON
KNOWING WHETHER WE'D SURVIVE.
AN ACCRETACC MOM SAYS, THE TERRR
OF WAKING UP IN AN INTENSIVE
CARE UNITNI AND N N KNOWI KNOHEE
OUTCOMEOM OF O YOUR CHILD BIR.
I KNOW THIS AND TOLD MY HUSBAND,
Y SON, I SAID SHAT IF HE'TN'
WASN'T OKAY, I DIDN'T WANT TO
KNOW THAT.
I
ASKED HIM TO KEEP THATHA FM F
ME, IF THAT'S HOWS HT ENDEDP,
BECAUSE I WORED THAT TF I
WA
THAT TTHT WOULD BREAK ME, IN A A
WAY THAT I DN'T KNOWNO IF I
COULDEAL WITH INEAN THAT SETTIN.
THESE ARE THEYPES OF THINGS
THAT YOUR PATRNTS ANT THINKINGNK
ABOUT AND DISCUSSING WITH THEIR
FAMILIFA.LI
SO MY HBAND DIDN' D H DEEE TO LE
TO ME,TOND OUR SON D S WELL.
WHICH WHTUALLY MADE IT VERY
LLING ME THAMEBECAMEECA YOU ARET
NO, HE DID.HE DID GREAT.
MADE TODE MYLANN DERY,
AND MY SON LEO W AT 33
WEEKS AND HE W 5 POUNDS
12 OUNCES, WHICH WS PRETTY
ENORMOUS FOR THAHA GESTATIES,ESY
THE WAY.
THAT CRAZY PLACENTACE DEFINITELY
HAD A FAVORITE, WAS LOOKINGUT
FOR HIM.
APPRECIATEE THAT.T.
BUT UNFOT UNATELY FOR ME, ATT MY
DELIVERY, IT WAS W DISVERED THAT
IAD A MUC MUC MORXPEN PA EXPSIVA
THEY ENDEDP STOPPING THE
SURGERY AND GOING OUT TO TELL MY
FAMILY TMIT THEY COULDN'T FIND
SURGICAL PLANE TO T BEGIN THEHE
ECTOMY THAT WASN'T COVERED
IN PLACENTA.NT
OLD MYOL FAMOLY TH THE
BLOOD BLSSD BL COMING OFF OF O Y
IN DIAMETER.E IEREX FINGERIN SIE
AND THERE WASERIOUS CONCERN
THAT NONATATF MY M M BLADDERDD E
SALVAGSABLE.THEY DECIDED IT WASO
PROCEED OCTH THE HYSTERECTOMY,
AN
MAN M CARELANN INSTANTLYTA
CHANGECHANGECHO UNE UTED
CONSERVATIVE MTIAGEMTIT.T.
I WOKE WE UP IN ICU,CU SHOCKED O
LEARN THATN HEYHE DIDN'TN'T DO .
I KNEW THAT EVERYONE H
EXPEED MY CASE C TO TO BE SO
SEVERE,VEO TON TO T FIND OUT THT
IT WAS ACTUALLY WORSE THAN
HADXPECED?
THE SURGERY HAD BEENEEMED
LAST RESORT, AND NO ONE REALLY
KNEW WHAT WASASOING TO HAPPEN
NEXT.
WHAT IT HAD EXPTED TO B A
SP
NT TURNED INTO A MARATHON.
I FELT LIKE L A A TIME BOMBAITIG
NARNINGAROW TO BE AULL TERM
BABY.
TODDLER HAD MOVED IN WITH MY
PARENTPA AND MY HUSND SPENTPENT
IT FELT LIKE IASTILLSPITAL WITIT
PREGNANT.NA
ANXIOUSLY AWAITING ETIHER THAT
SCARYSCELIVERY O SOME ACCIDENT,
EXCEPT NOW MAYBEBE FOREVER?
AND FOR THE FIRST SIX WEEKS THAT
I LIVED WITH MY ENTIRENTLACENTA
HAPPENED.NOTHING REALL RLL R
UN
L ONE MORNING, I WOKEE UP
WITH BLEEDINLE ANDATER THATHA
DAY, I PD MY KNEEY N THE
BEDSIDBETABLE AND WATCHEWA THIS
LIKE EGGANT PPLEPL BPLISE
SPREAD OVER MY SKIN LIKE IAD
NEVERNE SEEN, AND A STAT BLOOD
ST WLD SOON REVNL TNT I
HAD FIBRINOGENGE LEVEL OF 46 AND
I HADHA DELOPED DOP FROM F
RETAINED PLACENTA.
AS I MADE MY WAY FROMM THE CAR
BACK INTO THE HOSPITAOS AGAIN TT
BE RE-ADMITTAD FOR THAT
EMERGENCYGENCYURGERY, I FELT LEI
COULDNCO WALKAST ENOUGH.
I WAS SO SD THAT SOHATHING
ELSE WOULD HAPPEN, THAT I WOU
IMPLODE BODOREOR I GOT THROUGHOU
THOSETH DOORS.
7 WEE 7 OLD LEO AND MY 20
NTH OLNT EVERETT, THEY WERE
SSED ADETWEEN WTEVER
RFAMILY AND FRIENDS WERDS ABLE O
GET THERE TN TIME TOO HELP.
WHILE MY HUSBAND AND MY PARENTS
SAT IN AN WAITING ROOM ALL DAY,
WONDERINGER WHICH WAY THIS WAS
GOING TO GO.
I HAD AN A EMERGENCY HYSTERECTOE
INCLUDING BLADDER RESEC RON,
REIMPLANTMPION AND OTHER
REPAIRS.
TH
STHGERY WASAS CPLICED, IT
TOOK A FULL F DAY, AND INC ID
THE TRANSFUSION OF 26 UNITS U OF
BLOOD PRODUCTS..
EVERYONE SAID THAT T THE SGERY
WENT MUCH BETTER THAN IT WOULT
HAVE BEEN BN DELIVERY.
AND THAD MY PLACENTA HAD H
ACTUALLY DECREASED IN SIZEVER
L.ER
HAT PER P BETWEEN MY M
DIAGNOSIAG DEL DY AND MY
EMERGENCYGE SURGERY AT 7 WEEKS
POSTPARTUM, I HAD KNOWN THAT MY
BODY.NTA HAD BEEN RAVAGINGY
BUT IADN'T UNDERSTOOD UNTIL I
WAS DEEP INTONT THIS ACCRETAEXPO
MUCHMU MORE THOR A PHYSICAL
CO
ITION.
AND THADURING THIS TIME,E, MY
PLACENTA WOULD HD M HOSTAGE.GE
IT WOULD TAKE EVERYTHING I HAD
THOUGHT ABOUT THE WORLD AND I
TURNED IT UPSID UDOWN.
WHAT IS THE MOST OVERL OKED
ORGAN INVOLVEMENT THAT
'S BEEN BREE YEARS SRSCE THACET
MENT FOR ME.
AND NOT A DAY D GOES BY THAT I'T
SOMEHOSOCOLORECOBY THAT
EXPERIENCE.
ACCRE A MOM SAY HOW H WAS I
SU
OSED TOEDO BACK HOMEE AND
PPENED?N ASF NOTHING HAD HVER
PAINFUPA WHEN FRIDS OR FAMILYMI
SITUATION.TIAND THE TEVITEV OF
U LOOK HEALTHY,LT THE T BABY IS
DOING GREAT.
WHAT'S THE PROBLEM?
ACCRETA MOM SAYS,S, MYIDSS REALL
EDEDE TO BE TRE T TOR THEM
AND NOT N NRYING ALL T T TIME. .
FO
MANYAN US, ATA ISN
HENHE OUR PLA PAS ARE
GONE.
AND FOR M F I TOOK TIME AND A
ALLY SOLID NETWORK O O FRIENDS
AND FAMILYAM FAM ME TO T FEEL SE
AGAIN.
THAT I I SWITCHED HOSPITALS AT T
11TH HOUR AND THAT I H T ACCESSS
TO APPROPRIATE MEDAL CARE AND
AN EMPATHETIC CARE TEAM.
THERE'S MY SONEO..
TODAY YOU WOULD NEVER EVEN KNOW
TH LEO W L EVER A VEEEMIE.
HE'S AEISTY AND A DETERMINED
9-YEAR-OLD, AND, WE'RE W PRETTY
CONVINCED THCECE MY M PLACENTAAV
USUS SOME MAXMAN POWERS.
SO I CONCLUSION,US NEED TO T
YOU WITH SOME PATIENT
CALLS TO ACTION.
WE ND TO BETTERET UNDERSTAND WHY
DO TO PREVENT ITENORITEN ALL O E
INCREDIBLE WORKKHAT'S BEING
DONE IN THIS ROOM TODAY, WE NEEE
REDUCEEDUCUC AMOUNT OF WOMEN
ENWHO REQUI R ALL OF THIS T TO E
A BABY.AB
AN
WE NEEDD TO T TNK T ABOUT-
PROPERLYOPDUCATE PATIENTS ANTUT
NG-TERM RISKS.
WOMEN PLAYLA A ROLE IN THE RISK
FACTORFA TOOFA BUT THEY DON'T HR
THE WORD ACCRETATA UNTIL THEIL T
DIAGNOSED WITH IT.
WEWE NEED TO IDENTIFDE THESE WON
EARLY AND GET THEM TO THE RIGHE
PLACE.
THIS IS NO SHA INEFERRALS,
AND IANTHE MAJORITAJ OF CASES, I
KNOW THATHAT PRHAESSHAORKS,
BU
'M HERTO T TU IT
ESN'ESPPENES AS CONSISTENTLY
YASYOU MAY THINK.
THERE ARE LARGE MEDICALIC
PRACTICES OUT THERE LIKRE THE OE
AL INTERNANTERNT POLICY OF NOT
REFERRREG OUT FOR ANY PGNANCY
CONDITIONECSE T'S --
EY TREAT THEM ALL.
THERLL ARE OTHER PRACTICES WES
MAYMA NOT HAVE A POLICY, B THEY
DIAGNOSEAGNDEEP N-EMERGENT
THA THEY SHOULDN'T.
THEIR PATIENTS FIND F, WE HEAR
RTHRR STORIES, WE CAN READEA
BETWEEN THE LINES AND A IT'
HE
NO PATIENT SHOULD HAVE THE
BURDEN OF HAVING TO T BECOMEE AN
EXPERT IN AESSING MATERNAL
LE
LS OF CARF
TO SHARE A QUO FROM DR. N D SH.
WOMEN WANT MORE FROMM CLDBIRTLD
TH
TO EMERGE UNSCATHED.
AND THIS IS I TE FOR PLACENTLA
ACCRETA MOMSS TS
ESPECIALLY AS WE MAKE MOGRE M
IN TREATMENT METHODS, ANDS THE T
BAR RAISES IN THE CARE THAT'S
BEEN DELIVERED, WE CAN'TORGET
ILDBIRTH EXPERIENCE.'S
AND SOME HOSPITALS ARE OFFER OGR
THINGS TO THEIR PAS PATIE PS
LIKE DIFFERENT INCISION TYPES,
WEEE YDRAPES,APE HEAR ABOUTOU
AND IHERE TO SAY THAT
WHETHEWHYOU'RE AWARE AF IT OR
NOT, PATIENT EXPER ENCE IS
QUICKLY BOMING T NEXT
AT NATIONAL ACCRETA FOUNDATION,R
OUACCRETA PATIE PS AND STORIES
HELP.P.
THANK YOU.
>> FOLLOWINGRISTIN IS ALWAYS
DR. SHAINKER IS UP TO IT.T.
>>>>OU CAN HEAR MEEA
GREAT.
I JUST WANT WAN W TO ECH EVERYOY
THANKS TO BRETT AND CHRISTINA.
THANK YOUK TI FOR A GREAT, GREAT
DAY.
MY NAME N IS SCOTT SHAINKER, I'M
FROMFR BETH ISRAEL.
WE'RE GOING TO PIVOT A BIT.
ALWAYS TOUYS TO FOLW KRISTIN,ST
BU
TALK ABOUT BIOMARKERS.
HERE ARE MY DI MLOSURES.
TH
E IS ONE AT THEOTM THAT
PROBABLY ISS PERTINENT TO THIS
I'M NOTNO MAKING MONEG ON IT.
R THOSE OF YOU W Y FOLWEDWE
WORK WWO MWOE M KIND K OF EARLIT
OPPORTUNISTIC TO BE QUI
HO
ST.ST
SO
OFFOU IN THE ROOM ARE SOME
THERE.HE FIRHE TO PUT THE WORK T
WH
COULD KIND OF RETROSPECTIVELY
OK ANDOK SAY DID D ANEUPLOIDYY
EXAMPLESMPELP US TO
IDENTIFY PATIENTSSITH PAS, SOAS
HYPERTBLIE COSHYPERGHYCOSYLATEDG
EARLY E WORK I SYNONYMOUSS
WITH PWIEE CLAMS WRA W WORKOR T.
IT'S NOT SURPRISING THATHA MY
MENTOR WAS A PRELAMPSIA
BIOLOGISOLIS A NE FROF GIS NEPHO
WE'VEAKEN A LOT OF CLUES FRO
AT WE'E' LEARNEDEAN THE
CA BHALL AND S WHATHA PTE PS B
WE
IND AND WHATHA PEOPLE HAVEE
DONE WITH PAS.
SO I JUST WANTO WALTOTHROUGH A
STORY OFORIND OF WHAT W
DO KIN OFF CHANNELHA- THEY DLL T
HAVEVEOME BIOLOGICALGIGI
PL
SIBITY HERTY HUTUTHE FIRST
ONE THON KINON OIN-- AND I'M
GOING TING WALK YOU TOUGH
GESTATION TO DO THIS.
THE MOST SOSTTT LSTOBABLY MABLMA
BIOLOGICALLY WAS HEPP-A.EPEP
WHEN W W WEREER DOIN PAPP-A IS
ASSOCIATSO WATH PLACE PAL GROWTH
SO
FSOSO YOU EXTRAPOLATETE WHAT WEE
KNOW ABOOW AAS, AHAT WE KNOW
AB
T IMAGING, THEY'REY'Y' HEAVIER,R
PAPP-AAPA WOULD BE BEIG BR
WITH PAS.
SO THISHI EARLY WORK ACTUALLY
DID SHO THAT.
UNFORTUNATELY IT HASN'TT BEEN
REPRODUCIBLE IN I ROBUSTT WAY AT
ALL,AL BUT IT IOES SHOW S THAT
OVERTHE LAST 10ASEARS, WE HAVE
STARTED LOOKING AT THE BIOLOGY
GYOF PAS AND A AOW WE CAN FIN A
BIOMARKERAROR IT.
IF YOU MOVE A LITTLEIT BIT FARTR
ALONG IN I GESTATIESTA,
AFP MAKESMA SENSE, RELEASEELFROM
MATERNAL FAL INTER ICE, AN AN
THERE'S A BREDORE I MATERNAL
PLACENTAL INTERFACE WIAC PWI AND
NDSURENOUGH,UG WE FND THA A
P IS HIGHER IN PAS CASES.ESES
AGAIN, THESERE NOT
PARTICULRTLYUL SPECI SC, BUT DOS
SPEAK TO SOME APPLICATION OF
AND IF YOUIF FAST FORWARD AND A,
WELL, WHAT ABOUT SUBSETS OF ACGA
AG COMES FROM THE PLANTA,
THERE'TH HCG THAT IS ACTUALLY
INVOLVED IN I I THE PLUG -- THE-
DEEPESDE FORM OF OF THE -- MAYBE
THAT ACTUALLY COULD BE HIGHER IG
PEOPLE HAVE LKED AT THIS HCG,
IT
EXCRETED FROM T
DIDN'T REALLY PAN P OUT, FAIRLY
RO
STTUDY ACTUALLY LOOKING AT
NORMAL PREVIOUS AND P VARIOUS
RMS OF PLACENTALAL ADHERENCE,
D UNFORTUNATELY THAT DIDN'T
REALLY PAN OUT.
THEN I THINK IF YOU TRY TO LOOK
AT THEOMMENTARIES, MAYBE THREE
OR FOUR YEARS AFTER A NI BTATA
D COMING OUTAY
ACTUALLY THE ANSWER,
FETALTA FRACTION, OKAY, WLLIN
ENTIFY PAS EARLY,LY SURENOUGH,
JU'L USE IT SE IIT DIDITT
REALLY WALK WALORTUNATELY.
NOBODY HAS TO EXPLAIN WHY.
I THK BIOLOGICALLY I STILL
HAVE A HARD TIME UNDERSTANDING
SHOTN TO BE HELPFUL INTION HAS T
IDTIFYINTI
OTENTIALLY, KIND K OF
ACENTAL FUNCTION WILL WELP.NG OF
SO I'M GOING TO PIVOT AVOTIT
JUST -- THE P LGF RATIO.
SFLT A YOU KNO IS --AN
INHIBIT ---- IT'SN ANGIOGENIC
FACTOR AND INHIBITSIT THE FUNCTN
VEGF,F, PLGF DISPL DES VEGF,F,S
NOSURPRISINGLYNGLY FOR
SOAYBE IT'S THETHSE RUP
OPPOSITE FORM FRR A PHENOTYPE.
PEOPLE HAVE LKED AT THAT.THAT
IN PRETTY ROBT WAY ACTUALAC
HAVE ADVOCATEDAT FOR THIS TO BEL
BIR.
PERSONPELY, I DON'T THINK THAT'S
ERE IT I IUT FROM A BIOLOGY
PERSPEIVE, IT DOES MAKE SENSE.
SO THIS IS A STUDY LOOKING AT
VERSU V -- HOW- OW- I GET R G
GOFHAT -- PAS, P CTROLLED PASAS
D JUST PVIA, SFLTFL WITHINSS
AN ANGGENIBINIKER OR
EIN IS DOWNREGULATED PASONAS
VERSUS PLACS TAAC PREVIAS, THEE
PINK, AND, HEN PLACENTA PREVIA
VERSUS CONTROLON IS ALMOST -- IF
YOU LOOK AT PLGF, AGAIN, PF IS
DOWNGULATED IN I PREEC PMPSIA,
AGAIN, BIOLOGICALLY SHOULD IT B
UPREGULATED IN PAS.
WAS SHOWN, SLIGHTLY LESS
ROBUST THAN SFLT, AND THENN IF
YOU LOOK AT THE RATIO,IO IT
ACTUALAC IS T I MOS ROBUS R DA
DATA.DA
IN OUR LAB WE LOOKED AT THIS A
BACK AND SAIDELL, CELLD
WE LWEK AT A ST AND PLGF ANDANAY
WELL, CAN, WLOOK ALOLO THE
TA LEVEL IN VARIOUS FORMS
OF PASs BEFORE WEESE-- FIGO
CRITERIA.
SOEFT,HESE AREERMINAL
VILLI WITHTH SFLT, YOU CANEE
HERE KINDF LOW EXPRE EION
ERE THE DARROWND I HIGH
EXPRESEXON CREATED TATS TCALEPR
HAVE AHAORE HIGHER LIKELIHOOD TO
HAVE INVASIVE PHENOTYPE.
SO KIND OF APPLYING WHAT WE
ALREADALKNEW FROM F SUM
PERSPECTIVE AND PUT IT IACKAC TO
THE SAMPLES RETROSPECTIVELY.
AGAIN, TRYN,GN, TO TPPLY
BIOLOGY TO COME UP U WITH
FAST FORWARD TO KIND OF THREE
WHAT I THINK ARE THREE TF KIND
OF THE MOST ROBT STUDIES, THIS
IS
STUDY MTUY GROUP DID,, MY
OTHER SITES, AND USES -- BASED
TECHNOTECHNOOAPTURE A VERY
DIFFERENTIERE BWEEN PAS ANDEAN E
NON-PANO
THIS IS A PLATFORM THAT WE USE
ANDANOU CANANEE THE ARE JUST
REGULATEGU AMONGST THE PAS P THT
BLUE IS DOWNREGULATED, YOU CAN
SEE THEY REALLYEAO DIFFE DNTIATE
QUITE NIITLY.
THIS WAS AT THE TIME,IME,UKE --U
21 PROTEINS, YOU CAN DEDUCEOSET
WHAT QUITE NICE LIE -- THIS- SIS
OWING ANYTHING ABOUT
PATIENTEMOGRAPHICS, NO
ULTRASOUNDOU DATA, -- - AND TN
WHAT WEE DID W THAT ATHA TIME
ERE WASOMCONTROVERSY
YWHETHER OR NOT THAT T PLATFORMR
KINDKI OF BIOLOGICALLY ACCEPTABA
WE JUST CONFIRMED -- AND SURE
EN
GH WE DID FOUR COMMERCIALLYY
AVAILABLE.
PROTEINS, THEY T ALL WER
SIGNIFICANT AND CONFIRMRME ON E
ONELA.
TH
ISOT ANYTHING OTHEG OTAN
THE BIOLO B, THAT T T AUCs A THA
WERE SWEEWHEREHEHEETWEEN 75 7 A
90%90%.%.
ABOUT 50% OF CASES IN THE U.S.
AREOINGNGAR UNDIAGNOSED.
HOPE, WHO'S WH THE BACK, FIRST
AUTHOR ON THIS PAPER IS OUT OF
THE BRIGHAM, THEY LOOKED AT
MICRO PARTICLES.CL
SO MICRORO PTICLES LIKE --
BA
BISY,F YOUU WILL, AND SO THE
PINK -- SORRY, THE GREEN IS THE
MICRO PARTICLE EXPRESSIONSSOR
PA
COMPARED TO THE T KD K K THE
WHOLE COREE
THEYY FOUND IN THE SECOND
TRIMESTRR, THEY WERE ABLE--
THEEE AUC WAS .72 COMPARED TO .,
DEMOGRAPHICS, IN, THE THIRD
TRIMESTER, SLIGHTLY LESS ROBT
THAN THE T SECOND TR TRIMESTER,T
AGAIN, SAILLLLOPEFUL.
AND WHATD HEY DID WAS THWA
IDENTIFIEDFIFI BOTH SECOND AND D
TRESTER PROTEINS, AND I WOULD
JUST POINT TO T BIOLO BIOL
NCTION, KUDOS TO THE GRO F
DOING THIS, BUT, REALLY THINKING
ABOUT PAS IN A WAY O WHAT W
PROTEINS MAKNS SAKSE ISE TERMS F
HOWHO WE UNDERSTANDAN THEHE BIOY
THE DISEASE,SE ANDND CAN WE APPY
THESE PROTEINS TO IT.
PROTNS, UCsN T0% WHICH FOUR
AGAIN IS I JUST J FABUL FS.
AND ID I I THINK NOT SURPRISING
THIS MORNING ING THINK IS TRULYT
FABULOFA, AT UCL THEY THE USE TS
VELCRO NANOKINDOK OF PLATFORM TT
FOR CIRCULATING CELLS.
THEY FOUND F CIRCULATING
TROPHOBLASTS ARE MORE LIKELY TO
OBE FOUND IN PASASAS AS OPPOSED-
AND CLUSTEREDEDER CIRCU CTINGNG
SPECIFICALLY OR CLUSTERED, THEY
DID ADIABULOUS PAPER SAPWING
NGTHATERY, VERY KIN K KF DEEP D
BIOLOGY.
YOU CAN G C LOST IN IT, IN MY
N,INUT REALL REALL JUSTYY
AMAZING..
AND WHAT THEY FOUND, OUMPARED
PAS TO PREVIA A NORMAL AND
SHOWEDOW SINGLEININ CIRCULATINGG
TROPHOBLAST INT CLUSTERSTERSUSER
CIRCLING TROPHOBLAPHS IN
TO T BE -- PAS P THAN NOT ANDE
THEN APPLIED IT, THIS IS WRERE I
THINK THIS GROUP HAS GONE BEYD
WHAT OTHERS HERE DONE,ON ALTHOUH
I TNK WNKL WANKL WA APPLY T
ULTRASOUNDASOU.
TAK SOMEOM DEMOGRAPHIC,
BIOLOGICAL DICA, PUT IT I TOGETR
GRPP IN COMPARING IT, SO REA R
JUST FULOUS WORK.K.
AUCsF .9 AND ABO, THA T
WHERE WE SHOWE SBE, RIGHT?
FAR ASS I KNOW THIW IS NOT
READY FOROR CLINICAL APPLICAPPLP
YET, I THINK IS FAIRLY
EXPENSIVE, BUT THISSHOUL BE
OUR GOAL, TO APPLY WHAT WE'
BIOLOGY AND ALY UNDERSTANER THEO
TREAENTS.
I THINK WE HAVE MADE GRADE
ES IN I BIOMARKER
INVESTIGATSTN SSTCE WE STARTED.
IOINTEDUTUT O THAT NEXTEXT SLIDE
HOPE'S GROUP BUTP IMILAR TO
OUR FINDR GS AND SIMAR TOO
OTHER STUDIESDI I D NOT MENTION,
PROTEINS THANS PEOPL P ARE
SUGGESSUNG, AND A CERINLY TIS AG
GENESIS TISSUE INVAS INVAND
CELLULAR ADHARION ARIO THE PRIHE
GE OGEORTUGETY AND WEHOD T A
FOCUS ON IS, WHATEVER
KI
OFNOWLGE GAPS WS NEED
TOTO FILL, F APPLYINGIN URASOUND
CLINICAL DATA DO THE BIOLOGY IS
JUST CRITICARI
WE HAVE TO LINK THOSE TWO,
OTHERWISE WE'REIND OF NOT
REALLY MOVING THE BIOMARKERER
FIELD AT ALL.
THERE ARE ANIMAL MELS OELS O
TH
E, THEY'RE NOT THATT GREAT.
WE HAVE HEEF THEM.
IT'S'S MUCH MORE ROBUST MSTEL TT
NEEDS TO BE B DONE,E, VER
EXPENSIVE.
E.BUTE. APPLYIN THE ANIMAL MODET
EVALUATE -UATEFECT,FEIND OF GET
THE PLANTA AT THE END, SO IT'S'S
REALLY --LYE'RE GETTI G THE
BYPRODUCT OF POTENTIALLY THEHE
WHOLEE CASCADEASND WE DON'TDO
TREALLY KNOW, BUT T BUT ANIMALMA
MODEL ALLOWS YOU TO T KIND OF TT
IT ATIT VARIOUS POIUSS DURING TE
GESTATION WHICH WE'VEVE DONE DED
SHOWSH DIFFEREIFRE EXPSSION AND
RIOUS JESS TAIGA T T GESTATIONA,
STO THINK ABOUT THEIR
FUTURE TARGETS.
YING THE ADVANCEDV IN PROTEIN
PLATFORMS.
S.SO
DIDT TALK ABOUTINGLE
RNA SEQ, I DIDN'T TALK ABOUT
CELL.
THERE THE JUST SO MANY PLATFORMS
OFD HEARD THIS EXPRESSION,SSHED
SMOOTH EE ANALIENALOGY, K, K OFR
GAJGA IN,ARBAGE OUT, O THINK
IT'S REALLY ILLORTANT HOW THESEE
SPECENS ARE PROCESSED AND HOW
WE KIND OF DEVELOP THESE TISSUEE
BA
S ANDAN BBA BS.
KUDOSDO TOO BOB FOR KIND KINF
STARTING THAT S.O.P. BUT ALL
KIND OF CHANGED IT OVER THE TIME
OVEN IN BOSTON, WE HAVEAV
THREE DIFFERENT ONES GOING ON,
OBAB ISOTOT THE MOST
FICIENT WAY TO DO THISS.
LALY THELY MAY BE TWO OR REERE
ON METABOLOMABOL ANDND
NOTHING ON LIPID LMICS, NO,NE
IS
EALLYYTARTING TO GET INTOO
TH
LEVEL AT ALL SO I THINK
IT'SITINDD AN A UNKWN WLD
AN JUST KIND OF OPEN OPE TO
EXPLORATION.
THANKTHOU AND LOOK L FORWARD TO
HEARING MORE.
>> SCOTT, THANK YOU SO MUCH.
WE'RE GOING TO CTINUE WITH
TALKSTAHAT A SORT OF ON THE
ONTIERS OFTT IS S
RESEARCHSEURRENTLY AND WE'RE W
REGOINGGOO HEAR FROM D SILVER.R.
>>
THANK YOU GUYS FOR HAVING ME.
IT
GREAT TO BE HERE. H
TH
IS KIND OINF A FUNNYALK,AL
AND IT'S MY OWN FAUECAUSE I
SAID TO THESE GUYS, LISTEN, I'LL
LK ABOUT WHATEVEHATE IS LEFT OVE
AND NOBODY EODE WANTS WTS TO TAK
BUT IT'S ACTUALLY, I THI,,IND
OF FUN BUT IT WILLEE DIFFERENT,
SO IT'S OCCURRED UR ME AS I GET
DE INSTEADTE OF -- WHEN YOU'RE
YOUNG YOU WAN TO TAKE CARE OF
FTHE SICKESSIPATIENTSTIOU CAN
SSIBLY FIND, FHAT'SS T MOST
INTERESTINGST THINGHI TO DO, BUT
WOULD BE BETTER FOR R MANS IF
YOU COULU ACTU LLCT PREVENT THM
FROMETTI SICK IN THE FIRST
SO WE'RE GOING TO GO STREAM
TALKBOUT PREVE PION OF
SO HISTORICALLY,HE
PA
OPHYSIOLHYY,OLOU'VEE ALL
LEARNED THIS, ABSEN AEN OR
DEFICIENCY OFITABUCH'S LAYER
OR
PONGIOSUS LAY OF OF O THE T
CIDUA, THE THE PLACENTA DOES NOT
SEPARATE AND YOU GET BLEEDINGS.
WW W REAZEEAHIS IHIS PROBABLY
YNOT TRUE.
THISS INCSISTENTITH ININ
INFINDINGS ANDONSISTENTT, WH
SO DESPITE THE FACT THAC I KEEP
PROBABLY SHOULDN'T DOO IT
ANYMORE.
AN
ORE.E.
THE IN VIVO EVIDENCE,E, KREDD IE
INCREDIBLCREDITTO BRETT B, IT DO
THROUGH.
IT MAYEE CONTAINED BY SCARCA
TISSUE BUT THERE T NO TRUE
IN
SIIN.
AND THE PLACENTACE AAEARSOO
PROTRUDEOTR INNOVATE SOMETIMES
AFTER YOU PULL ON THETH URUS AND
THEN TH THE PATHO PGIST SAYS, O,
LOOK, THIS THING T I COMING
THROUGH,H, IT'S A P PREKR PERCR.
SEVERE MORBIDITY RATEDAT TO
ADHESIVE DISEA D,BNORMAL
VASCULARITY, THEY'RE NOT
AC
ALLY DALTH OF INVASIONN AND
THEREEAY IS CORRELATION
BETWEEN SCARREDARXISTENCE AND
DEPTH OF INVASION.IO
SO YOUOU NEED N A SCAR, YCAR, NA
OR YOU N YD A DAMAGED
UTERUS IN SOMN WAY, AND AGAIN,
IS THEHE PAP THAT BRETT HADHADPG
ATTENTION TO T TS AND THE HAVE
SEVERALERALTHERAL PAPERSS WITHH
THE SAM S FINDINGS.
SO TS ALTERNATIVE MEL, THE
GR
TH IS I BY DEHISCENCE, NNC
INVASIONVAAND MORBIDITY IS
REALLYAL DUE TO ABNORMAL BMAODMA
VESSELS OR VASCULARITYLA AND
ONS RATHER THAN DEATH.
AND AS Y'ALL SHOW WHEN A
PLACENTA ATTACHESHEOO SCAR
TISSUE,,IOCHEMICALLY, IT DOES
SO THE T PRIMARY PROBLEM IS THIS
EE UTENE WALL
USUALLY DUE TOOURGICAL SCAR SR
CESAREAN AND THEN YOUET THIS
ATTACHMENT TO THE SCAR TISSUESUR
DEFEIVE DECIDUA AND
PROGREPRIVEPR DEHISCENCE OF
RIUM.
SO YOU'VE HEARD ABOUTUTUT THE
INCREASED DRAMATDRALATDRVER THE
YEARS, AND THERE'S NO QUESTION
THAT IT'S INCREASED DRAMATICALLY
ITANTLY WITH WH IREASE IN
SO EDEMIOLOGICALLY, I THINK
THAT OBSERVATION ITITI IMPOR INT
YOUYO ALL KNOW THERE'S BEENEE
DRAMATIC INCREASE IN RATES OF
UNTRIES,TRUT ITR ALSOO WONDER
WHETHEWH THEWH'S BEEN A CHANGE N
AN TECHNIQUE.
EVEN THOUG TI'VE BEEN BN DOING S
FOR A LONG TIME AND I'M GOING TO
N SOMEOM OF MY OLDERER
COES, BAJA, ALFD AND
GEORGE, BACK IN THE DAY WHEN WE
WERE TRAIN TG, WE ACTUALLCTSAW
WPATIENTS WHO HAD LOTS OFS
NOT AS MANY AS DAY BUT THERE
WERE STILL PTINT PNT OF THEMNDE
DIDN'T SEEEE TS.
LIKE A CASE A YEAR.
AND MAYUR CESEAN RATE WAS
18% OR 15%, NOT 30%, BUT WE JUST
DIDN'T SEE IEE
SO
YOU HAVEAV TO WONDER, IS THERE
A CHANGE IN THEESARN
TECHNIQUE.
IS IT BECAUSE WE'RE USI
RUNNINGNNG SUTURES,ECAUSE WE'RE
CKING THE SUTURES, BECSEEC
CLOSURE, IS IT THE TYPE OL
SUTURESU
ANALLL THE CESAREAN STUDIES
WI
HE DO, MOST OF T OM, WE
DA, DAX WEEKS AND WE SAY THEY TY
T BETTT TTT TT FASTER AND ITT TS
THREE MINUTES LESSES TESDO THE
CESAREANREO THISS IS GOOD.
WE HAVEN'TENEN FOLLO FD THE LONG
NGTERM CONSEQUENCES OF THIS.
SO YOU HAVE TOO WONDER, IS I ITT
REAN TECHNIQUE..
I
DNI SAYF WE QUIT DOINGOING ANGS
MANY CESAREAES THAT WOULD BE
GREAT.GR
THAT WOULD BELD A WHOLE W DIFFET
AND IT WOULD BE A DIVERSION
BUT I DON I WANT TO LOSEE SHT
OF THE FACT THAT IF I WRE GOIRE
TO PUT F PTH A PESEARCH CHARGE
AND KWLEDGE GAPS, I DON'T KNOW
WHAT THE THE OPTIMAL CESAREAN RE
FOR THEEST MATERNAL A
FETAL OUTCOMES BUT I BETT'S
NOT %.%.
AND WE SHOULD WORK ON THAT.
AND YOU KNOW, THERE ARERE MEDICL
THINGS THAT CAN HELP REDEEDE THE
CESAREAN RATE,ATERTAINLY
REVISINGRITERIA FOR FABORE,CE
ARRESTS SEEM VERY PROMISINGSI
ALTHOUGH ITASN'T TRANS TTENS ASA
LL CLILL CLLY.
ACTIVE MANAGEMENAG OF LABOR,AB
THERE'S STILL S SOME PROMISING
STUDIES AND IT SURE S WOU BE
EATEA TO HAVE BHATE BSTRA BSTES
ADDRESS FETAL STATUS.
THERE HAVE BEEN SEVAL
ATTEMPTS, NONE OFFF THEM HAVE
TR
YMPACTED OUR CESAREAN
AGAIN, YOU'RE -- LOWER L CESAREN
RATE, I'M NOT SAYING EVERYBODY
G G ELECTIVENDUCTION BUT
IT CERTAINLY IS A STRATEGY THAT
SHOULD BE IN THE THE THELBOX.
THIS IS A SLIDE THAT I SHOW WHEN
37 WEEK7 BUT IF YOU LOOK ATATF
THESE STUDIES SHOWE S A LOWER
RATECESAREAN SO THAT'S A
POSSIBILSSY.IL
AND THERE AREANY NON-MEDICAL
WORK SOME S THE TIME, NONE WKEM
ALL OF THE TIME TT YOU CANAN DO
AND FAMILIES A EDUCATION, TINSNT
YOU DO IU DOVEU IONS TARGETING
HEALTHCARE PCAFESSIONALS WITH
EDUCATIOUCATUIDELINES, SECOND
IONS, AUDITS, ANTS, EN YOU
N DO THINGS WNGH HEALTHCARE
ORGANIZAGAONS.GA
WE PROBABLY OUGHT O TOO LOWER L
ESAREAES RATE.
THAT'S ONE WAY TO DO PRIMARY
EVENTION.
ANOTHEANTHING, ANDLFRED TALKS
ABOUT THIS A LITTLEIT B IS
CESAREAN SCAR S E E E PREGNANREE
IMPLANIMTION OF THE EMBRY ERYRYO
OHIS TERROTOMYCAR AND
MICRO OR MACRO SCOPIC DEHISCENCE
AND EARLY ALTERATIOER OFF THE
IN
RVILLOUSND UTEROPLACROTAL
CIRCULATION AND THEN YOU GET A A
CESARECE SRER OR ECTICCT
NCY.
WE'RE DOING EARLY EKE SCREENINGN
EVERYBODY WOULD HAVE H A VALUE,
EARLY DIAGNOSIS OF
ABNORMALITIES.
I ALWAYS LIKE TE SAY WE HAVEN H
NECESSARILY GOTTEN STTRTER BUT
AND WE CAN HE ANRGUMENT OVERETTR
THE COST-EFFECTIVENESS OF THAT,,
BU
I THI THIT HAS POTENTIAL.
AND I'M NOT N REQUESTING TO GO
INTO HOW T DIAGN DEGN THISHI
NLY BUT THERE ARE REALLY
NICE CRITERIA FOR HOW TOWO TOW
DIAGNODI ANOESAREAN SCAR TOPIC
IF TWO THIRDS OF THEOFAC IS
SABOVE THEHE ENDOMETRIAL LINE, T
IS A NICE SLIDE THAT SHOWS S IT.
HERE YOU Y CAN SEE MRI AND A THN
IS CESAREAN ECTOPICCTND IT ITT
DS UP BEING BEIN ACCRETACC A
AREN'TERYER GOOD INYN CASE SERSS
BUT BOTTT LINE IS IFS OU HAVE
AN SCAR ECTOPIC, IT',
REALLYREOING TO BE A PLACENTLA
ACCRETA AND WHETHER IT'S 82%,
92% OR 9 # 99% DOESN'T REALLY
MA
, THIS IS HOW IT HAPPENS.
SO IF WE GOT TM EARLY, WE
COULD TREAT THEM AND THEN HAVEEA
BETTER OUT COMUT AND THAT'SS
ANOTHER PREVENTION STRATEGY, AND
MOR-ISCH HAD A
NON-RANDOMRAED RETRO RECTIVE
THESE CESAREAN SCACA ECTOPICS AD
YO
TREAT TEATT EARLY, THEY T DO
TTERER THAN IF YN T YAT THEAT
LATE.
IN RED YOU YANANEEANHE RATE OF
ADVERSEE OUTMES -- 9 WEEKS,
MU
HIG HIF Y H TREAT THEAT
LA
THANF YOU F EAT TEAM
EARLY, DRAMATICALLY.CA
IT MAKES SENSE.
LESS VASCULARITY,TY YOU KNOW, SO
ON AND SND FORTH.
NOW, I ALSO THINK THERE'S AN
OPPORTUNITY TO FIGURE OUT WHAT
THE BESTREATMENT IS, AND THEND
NDUTHUT IS, REALLY DON'TDONOW.
IT
JUSTUS LIKE IT'S BEENN
FASCINATINGATO ME BECAUSE WAURE
ALLL THEORETICALLY EXPERIENCEE
PEOPLE WHO KNOW MOREOR ABOUT THN
R COLLEAGUES, ANDND D'T
TH
KTHHREE OF US DO THIOO THE
SO HOPULLY AT LYE END OF THIS
ETING, WE'LL WORK TOWARDS
FIGURING THAT OUT.
BUT IT'S THE SAME SING WITH
THCESAREAN SCAAN ECTOP E
SO ACCEPTABLEBLBL OPTIONS ARE
ULTRASOUND GUINDD UTERINE
ASPIRATION ESPECIASPY WH
BALLOON OO OCCLUSION OF THE SCAA
ALSO HE HE LAPAROSCOPIC
RESECTION REPAIRREF THE SCAE
YOU CAN SEE THESE
INTRESTATIONALTIACALTI
ME
MY O PSONABIAS IS WE'VE
GOTTEN AWAY FROM TFRT, BUT
OTHERS MAY STILL BE DOIOI THA
EVERYBODYGREES JUSTUS DOING A
AD
C WITHOUT SEEING WHAG W YOU'R Y
DOING IS I NOT A GOOD IDEA, ANDA
METHOTREXATE I'T A GOODD IDEA.
WE
DO OW ALL THESESEHINGS WILL
LL -- NONE- OF THESE THISES LET
US KNOW K WT'S THE BEST TESNG IF
THEY DECIDE TO T GET PREETANT
AGAIN.
CERTAINLY A THE RET R CAL BALIS
IF YOU Y WERER TERO PUT SOMEE SS
D HEAL THAT SCAR, ICASEEMS
LIKE IT MIGHT BE BETTERR THAN IF
YOU JUSTEFTEF HOLE FOR F THERE
TO BEE ANOTHER CESAR CESSCAR
EC
PIC.
BUT WE DON'T REALLY KNOWNO THAT.
IF YOU EVALUATEE CASERIES OF
WHO WON T GET
PREGNANTEG AGAIN, MOST OF T TIME
THIS WORKS PRETTY WELL BUT THEEE
XPECTED RATE OF PREGN PCY
LO
ABOUT 15%.
THERE'S NO CLEAR ADVANTAGE BASED
TREATMENTATYPE.AT
SO WE W REALLY ND MORE DATA,UT
EARLY SONOGRAM IS ADVISED,IS NO
TWO WAYS ABOUTT.
SO LET'S L TALK A LITTLE BIT ABO
TYTH OF CLOSURELOHEAING AND THEH
THERETHAVE BEEN SOMNTUDYS THAT
HAVE TRIED TO ASSESS THIS.
CERTAINLY SINLLE VERSE YOU
DOUBLE LAYER L SOMETHING WE ALL
THINK AUT, EXCLUSION O
CLUSIOCLOF THE DECIDUAUAUA SHOUS
SUTURE. CONTE UOUS OR LOCKING
WE'RE ALWAYS TAUGHT THAT T T LOL
SURE I MORHEMOSTHEICSTHE
MAYBEYB IT CAUSES MORE TISSUE
NECROSIS.
THINK SOMEOM OF US US UITA L OF
ENBABLY THINK IT
DOESN'T MATTER AT A
BUT IT'S A THING.
CERTAINLY DIFFERENT SUTUREE TYPT
MAY MAKE A DIFFERENCE.
YOU HAVE HAVE ANOTHER PREGNANCY
SEEMS TO MAKE AIFFERENCE.
WHETHER OR NOT YOU HAVE
INFECTION AND WHAT KIND OF
HE
INHEIN PROBABLROMAKES A
FFERENCE, AND THEN ARE THERE
TREATMENTS TO PROMOTE HEALING,
CAN WE DO A BETTER CTEAREAN.
IT'S'SERY DIFFICULT TO T STUDY
THISECAUSE YOU ROUO REALLY NEED
RA
OMIZED TRIALS, IT'S J NOTOT
CO
STUDIED THISD N A MEANINGEAL WAY
SO YOU'R Y LEFT WITH CE CTROL
NO ACCRETAS AND THEN GO BACK AND
Y TO SEE WHAT W KIND OF CESAREAN
THEY HAD..
YOU COULD UOU SUROUGATE
MARKERS SO YOU CAN CSECARR
THICKNESS AESS Y CAN UAN NICHE
ANDDHEN YOU CAN U ANIMA A A
MODELS.
THE UTERUS,EFINED AS BEINMUS OFO
MORE THAN 2 MILLIMETERS IN
DEPT
YOU CAYO ALSO MEASU M THEESI
DU
MYOMETRIAL THICKNESS, WHICH
HOW HH NORMAL MYOMETRIUM
THERE IS, AND THERE ARE CRITERIA
FOR HOW TO TEASU T THIS. T T
IT SHOULD BE IN THE SAGETAL MID
PLANE PL A NON-PREGNANT PANIENT.
THE SITE O PRIOR CESAREAN, ANDN,
YOU CAN USE SEVER SEVERGING
MODALITIES.
2D OR 3D SONOGRAM, IRA SHOULDULB
TR
SVAGINAL, BE YOU CAN USE
SALINE OR GEL INFUSION, MRI, ANA
CAN BE TRIANGULARR SEMICIRCLE
SHAPEDSH
SO HERE ARE PICTURES OFF NICHESC
FROM PAUL WDWARDAR.
THIS SHOW UP?
HERE YOU C SEE THERE'SHERE'S A
LI
LE D THERE, THAT'S WATRE
YOUR SCAR IS.
HEREOU SEE A S HOLE, ANDND THE
HOLE IS WHERE THE NIC IS AND
CAN MEASURE THESE THINGS.
THE GROSS SPECIMEN, YOU COULD
SEE WHAT THE NICHE LOOKS LIKE.
SO THESO INCIDENCE OF OF NICHE
BECAUSBE YOU CAN USE THESE
ANDIFFERENT DEENNITIONS HASS HAS
REPORTED SOMEWHERE BETWEEN 199
AND 100%.
AT'S NOTERRIY USEFULSESE..
THIS VARIATION TECONIQUE AND
DEAF ANYTHINNY, BUTERTAINLY
BIGGER NICHES SHEMHE TO BE WORS.
AL
MOST PEOPLE WITH NIITES
ESARE FINE.
THERE MERER BE ASSOCIASSON WITHW
DOING A CESAREAN THAT'S IN THE
CERVIX RATHERHEHAN IN THEHE LOWR
UTERINEEREGMENTEG
SOMEBODY YOU WOULD DO IFO
MEBODY HBO SECONDEC STAGE ARRT
AN
PUSHING TOO T LONG, YOU GETOU
FRACTURING OF T O LOWER UTERINE
SEGMENT.
E THOUGHT IS IF YOU DO A
THERE'S MORE GLANDS AND THATTUE,
SHEN IMPAIR HEALING
NORMAL DECUA.
THERE MAY BEOMELATIONSHIIO
TO THE HYSROTOMY CLOSURE
TECHNIQUE.
WHETHER YOU'RE LOCKINLOONE OR
O LAYERSUTURE TYPE.
HHERE'S SOME ASSOC ATION W
E RETRO REEX UTERUS.RU
A SSET OF THESE PATIENTAT WNTL
HAVESE GYNECOLOGIC SYMOMS.OMS.
THEY'LL HAVE PAIN, CHRONICHR
BLEEDING, AND THEY MAY EVEN HAVH
PROBLEMS WITH FERTILITYTI BUTTIE
VASTAJORITY OF THESE PATIENTSIE
ARE FINE.
SO IT NEVER BEEN -- IT'S NEVER
SEEN CLINICALLYCA WORTHWHILE TO
SCREEN FOR THESE PATNTAT
SYMPTOMATICALLTICAF SOMEBODY
COMES IN WITHH BLEED WLEEDED ORR
AND YOU DON'T KNOW WHAT TO DO
AND THEY TAVE THIS, THEN YOU MAY
TREAT THEM.
OBSTETOBCALLY,HEY'REHEORE
LIO HAVE PAS,AS UTERINE
RUPTURE OR A CESAREAN SCAR
ECTOPIC, BUT AGAIN A THE POSITIE
PREDECORATIVE VALUE OLUEUSTTFINH
THAT NO ATE I RECOMMENDING THAT
WE ASYMPTOMATICAMAY SCMAENSCOR
ORTHESE FOLKS.
WE DOO BETTERETRR CESAREAN,
AND IT'SERY DIFFICULTLTO
STUDY,STGAINSTYOU NEEDU RCT
WTE CAN USE THESEHE OTH
MARKERS.
PEOPLE HAVE TRIED TO DO TO T
USINTHESE SURGATE MARKERSAR
SO THERE WAS ONEAS RECENT
SYSTEMATIC REVIEW META-ANALYSISL
2020
STUDIES, 15,000 PATIENTS IN
RCTs, THEYHEY ADDRESSED URINE
NICHES, THE RESIDUAL YOU'LL
MY
ETRIAL THICKNESS AND HEANG
RATIO.
IN
THIS META-ANALYSIS, A SINGLE
CLOSURCL WAS WORSE THAN A
DOUBLE LUBER CLOSURE, AND YOU Y
HAD DECASED RESI DUALESIDUALOU'L
MYOMETMYALET TCKNESS OF O 1 TO
CENTETERS.
WHETHER THAT'S CLINICALLNI
IMPORTANT IS HT D TO SAY, YOU
UHAD DECREASEDRE EL HEALING RAD
IT
AS WORSE WITH A LOCD
SUTURE.
THERE ALSOLS SEEMEDD TOO BEE
SED NHE IF YO I EXCDEXCXC
TH
ECIDUA.UA
SO WHEN WHE W I WAS TRAINED,, IS
UGHT TO EXCLUDE THE DI SYD EXCLA
BUT AT LEA INN THE POOR QUALITY
EVIDENCE INCLUDING THE DIDUA
IN YOURR INCIS IN, SEEME SOE
ASSOCIATED WITH -- ANOTHERTH
AND AEE COHORTS, THE,RE WAS
DID THE SAME STUFF STHEY STHEY
MIXED RESULTS, BUTS,GAINS,THEY
HAD BHATERTEUTCOMEUT WITH WO
LAYER CLOSURES AND INCLUDING THE
A IN THE CLOSURE.
YOU WOULD ARGUEHIS IS STILL A
DGE GADG WHAT THE BEST
AN TECHNIQUE IS.UE
BUT IF WE'RE GOING TO TAKE
WHAT'S OAT THERE, IT SEEMS LE
ETWO LATWRS ARE BETTER THAN
NWURNTIWU ANDWUNCLUDING THEHE
DECIDUA IS BA ISRHAN NOT
CLUDES T DID D.
AND THEND HERE'S A WHOLE FIELD F
THERE THAT'SEALLY, REALLY
INTERESTING, BUTG, IT'S VERY
PR
IMINY.
OF IMPROVED HEALING.
CAN WE MAKEAK A BETTERR WOUND BY
ADDING STUFF
AGAIN, YOU ALL A RAISEAISED THEE
OF THEHE
NFLAMMATORYAT RESPONSE,
WO
D HEALINGEQUIRES
INFLAMMATION BUT N TOO MUCH
INFLAMMATION, AND SO HERE'S A
LI
MOLECULES OR AI-INFLAMMATORY
MOLECULES, YOU CAN USE KOL JEB J
LDS,LD MESENCHESAL STEM S
CELLS.
WE DID SOME STUDIES IN UTAH THAT
HOHT WERE VERY INTERESTIER
BUT WAYREMATURE AND I'LL JUST J
SHARE A LITTLE BIT WHERERE YOU
COULD USULTEM CELLS C ANDNDND TE
WERE STEM S CELL SHEETS WE W DID
THEM IN MICE, YOU CAN USE
ALLOGENEICGETEM CELLS WHICH IS
LESS CUMBERSOME TO TRY TO BUIO
BETTER SCAR.SO YOU HAD THISHIHI,
U COULD PUT THE STEM CELLNS, OR
ON O ONE H ON, NOT THE OTHER
HO
, YOU DO YOUR CESAREAN, YOU
HORN.THE STEM SLL SHEET ON ONEO
AN
T TURNS T OUT IF YOU SLAP THE
STEM CELL SET YOU GET AETTER
SC
.
THIS IS DIFFERENT WAYS OF
RATING THAT.
THEN YOU HAVE A GREATERRETERINE
WALL THICK TSS AND A A LESS
ARRING ANDND THIS IS A STUDY
THAT SEVERAL FOLKSNCLUNGLU
BRETT DID D IN UTAH.
SO THIS IS VERYERREMINARY AND
A LITTLE BIT OUTITHERE BHE I
T WILL STIMULATETE A LITTLETL
CONVERSATIERSA
SO THESO BESTHE SATEGY IS FEW
CESAREAN DELIVERIES.
LET'S LESO THINK AHIUT DOING
BETTER CESAREAN DELIV DIES,IES,D
THEN EAR DIAGNIS OF CESAREAN
TREATMENT OF CESEAN SCAR
PICS
THANKS.
>> DR. SILR.R, I DIDN'T THINK IN
WAS YOU THAT WAS GOING TO BRING
US BACK ON OIME BUT THAT WAS
FANTASTIC.
IN THE LAST OF OUR SPEAKERS FOR
THE DAY BEFORE THE FINAL F PANE,
WE'RE EITED TO HEAR FROMRO
DR. BARTELS.S.
>>
HANK YOU SO MUCH FORORAVININ
I'M HELENA BARTELS,TE FROMRO DUB
I KNOW I'M THE LT SPEAKER OF
THE DAY, THE D TAD DAD D LT SLOT
OPE YOU CAN GIVE ME YR
ATTENTION FOR THEHE LAST 202020
MINUTES BEFORE WE G TO OUR GIN
AND TONG TONICS OR WHAVER ELSE
SO T TITLE OF MY TALK,ER ON.
PSYCHOPSGIHOLGIALL OUT OFF PAS,,
BU
WE'RE SUCH AROUP OF
PROBABLY K ABOUT TBOS SO S I S
KINDHIKINDF THOUGHT INSTEAD I
HIGHLIGHGHSOME THINGS I THOUGHT
WO
D BE INTBEESTING FOR
DISCUSSION TOMORROW RATWR THAN
GOING VINYY DEEPLY INTHINGS
TH
HOPEFULLYEF MANY MFOU A
FAMILIARARITH, BUT MAYBE WE CAN
COME BACK AT THE PANELEL TALK FF
TOMORROW.
I'M GOING TO BRIEFLY BE
TALKINGLK ABOUT KIND OF OUR
EXPERIENCE OF FAMILY CEILERED
CARE ACA I SUPPOSE OUR
ENCE OFXPRING THE
LIVED EXPERIENCE OFCEARFTS.
I GUESS G MY M RE R COMESOM IN,
SURGERIERG LOOKING AKIER THESE
MOMS, BUT APART FRORT THAT, I
ALSO CALCHAIR OUAI PATNT
ADVOCACY GROUPRO CALLLED PLAEDNT
WE ARE FIVE YEARS OLD NOW.
I WORK WITH AN AMAZING GROUP ORP
PEOPLEPEHATT ARE IMPACTEDDD THIT
CONDITION THAT RY COME BACK
ANDDVOCATEOC AEE SHARE THEIRHE
STORIEST W US IN OUR GROUP,,
BU
I'VE REALLY SKEN TH
HUNDREDS OF PEOPLE FROM ALL OVER
THE WORLD THAD HAVE TAVS
CONDITION AND I REALLYYANT TO
ECHOHATT KRISTIN SAID SAT THIAT
IS
SO PROBABLYBA WHEREVER YOU'RE
DELIVERING CARE TO THESE
PROGRAMS, THE ---S PROBABLY
FLECTED IN TH I WORK THAT WE'VEW
DONE, AND TN TALK A LITTLE
TREATMENT.EE PREFERENCESRENC FOR
WHAT ARE A SOM AOF THE IMPORTANT
TH
GS ABOGSOR WH
ADVOCATES.
SO IEALLY BELIEVE THAT WORKING
ANY OF THIS T WORK BECAUSE WEE S
ALTHCARE PROVIDERSRS AND AS
PEOPLE HEREERN THIS ROOM, WE
LOTS OFOTNOOFEDGE BECAUSE
ARE EXPERTSTS ITS WHAT WE DO, E
HAVE GONE TO MICAL SCHOO SCHOO E
HAVE STUVEED THIS CANE, CDITIOT
WE REALLY NEED TO HAVE THE
PATIENT EXPERIENCE AS PART OF
THAT BECAUSE THEY AREXPERTS BER
EXPERIENCE.
AND BY B DISINVOLVING THEM WE'RE
MISSING A HUGE PART OF THE UMIIT
PUZZLE AND WE HAVE TO UNDERSTANR
THEM AND WHAT DO THEY CARE C
EABOUT, BECAUSE WITHOUTITHAT, WE
EDON'T REALLY KNOW HOW H TO IMPE
LI
FOR THESE PEOPLE.
THISTH IS THE EE KO T T T ETHOSW
ERE WE HAVEEATIENTAT RLLY
INVOLVED IN ED IY S IGLE ASPEC A
OF CARE, SO WE ALWAYS SAY
WO
ING A LOT LN AN ONCOGY,
TH
E'THNOTHING ABOUT ME WITHOUT
ME.
SO EVERY PIECE OF WORK THAT
WE'RE DOING AND RESEARCH TT
WE'RE WEING, THERE HAS TO BE A
VOICEVOHERE THAT' T REPRESENTING
THE PATIENT.
DOESN'T HAVE TO BE SOMEONEOM
BE SOMBENE TBENE IT'SS THEIR CAC
FAMILY.
-- THE SISTER OF A LADY L THAT
UNFORTUNATELY DIED FROM
COMPLICOTIONS BUT WE HT WE TO
HAVE SOMVEOM VOI THEREHE THATS
HELPINGS TO INDICATE A A
PERSPECTIVE ON WHAT THIS IS ALL
ABOUT.ABAB
AND I D'T D WANT TO GO INTO I TO
MU
DETAIL BECAUSEEC I HOPE LOTS
OF YOU ARE FAMILIARITH THE --HE
AND OTHERS A SAL COLLINS IN
THE K. BUT REALLY THE T
IMPORTANT THINGSTH FRO LIVNG
WITH THIS CHIDI CON IS THAT WEHA
KNOW THAT IT'ST' HUGELY -- IT'SA
AL TOLL FOR F MOMS AND
THEIRRAMILIESIL TO RE TIVE THIS
YOU MIGHT HAVE THIS CONDITION.HI
LOTS O THEMM GONTOO SURVIVAL
MODE AND THE IMPRESSION THAT WE
OFTEN GETE WHETHER THEY'RE IN
THAT SURVIVAL MODE IS THERE
DOING WELL BELAUSE I ILWAYS SAYY
THEY HAVE THEIR EYES ON TH O
PRIZE HOW TO DO ANYTHINNY TO GET
BABY,BA SO THEY MIGHTHT BE OPENO
HAVING A CONVERSATION ABOUT HOW
TH IS IMPACTING THEM T OR EVEN
BEING ABLE A TO THINKHI ABOUTBOT
IF WEEON'T START THAT
CONVERSATIONSAND CREATE THAE
SA
SPACE, SO WE ND TO
ACKNOWLEDGE THAT THIS IHI REALLY
NALLY CHLLLENGING FOR
BUEMBU THEY OFTEN O COPE WELLEL
BECAUSE THEY GO INTTHE
SURVIVAL MALE.
THEN REALLY THEOST IMPORTANT
RT IS FROM THE LIVED
TRIMESTER,TE SO THEY'VEIVENTHRTT
BIRTH AND IT'S ALL OVE
AND TANS IS WHEN A LOT OF ITF
THE CARE TT UNFORTUNATELY WER
EPR
EE.
THIS ISS NOT JUST ABOUT PAS BUT
IN PGN P I GENAL, WOMENOM
HAVE HIGVE RIGK PREGNANCIES, THY
GET A VERY STRUCTURED CARE
PATHWAPA ANDPAUDDENLY THEY'VE
BIRTH,, IT'S ALL OVER AND
THEY DON'T GET GET ANY SUPPORT.
SO ACTUA AY TH A HAVEN H REALL R
BEEN ABLE AO THINK TBONK HOW H
THIS HAS IMPACTEMP THEMPHEURING
THE PREGNANCYNAT ALLAND NOWOW
THEY'VE GIVEN BIRTH, NOW NHEY N
ALLY NEED SUPPORTRT A SOMNE
TO TALK TO AK THE MILESTONEES
ARE REALLY AROUND SIXD ONTHS AND
ONE YEAR.
T ONE-YEAR MAR IT'S THEHE
RTHDAY, EVERYONE ISNE REALLY
EXCITE, BLOWING OWI CANDLES,DL
FAMILY IS THERE, BUT BEALLY FOR
THEM, THE T THINKING BACK TO
THIS REALLY, REALLY FRIGHTENIGH
ISOLATEDOLATAUSE THEY DON'TBE HY
ALLYLY HE ANYONE TO SPEAK S TO,Y
PSYCHOLOGIHOL FOLLOW, THEIR
PARTNERS HAVRS MOVED ON, EVERYOE
KING AT THEM AND SAYING
YO
BABY IS HERE, EERRY EING E IS
FINE, SO REALLYOSTNATAL
PART IPA REALLY, REALLY
IMPORTANT.
ABOUT OURUR PANEL DISCUSSION
TOMORROW, WHAT WRE THINGS WE CAN
TUALLY DO TO HELP MOMS AMO
THEIFAMILIFA.
I THI OHI O OHI THE THINGSNG IN
FAMILY CENTERED CARE, THAT WE'T
ALLY TAKING A APPROACH WACREACRT
MRI, PLANNING THEIR SURIR S, BUT
ACTUALLY MAKING SUREURHIS FAMILY
IS REALLY WELL LOOKED AFTER.
THIS PTHIE P IS SAYING THENGDIHE
E BEST THE COULD BUT THE
WHOLE EXPERIENCE WASERRIFYING
AND I THINK THAT'S REALLY
ECHOING SOME OF THE THINGS WE'RE
UT TODUT.
WE WANT TO T BE DOI SO MUCH
BETTER THANUST HING MS
SU
IVE THIS CONDI CON.
BU
ACTUALLCT THATHAT THEY ARE WELW
IN THEIRHEIRHEENTALL A PHYSICAL
IN THE LONHE LRM.
LK ABOUT THINGS FOROR
EVIDENCE-BASEDRAUMA TREE
VE
S,PREVENTION, INONLVING THIN IN
DE
SION-MAKING,G, LKI LKI ATT
CARE.
THESE ARE THE RECOMMENDATMENS
FOR CARE WE'VE MADE BASED ON OUN
CHSE
I'M NOTI IFF OT GOING TONG T G M
ALL, BUT EVEUT TVEEE THAT YOU'RE
REINTERECTING WITH THESEHEHE PA,
ALSO TAKINGAK IO ACCOUNT HOWNT E
SUPPORT THAT THEHE NEED?ND MTA A
WE PREFER ALL OF OURF PATIE PS
I CHAT WIT W THEIR PTNERS TO
E THEY'RE INFORMED AND
THEY NEEDEEEE TO HAVSOMEBODY WIH
THEM THAT'S GOING TO HG E THEIR
BACK AND MAYBEBE IF THEY'RE IN A
SITUATSIN WHERE THEY'RE NOT ABLE
TO ADVOCATE FOR THEMSELVES, THAS
WHERE YER HAVE EDUCATION
INFORMED.
MAYBE WE CAN C COMNT IN OUR
OUP TOMORROW A LOWTLE BIT.
AND IN THINKINGGBO- ONE OF
TH
THINGS THAT A ACTUA ACT
EVIDENCEVIDENCE-BASCE ALREADY,DD
TO BUILDUI TRUST ANDELATIONSHIIS
WITH THESE PATNTATAT DINGIN WHEN
THEY HEY THIS BUT ALSO THAT WE
CONTINUE THAT THA THE POSTNATAL
PERIOD.
YOU WON'T BELIEVE HIE MUCH YOUR
CARE, KINDNESS AND S MPASSION
MEANS TO THESE FAMILIES AND A
CONTINUITYINF CARE C C IS ABSOLY
ESSENTIAL.
THEY'RE NOT JUST IN THISN YOU
KNOW, KIND OF ASS OF FEAR O O
TH'RE TOO AFRAIDFR TO ASKSK
QUESTIONS OR THEY'RE TOO AFRAID
DTO
VEN TALK TOUT WHATHAIGHT BE
HA
ENING TO T THE T BUT THEY'RE
LY -- A RLLY SAFE SPA
D AB TO SAY WE'RE A
SPECIALIST TEAM, WE'VE GE' THIS,
WE'VE DONE THIS TEFORE, THISHI S
WH
'S GNGNG TO PPEN DURING
E PREGNANCY, AND CREATINGIN
PLACES WHERE WE CAN HAVE REALLY
MEANINGFUL CONVERSATIONS WITHH
THEM.
ADD VOD VOCACY GROUP, WE HAVEE S
WEBSITE, ALLE,F THESE THINGS,
THERE'S JUST SOMETHING ABOUT
HAVING SOMET SNG TANGIBLE THAT T
TH
CANO HOMEE WITH.
Y DON'T HAVE INFOR ITION,
TH'RE T A A PRIORITY, THEY'RE
CONVERSATIONS WITH YOU.SE
AND DDENLY GET ARETA.ARE BORNOR
MO
OF THEF PEOPLE BECAU B OF OFTHY
GI
BIRTH AND SOME OF THESE T
TIMES THEY'VE ALREADY
EX
RIENCED BIRTH TRAUMA.
BI
H TRAUMA IMPACTS 1 IN
N IS THIS IS VER LIKELYY
TO HAVE HAPPE HD.
SS REALLY,LLEALLY IORTANTOR
NTWE SPEWEPEWE ABOUT TBOT AND AS
ABOUT THOSE PAS EXPERIENCES
BECAUSE THAT'S GOINGNG TO
NCE HOW THEY'REHEOING TO
RECOVER FROM THISHI AFTERWARDS.C
LITTLE BIT. B
IS IT CHOICEHOHO?
CHOICE OR HAV THOSEE W CSIDER AA
CONVERSATIONS, AND I TNDK AUT
THOSE --UT FOR THEHE ANESTHESIA
RT, FAMILIES WHERERE WE DO THINT
TH
S SOMETHINMEIMPORTANPOTHAT
THEY FEEL IS AN I AOR INT
DECISION THAT THEY CAN MAKAN AND
BEBENVOLVED WITH, BUT B THEY CHE
O THATO F WE PROVIDE THEDE
TH INFORMATIONTI.
WE WORK THROUGHOU DECISION AIDID
WITH OUR PATIENTS, WHETHER OR
SCREENING OR ALL THESERENTAVEROU
THINGS SO WE KNOW THAT THEY
RK.
THE WAY WE U THEM,M, YOU YIVE
NFORMATION DURINGUR THE
CONSULTATIUL, YOU, IVE THE
READ ABOUT.HEYG ANG GO HOME ANA
IT'S NOT FRIGHT EPIPI
INFORMATION BUT IT'S REALITY OF
AT C C HAPPEN, TPEY CAN C
CKCK AND YOU CANOUHAT ABOUT IT
AGAIN.
ENDT MIGHT BE SIMILARIM
HAT YOU DISOU DED IN THEHE
FIRST PLACE, ITIGHT BE YOU
NEED ONE PARNECULAR TYLA OF
TR
ENT BECAUSE OF HOW YOUR
CO
ITION I BUT THIS IS GOING
TO THEN UNDERSTAND THE
REASONS FOR THAT.
USE AUSOT OF TH O TIME WITH
THE POSTNATAL PERIODIOHENN
THEY'RE THINE NG BACK, THEY HAVE
A LOT OF REGRET, THEY HYE A LOT
OF GUILT AND TNDT'S BECAUSE THEY
DIDN'TEALLYEA UNDERSTAND WHAT
TWAS HAPPENING AND THIS ISHIEAIY
TO PLAN FORNHAT LATERER SO THEY
REASONSRSTANER ALL THE
WHY DIFFERDIT MANAGEMENT
DECISIONS SIRE HAPPENIAP.
AND THEY WILYALSO UALERSTAND
THAT WE CAN PREDICT ERYTHING
BUT SIMPLY -- IS RE ILYRE
IMPORTANT AS WELL.L.
I DON'T'T KNOW K K I-- THEIR THE
PRIORITIES, WHATEVER WE W WT TO
CALL THEM, BUT I TNK IT'S
OBVIOUOBTHAT BY B FAR THE MOST
IMPORTANT THANG TO ALL OFHESESE
PEOPLE IS THAT T THEY'RE SAFE, S
THERE'TH THREE MANAG MENT OPTIOS
NSWE CAN ONLY DO ONE OF THEM
SAFELY, OBVIOUSLY THAT'S WHAT'S
SGOING TO HAPPEN TO THAT PATIEN.
BUT EQULY, DIFFERENT COUNTRIOU
PARTICULAR MANAGEMENT, ARE YOU
ABLE TABLEAB REFER THEM SOMEWHEH
ELSEWHERE WHEY CAN HAVE THIE
AND IFAN NOT, MAYBE THAT'S OKAY
INTERNETET EXISTS, AND THE NEED,
TO UERSTAND IF THEY'RE MEETINGEI
AN ADVOCATE IN I A CHAT RM OR
SOMEONE ELSEM DOWOW THE LINEE I
GOESACK TOTT REGRET PCE
THEY FEEL LAT.
IF WE IFVE ESTABLISHED SAFETY
AND WE HAVE -- ABLE TO HAVE
CHOICE,OIXPANDING WHAT ARE THE
DIFFERENT OPTT O THAT WE OFFER
AND ACTUALLY --Y MAYBE ONLY
SUITABLE FOR ONE OF THEM BHE
THIS ITH I THE REASON WHY.HY
NG THINGS OUT,AVG
VISUALSUAL AIDS, PATIENT ARE
UNDERSTAND OH YEAH, IF THIS IS
RIGHT HERET NN THE SURFACE, IT
PROBABLY DOESN'T MAKE SENSE THA
YOU CUTFF HALF MY --Y AND I
VE NON N LEF N TO T PUT P BACK
TOGETHER.
INFORMATION ISIOEALLY
WE OFTEN O HEARR THIS BUT A LOTF
ME,,F THEY'RERE SAYING
THOSEOSE KIND OF THINGS, WE NEEO
T PTPLEE INFORMATION SO THEY
CAN UNDERSUNND THE REASON.
LOT OF THE TIME PEOPLE DO WANT
TO BE INVVED IN THEIRIR
HEALTHCARE AND DECIS DN-MA DNG
ANDAN THE CONFUSION, ACTUALLY --
ER YOU'R YSAYING IS BEST,
TH
'S OKAY TOO, BUT WE NEEDO
HAVE THOSEHO CONRSATIONS.
I'M N GOINGO REALO G G
THROUGH ALL OF THESE, KRISTIN
OF THE T PATIENT STORIESRI ALREY
T WHEHEE TALKBO DIFFERENT
TREATMENTS, EN KNOWNON TRUK
ECTOMY THERE'S A GUPUP OF
MOMS THAT A VERY UPSET, TETS
ISN'TH ONLYPTION,PT AND THI
KIND OKI GROUP INUP TNUP MDLE TT
E LIKE WOWKE I DON'T REALLY
KNOW, I SUPPOSE WHATEVER YOU
THINK IS BESTOR ME.
AFTER ALL OF TSE T KIND O O,
THERE IS A HUGE VARIETY OF TYPES
OF PATOFNTS THAT WE'RE SING.G.
WE NEEDOEMEMBER THAT
HYSTERHYTOER, IT'S T JUSTT
ABOUTER FERTILIER.
THERE'S HUE' PSYCHOSEXUALUAUA II
WHEN MOMS HAOM THIS DONE AS
THEY WON'T REALL R THINK
ABOUT THAT DURING THE PREGNANCY.
THEY'RE REALLY THINKING ABOUT
G A BABY THAT' T ALIVE AND
THEY'LL DO ANYTHING TIN MAKE THY
, AND IFOU'REOUAYEGAY THE
LY THING TS NGSTERECTOMY, THEN
THAT'S WATT WHEY'RE GOING TO
HEAR, BUT WE ALLOW A THESE MOMES
LATER, THIS IS REALLYEA AFFECTIG
HOW I FEEL ABOUT AT A WOMAN AND
FORWARD AND ALL O THOSE
INGS
WE DIDN'TID FTD A DIFFERENCE BY
EGNANCY OUTCOME.
WHAT I MEAN M BY B TT T IS WHATI
MEAN --OTS MOMSOM WHO REA
TAINED TINIR UTERUS ALSO DID,
THAT'STHECAUSE TAUY' T GY'E
THROUGH THEHE WHOLE PHOGNANCY
PERIENCE THECE SAMEAYS --
HYSTERECTOMYECTO E, THEY STILL
HAVE THAT FEAR, AR,IETY ANDTY
WORRY, AND INFORM@MAFM@HEY
EXCE A LOT OF
MPLICATIONS IN T SAMWAY.
Y.
ABOUT THIS NO ONE IN THE ROOM
EDS TO BE TOLD THAT WE W SHOULDO
BE GIVING SPECIALISTIS, MULTI- -
CARE TO THESE PARTS, SO WO
SHOULD BE GIVINGIN IT BAUSESE
THEY WAND'AN DESERVE,
NOT ONLY BECSE WE KNOW IT'S
BE
PRACTICE.
THESE ARE JUST SOMEOM OF O THEHE
QU
ES ITHESEE MOMSIN--
AS OPPOSED TO THEY'REY'RE FEELIG
THEY'RE BETWEENWE HOSPITALS THA
AREN'T LOOKING AFTER THEM, IT'S
REALLY UNSETTLNSG.
LASTLA WANT TO TALK ABO OUR O
ROLE IN OUR PATIENT ADVOCACYOC
WO
.
IS IS A HUGEA ART AND REALLY
I REALLY SEEEE THIS AS VY
SYMBIOTIC THAT TTHAT LEARN FEAMF
ME BUT I LEARN SEAMUCH FROM
THEM.
IT'S HUGE PRILEGE FOROR ME TO
HAVE THESE CONVERSONIONS WITHH
SEMANY MOMS FROM AFROMVER THE
WORLD WHO REALLY LEARN WHAT W
THEIRTORIESTO ARE LIKE AND HOW
WE CAN HEL HEM.
THIS QUOTE KIND OF FD S A LITTLE
IN KRISTIN'S, IT'S ABOUT BEING
ANDVOCATE OF THEHEHEEOPLE AND
USES IUSORTANT TO USING TSI
MO POWERFUL TOOL YOU HAVE,
AF TRMATH OF THIS PREGN PCY,E T
CA FEEL QUITE ALONE, SO BEINGNG
ABLE TO CONNECT WITH A GTHUP OF
MS OR PEOPL PEOHAT WE
UNRSTA, THIS, S SO POWERFUL,
AND ITHEY CAN KNOW KARING
THEIR STORYORYY HELPED SOMEONE ,
THEM, AND IT'S SOMETHING THAT
THEY'RE REAEY PROUD TOUDO.
AN
I SUPPOSE SOME OF THE THINGSNG
CONSIDERING WHEN WE'RE WORKING
WITH ADVOCATDVOC AN ADVOCATE
DOESN'T HAVE H TO BE SOMEBODY LL
KRISTIN, IT JUST HAS TO BE
SOMEBODY AT THE HOSPITHO THAT
WANTS TO COME BACK AND G AE YOUE
THAT'S A SIMPLEHI TO DO,DO
ON'T NEED N START A
PATIENT TIOUP OR START A CAREERE
WI
THEIR LIVES,, BUT WHE WE
ARE WORKING -- WE W DO NEED TO
PERSONAL JOUEYS. IN I I THEIR,
SOME OF THESE PEOPLE THAT
CONTACT OUR GROUP ARE VERY M M
INHE TRAUMAUM PHASE, THEY'RE
SEEKINGGUPPORT, THERE NOT
REALLY READY TEA BE INVOLVIN IN
RESEARCH, SPEAK AT K CONFERENCE
OR ANYOR OF THOSE THIS.HI
TH
'RE VERY MUCHUC THERE FOR
PERSONAL SUPPORT.
AND THEY'REOCUSEDOC ON TIR OWN
EXPERIEXCE WHERE SOMEOM MOMRR
PARTNERS OR ANYBODY THATY
IMPACTED BY TH B CONDITION, THEY
TH
THRANSITRAN TO WANTING TO
AD
IN A MUCH MOREEANINGEAL WEA,LVEV
AND I DD 'THINK THAT' T RELATED
TOTO TIME.
SOME PEOPLE EOE THERE DURING THE
PREGNANCY, SNCE PEOPLE WANT TOT
DO -SOME PEOPLE DON'T G
TH
E FOR YEARS AND SOME PEOPLE
THAT'S FINE ASE WELEO THAT ANDND
WHEN WE'RE W WORKING IN A RLLY
CLOSE RELAT RNSHIP WITH
ADVOCATES, WE HAVE THA T TNK
ABOUT THINGS LE ADVOCACYOC
FATIGUE BECAUSE WE WE OBVIOUSLY-
WE'RE COMPENSATED FOR D R TIME,
THIS IS OUR JOB, THIS IS OURUR
CAREER, EVEN THOUGH WE'RE DOI
LOTS O THESE THINGS VOLUNTARY,
IT'S STI'S A LITTLE BIT B
TO COMPLETELY GELE UPHEIR TIME
RESPECTFSP OF O THATT INN THINKG
HOW MUCH THEY'RE ACTLLY
A VERY TRAUMATIZUM WAY AND IT'SN
ALMOSTALIKEE TO DISTRACT
THEMSELVEM FROM TIR OWNTORY
WE HA W THABE MHABE M ABO M
THAT.
AND ESPECIALLYLL WITH
COMPENSATION, IN THIS GROUP WSA
MOMS FINANCIALLY FOR GIVING
IME, NOBODY IS GIVINGG
MONEY TO ACCRETA SO WON'T
HAVE ANYON MONEYATIES ARE
VE
ACTIVELY INVOLVED,HEY'REHE
LIKE WELLL NO I DON'T WANTT YOUO
GIVE THIS BACKS O ME, LME'S DO
SOMETHINMETH RLLY COOL, LET'S
E.BSD RESOURCES, L,'S DO OUR
WHERE IN IT'S VET'-- THE'SHE'S
TONS OF DRUG COMPANIES, WE HE
IAL SUPPORT IN THOSE MOU G SO MH
CA GROUPS,UP IT'S VERY EY
TO
IVE MOMS BK FOR THEIR TIME
BUT ALSO WE HAVE TO REMBER
THOSE ARE CONRSATIONS YOU TONGO,
SHOULD BE HING BECAU B PEOPLE
MIGHT FEGH DIFFERENTLY.
WE
FREQUENTLYLYLY WITHINUR GROUP
AN PD THAT'S AN IORTA THING THI
DO FOR INVOLVING PEOPLE IN A
PROFESSIONAL WAY.AY
AND MOST MIMAR TO NATIONALIONANA
ACCRETACNDION,E WANT TO T
SUPPORSUMOMS AND WE NDNT TO
ADVOCATE FOR THEM.
D THE WAY WE'VE DON THAT I
REALLY ---ESOURCESES THAT ARE
BL TO PEOPLE, WE'VE MADE SOME S
VIDEOSVI ARE WE HAVE THE WEBSIT,
ALL OF OUR WK IS I DONEN
COLLABATION WITH OUR PATIENTSIE
SO THAT IT'S INFORMATION TT
FIND F ACCESSICCE AND THEY
FINDFINTERESTING AND IT'SN A
WAY THAT THEY CAN SHARE WARE
ETHEIR FAMILIFA.
WE'VE BEEN DOING THAT IN IRELAND
BUT ABUO SETTINGET UP GROUPS
EL
WHERE NOW BECAUSE WE RLLY
GROUP, WORKING TOGETHER WITH LET
CARE PCAVIDECA IS SO IMPORTANT,
SO WE'VE SETP A GRORO IN I
FRANCE NOW WHICH IHI ANMAZING
GROUP OF MOMS THAT HAVE REALLY
YTAKEY THIS ON ANDND HAVE BN
PRODUCING THEIRIR OWN INFORMATIR
IN
FRENCH, OBVIOUSBVIOLL OFLLUR
RESOURRES ARE IN ENGLISHLI, AND
TH
REASON WEE NEEE NEE TO T HAVE H
RESOURCESO IS NOT J NT TO PROVIE
ITH EDUCATION DURG
PREGNANCY BUT AUTOITH THE
AFRMATH, ALL OF THESEF
NOT NECESSARIESES HE TIMEO DOGHG
DOIN
OUR PRACTICE BUT ACTUALLY
VING -- TOALK ABOUT THAT IS
A
RLLY G G RESOURCES
SIMILARLY OURATIENTS SRE OUR
IFEANS THEY DON'T HAVE TO BEUSEU
HAVING TVIT CONVERSATN AGAN
AGAIN EXPLAINING WHAT WHIS
IS, TY T CUST SAYAY WAT THIS
VIDEO, LDETEN TOTEHIS AND T AN
THE A GROUPUP OF PEOPLE
AROUND THEMHE THAT ARE ARE EDUCD
AND -- THAN TO HAVE A GRE P OF
OP SAYING OH EVERYTHING I
FINE, WHEREAS ACTUALLY SING I
RIS LISNEISIS TO THIS, I'M GOING
TO CHECK IN AND A MAKE SURE THAT
EVERYTHING IS OKAY.
WE HOLWE A HE ARETA
FUER EVERY EVERY YEAR, WE CALL
THE WORD THERE SO PEOPLEPEOPWWAN
WHAT THEY'RE COMING TOO
FU
IS
HAD 50000EOPLE COMING TOG THIS
EVENT, IT LIKE HAVINGAV WEDDING
YEAR, WE LOVE TO HAVEAV A
GREAT TIME SO THIS IA
BRILLIBRT WAY TO GET PATIENTS
STOGETHER.
THIS PICTURE HERE IS OF A A MOMM
D -- WHO HAD A HYSTERECTOMRE
SHE LOSH HER TWINSWIWI UNFORTUNY
BUT WE ALWAY A HAVE A VIDEO AT
THIS LUNCH LHICH CAN BE QUITE QQ
HERE TO UNDERSTAND AND LEA ALLLL
THIS TOGETHERRND,ROU KNOW,NO
SHOWING THEMHE THE RESOURCESOUND
SO I JUS WANT TO FINISH WITH A.
QUOTE THAT I REAY LIKE, AND I
SUPPOSE IT'S AS PLAY ON REALLY
LISTENING TO UNDERSTAND, RATHER
THAN JT LISTENING TO RESPOND,
AND I THIHAT'S THE ONLY WAY
WE CAN MAKE MEANINGEALNG CHANGEN
OUR SERVI SS AND IN I OUR
PRACTICE, IF WE INVOLVE
PATIENTS, INVITE PEOPLE TO TELL
ACTUALLY WE LISTEN ANDND SAY YOU
KNOWOW WHAT, WE'RE GOINGNGO MAKE
CHANGE BASED ON WHATHA YOUOLD
US.
I
ANK YOU SO MUCH, AND HAPPY
OF THE PANEL.ELUESTIONIONS ON PR
>> DESPITE DR. BARR.E'S
ADRTISEMENT,EME'RE NOTOT QUITE Q
AT GIN AND TONGUE
C
ARICS YET SO WE'LL TURITVER TO E
THIS PANEL DISSSION.SS
>> THANKS, EVERYBODY, FOR
STICKING AUND AT THE FINAL F
MINUTEMI OF OUR SESSION AND THE
DAY HAS BEEN LONG IN HOURSRS BUB
REALLY SMULATING A
INTERESTING AND FANM MY
PERSPECTIVE FLEW BY.
SO THANKS FOR B FNG HERE.
ANYBODY HAVE QAVEION FORHE
I KNOW IT WAS A WATTLEWAIT OF IT
MIXED BAG OF TOPICS, BUT REAY
INTEREININGIN TALKS.
DR. FOX.
>>>> HELENA, YOUA,OUCHEDOUN I
VERY BRIEFLY, AND I'M GRATEFULTE
TO YOUHAT YOU YNCLUDEDATRS
OR OTHER FAMILY MEMBERS INNHIS
PSYCHOLOGICAL IMPACT.
I'D LOVE TOO HEAR H YOUR
PERSPECTIVE AND WHATD OURD AMILY
MEMBERS WENT THROUGH BOUAUSE I
CA
T TELL YOU HOW MANY TIMES T
IT
BEEN THE PARTNERAR WHO
SAYS -- OR EVEOROR THE PATIENT L
SAY I THINK HE WAS MORAS
AUMATIZED THAN I WAS JUST
AKCAUSE I WAS AEEP, HE WAS WAS
CTIVES.TED TO HEARO OUR
>> 100
I TNK ANY ANY REARCH INTONTO THS
KIND OF NDRK HAS TO INCLUDECL TE
PARTNERRT A PTNERS CAN SUFFER
PTSD, BIRTHTH TRAUMA AND ALL
OF THOSE THISES.
THAT WAS IMPORTANT TO US O THE
TSET.TS
SO THERE'S A COUPLE OFPLE REAS.
FIRSTLFITHTLFITHARTNERS OFTEN FL
LIKE THEY'RE AYSTANDYSTANDYSHEY
DON'T REALL RFEEL R INCLUDED LUE
TO AT THE ANTENATAL
CONSULTATION, THEYTHRRIVE ONHE
DAY OFHE BIRTH, THEY'RE
COMPLETELY BLIND BIDED B WHAT'S
HAPPENHAG ENHAHEY DON'T D REALLY
KNOW HOW TOOW HELP BECAUSE THEY
TH O POSTP PTUM PD, WE SAWAWO
THIS TRANS TION WHERE W THE
PARTNERS ARE JUST SO -- THEY
DON'T WANTNTO TALK OR -- WHE--AS
FO
THE MOMS, LIKE LIKE I WAS SAYIN,
THEY'RE INE THA SURVIVAL MODE
NOT TALKING AKIUT IT, NOT HAVING
A CONVERSATION WITH THEIRIR
PARTNERS BECAU B THEY' T TOO T
TERRIFIED TO ACTUALLCT TAL ABOUT
OH MYOH GOD, I MIG LOSEOS MOSY F
AND MAN CHILDREN OR MY BABYY THT
I'M GROWING NOW, SO THEY TN'T
HAVE ANY CONVERSATIONS, THEN THE
BABY COMES ALONG, THE MOM
SEVENSEONTHS LER IS REL RGSIX OO
EVERYTHIER THAT'S BEEN HAPPENINI
THAT'S FINALLY TAL PCE WHERE
E CAN TALKN BOUT, BUT HER
PARTNER HAS MOVAS ON, ERYONERY
DOESN'T HAVE ANYONE TO TALK
AB
T SO'S'S REALLYLL ISOLATED.
SO THEHE PARTNERAREEER TO T BE B
INVOLVED DURING URE PREGNAPRY SO
THAT DOESN'T HAPPEN, SO THEY AHY
INFORMEDFOND E ED THAT THEY
KNOW WHATHA TS T GOING TO BE
LIKE.
PARTNERS PREVIOUSLY SAY TOYE,
IF I HAD KNOWN THIS AND THEN
THEN IENEN COULD HAVE DONE THIS,
ANY O THAT.TEAD THEY TON'T KNOWO
UNDERSTAND THERE'S'S CHILD CARE
TH
GS BUT I JUST HAVE MY OWN
CONSULTATIONS WONRE I EXPLAIN TT
EM WHAT' WHAHA GOING ON O TO PRE
THEMTH HOWHEYAN HELP THE
PARTNER DURIR THE PREG SL, S
MOSTMPORTANTLY IN THE POST
POSTPARTUM PERIOD, SAME FOROR
OTHER FAMILY MEMBERS, THRS, HERS
VE TO BE INVOLVENV BECAUSE
THEY'RE ALL PART OARF THIS LIKE,
U KNOW, MOMSOMNDOM WOMEN ARE
OFTENOF THE LINCHPIN OF THE FAMY
ILL TODAY, SO WHENNHAT PERSON
IS MAY ADMITTED TO THE
HO
ITAL DURINGUR THE PGNANCYCY
FOR A LONGA IME IF TE T' T THE
CASE OR ISS VERY UNAWARE AARERAR
THE BIRTHND THERE'S OTHER
BE PREPAREDEP TO DO UP THE PIEE
THAT IN IN WAY THAT'S MEANINGFUL
AND I I I THINK IT'S IMPLETELY
SENTIAL THAT WE INVOLVE TLV
PA
NER, WHOEVER ELSE TRE
THERE TERE SUPPORT.
SOMETIMES THETH PARTNERS ARE NOT
THAT GTHAT OR ARE NOT AVAIT BLAI
FO
ATEVER REASON.
TH
AND I'VE HAD LOTS OF FAMIF ES
WHERE IT'S ACTUALLCT THEHE SISTR
THE FRIEND THAT COMES IN TOO
THEONSULT ORLT REALLY WAN TO
BE THAT PERSONPEHAT'S GOING TO
HELP AND ADVOCATEOCR ISOING TONT
BE ONBEN THE T POSTPARTUM FLO, ,
WE'VE BEEN THROU T ALL TF THIS,
BECAE SOMETIMES PARTNERS ARE A
THETH TIME THEY'RE DELIGHTED TOE
THE STEPS AND THINGS THAT
THEY CANAN DO AND REALLY BE
INVOLVED.
>> I'LL JUST -- I AGREE WITH
EVERYTHING YOU SAID, HELEN HEN
BUALLY BEING ABL TO INVOLVE
.O.SPATIENTS' NETS'RK AS A MUCHS
IN MY SITUATION, I HAD A BIG
OFAMILY, DEFINITELY
LEANED ON MY M HUSBAND AOT FOR
OREMOTIONAOTSUPPORT, AND HE WAS
IN
LVED THROUGHOUT THEHE PROSS
SSWH
H HELPED,EL BUT B I DID PUT A
T OF BUROFN ON HIM BECAUSE HE
WAS RESPONSIBLE FOR HELPING ME
TO G THROUGHHIS WHILE ALSO
GO TO WORK AND TING CAREG F
OUR SON AND HOLDING A LOT O
RESPONSISPLITY AT THE SAME TIME.
HE HADHE H SOME STORY,RY AFTER
DELIVEDE WHEN I HEN IN ICUIN I
SAID HIS FEET DIDN'T WORK, HE
THIS CRAZY C STO OF H H H PAI P
ET WERE.
AND HE KEPT KTAWING ABOUT IT,
EVERYONE IS LIKE WHO CES ABO
YOUR FT?
BUT JUST POINTING OUTG HATHE
NEGLECT THAT T WEE OEN PLACE ONO
SUPPORTPPEOPLEPLELE W THERE
H IT WHICH,HI IN TURN,
MAKES THEM LESS ABLE TO SUPPO S
MOM.
>> HI.
YOU GUYS SO MUCH FOROR ALL
UR WONDERFUL TRFKS.
I JUST WANTED TTE T JUSTUS UERSE
WHAT WAS SAI DING D THE TALK
ED FOROR SOPs A
TH
MPORTANCENCNCHENHE COLLECTINLE
OSPECIOSNS, AND A THINK THE
RIGOR OF OUR VALIDATIOID STUDIEU
ANDININ T FUTURE WILL NEED TO BE
MOREIKE MULTICEULERS SS
IN A STANDARDINDD WAY WILL BE
D THEN ALSO AO ECHO ACHO LOTF
WH
THOSE HAVE SAID EARLIERERN
THE DAYBOUT TUT IMPORTANCE OEFF
STUDYINGUD OURURUR NON-R ACCRET,
THATTH REALLY HAS - DECTION,
ENSURING TT WE'RE BRIDGINGIN OUR
YBE WE CAN USE -- TOMORROW TONDN
STRIKE THAT JAIT HOW T H DO THAT
OME SORT OF SYSTEMATIC WAY,
IT'S DIFFICULT TCU PICK THEM UP
YOU Y DON'T HAVE H ANNRETA BUT
FINDING A WAY W TO START --
>>
HRISTINA.
I WANT TO FOLLOW UP ON THAT
CO
ENT BECAUSE I WE REAY
INKING ABOUT SCOTT IN TS
BUT HAVING BIORKERS, ANDND IF IO
REALLY HAD H A PIEN THE SKYKYKY
DREAM ABOUT WHAT WE COULD DO
WITH ACCRETA CARE, IT WOULD BE
NALT TO KNOW IN ADVANCE
CEWH
HADAD A PREDISPOSITION FOR
WOUNDWOEALING SUCH THAT WHAT IF
WE COULD PRECISIONON MEDICINE
RCONCEPTIONAL INTERVAL FOR
PATIENTS SUCH THAT WEIDHEIR
SURGERY, TO T DR. SILVER'S WAY
TH A COLLAGEN SNET IN THERE,
OTED WOUND HEANG BUT ALS
UN
ENOUGH TO SAY YES IVF MOM, M Y,Y
CAN HAVE A PGNANCY AGAIN IGA
NTHS EVEHS THOUGHUG WE W
NORMALLY TELL EVEBODY 12 TO
18, SO TO ME, IFF YO IT WOULD BE
REALLYRE NEAT TO KNOW NOT ONLYYN
PREGNANCY WHATT THEIOMARKERS
SHOW FOR THE ACCRETA -- BUT ALSO
WHAT DO WEO NOWBOUT UPSTROMA,
TH
ONE TO BEGIN WITH.WIHAVING
SO THAT TOHAE IS AIS REALLY COOL
FRONTIER, IF YOU HAVE ANY
THOUGHTSOUBOUT THAT.
CER CLY NOT DOING IT BUT
AFFILIATFI WITH ME AT ALL THAT''
ACTUALLY COLLECTING MEINTRUAL
D IN DE DIVA CUP AND
ING PROSPECTIVELY
AT NOT ACCRETA BUT OTHERTHNG
PREGNANCY OUTCOMES, SO PEOPLE
ARE LOOKINGOO FOLLOWINGLOWI THA
TRN OF LOG.
I THINK IT'S -ITYOU KNOW, I
DON'T KNOW,NO Y'ALL LOO AND --
WE DO THAT?
I MEAN, LIKE MAYBE, MAYBE
THERE'S SOME SIGNAL COMINGG IN
MENSTRUAL BLOOD THAT WLD
IDENTIFY WOMEN WOMON'TON
AREN'T -- WHO'S GOINGNG TO FUN
IT.
>> DR. WRIR. WRI
>> CONATULATIONSNS ON ALL THE
GREAT TALKS.
I WAS S WUCK WITH D SILVER'SS
SSLIDE WIT19 TO A HUNDRED% OF
PATIENTS WITHIST MUST SEALS OR
CALL THIS EITY.VER WE WANT T T
IT JT DN'T EXIST 10 YEARS
AGO, AND N A THE INCIDENNC IS SO
HIGH.
I'
SURE THERE'S MEASUREMENT
PEOPLE WITH A HOLE IN THE UTHRUS
SOMEF THESESESE FOLKS ONKED UP
ULTRASOUND, IND GUESS WHAT'S
CHANGED SO DRAMATIRALLY IN THEHE
BIOLOGY?Y?TORS AND THE UTERINE
THAT'S WHAT WE'RE ALL HERE TO
FI
RE OUT.
SO TWO COMMENTOM
NUMBER OMB, O I DO THINK THERE'S
BEEN A CHANG CIN THE TECH KNEC
SOMEHOW AND TECHNIQUEAND WE REAY
THAT.AT
COND, CO DID NOTICE SOME OSO US
A CERTA C C AGE IN THE ROOM,
BACK WHEN WE DO A A TRIAL AFTER
CESAREAN WE'D HAV SUCCESSFULSS
FEEDBACK, WE'D STICK OUR HAND II
TO SEE IF THE WAS AOLE, AND
NDA LOTAF TIMES THEREAS A HOLE
AND WEANIDN'T DO AT DOING.G.
AND NOTHING BAD HAPPENED AND WE
QUIT DOING DNG IT, IUT THERE WAS
S THIS NICHE.IC SEEHETHER THERE
WE CALLED IT SOMITHING
DIFFERENT, YOU KNOW, WE CALLEDAL
FOUND A LOT OF TSE THINGS.DR, YU
BUT THEHEHEUESTION W HAD IS, WAS
IT SAFE F THEM TO T HAVE A
D LABOR?
WHAT WE FOUNDOU IS IT DIDT M
ANY DIFFERENCE, AND AOST OFHEM
DIDN'TDIAVE ANY SYMPTOMS W
QUIT THINKING ABO IT TIL
THEY STHRTED HAVING ALL A THESE
DAMN ACCRETAS AND NND WE HE TO
REVISIT IT. IT.
SO I THINK WE'VE ALWAY AHAD
THESE SCARS.
JUST ONLY ASSESSSHORT TERM
OUTCOMESTCF THE SCARS WHICH
WEREN'T SO BAD, AND WE HAVEN'TTM
IMPLICATIONS OF THEF SCARS.
BUT I'MTTAKINGAK THAT UP AND I'D
LOVE TO HEAR FROM AROBODY ELSE
ANOTHER THOUGHT. MIGHT HAVE
>> I WONDERR IF ANOER TNG T
THAT CHANGED ING ULTRASOUNRAUN E
OUR ULTRASOUND ISNDS MUCHETTERET
THAN THEY WERE WHEN IEN STARTED
PRACTICING AND - ANDND SO
HISTOGRAMS HAPPE H H PATIENTS
ARE -- I GET AOT OF NHE
CO
ULTS CULING FROM FFERN TILT
ACTICES BECAU B THEY'RERE DOINGI
SOME HISTO HISS H SO IT' KIND OF
NOWENOE SEEINGEE A THESET ANDND
THINGS TINTIN MAYBE MERE ALWES
THERE.
INTERESTING THAT DEIRD DEIROUGHT
UP IN THE VERYIRSTECTURE IS
THATEEON'T TALK ABOUTUT PREVIA
REALLY AT ALL,LL A IF A PATIENT
C-SECTIONS, FUND, PLACENTA,
SAYS HOWYSONCERNED ARE Y A ABOUT
ACCRETA AND WEE SAY WE'RE NOT, N
ARE WE HAVING MORE M PREVIAS?
DON'T KONW THE ANSWER TO THAT.
BUT -- THERE OTHER THINGS, WE
HA ASKED THE QUESTION, WE
DO
T KNOW WHAT THEY ARE, BUT
MAYBE THE ISSUE HAS AAY AAY A BN
HERENUTUTOWUTOW WEE HAVE HAV PRI
SITTING INN NICHES SO MAYBE WE
WENEED TO BE LOOKING AT THAT.
>> JUS>> TO JASON'S POINT,,OT
ONLY IS THE CLO C DIFFE DNT
POTENTIALLY BUT I THINK OHI
OBSTETRICS IS JUST DIFFERE I.
WE'RE LETTING PATIENTSIE PUSH MH
LONGER, SO AIB THAT'S -- AND
E'RE DOINGOI SECON MUCH
LAR IN THE SECOND STAGE THAN
USED TO OR -O I THINKHERERE
ARE OTH O VARIABLESESHAT MAYBE
WE'RE NOT QUITE TNK TG ABOUT.
THE EFFECT OF INFLAMMATION AT
IN
CTION ON THATEMELING.
I THINK THOSE T ARE ALLRE KINF
PRIME TARGETS TO HELP IDENTIFY
THE WHY.
.>>
-- DS NOT REFLECT THE
NATIONALTI DOTIE HEEEE ACTUALLY
NATIONAL DATA?
I ALWAYSWA GIVEE THE EXAMPLE, II
WERE TO REPORT EPTE OF ECLAMPSIA
WHERE I AM,ROBABLYBL ABO 2250,
NATIONALLY IT'S 2,000.
IT'S A REFLECTION OFIO THE T CT.
THERE WERERE ACTUALLYLL -- I DOT
THINKINE HAVE THIS THING.
>> DR. HERRERA.
>> JUS>> TO KIND OF PIGGY BACK,I
WAS GOING TO T SAY BEFE SCOTT
BROUGHT IT UP, WE PAY ATTENTATN
NTO TNTO NICHES ANDN ANGS BNG
WE DON'T G'T BACK TO WHAT WASHE
PRIOR SURGICAL HISTORY TO THE
EXTENT ONT WTT IT FIRST STAGE,
SECOND STAGE, TACOND STAGE WITH
BECAUSE WE KE W TE RE'S
ASSOCIATIONS WITH PRETERM BIRTHS
SO THERE'S SOM'SHING CHANG CG IN
AT LOWER UTERINE SEGMENT
ALREADY, SO Y, REALLY THINK THAT
WE NEED TO KIND OF POWER THE
DATA LOOKING AKIA LITTLEITOREOO
DE
LIVERIESRIS WE CARRY IT
FO
ARD WHEN WE'RE LOOKING AT
OUR CLOSURE, ANDND I DO THINKTH
THERE ARE -- ANTON HAD THIS
PAPER WHERE MAYBE WAYRE ACTUALLY
EVERTING PARTICULARLY IF I IS I
ALREADY THINTH AND YOU ALREADY
HAVE VERY, VERY LITTLE
MYOMETRIUM THAT YOU'REE PUTTING
TO
THER, IT MAKES SENSE T
MAYBE IN SOME OOMF THESE CASES
WE
E CREEING THAT DHATT.
>> DR. SHAINKER'SS QUESTION --
SIGNALSIIGN FORMMUNE PATHWAYAT
DR. DID CAN WEIGH IN, BUT
IS IFH -- HYPERACYPVATION IN I
THISMMUNE ACTIVITY, THEN I WAS
THINKING BASED ON SOMEN EVOLVINN
CONCEPT OF OUROUOU USE OF --
RECEPTOR -- FOR THEHE GESTATN
GESTATIONAL -- PLACENTAL SITE --
DATATA F RUSSIA,USUS PATIENTIE
DIFFUSE -- AND THEY PROVIDERO A
MEMBERER OF ---- THERAPY -RA
DISAPPEARED, IFD, SO -- SCCRETA
OF -- TREATMERE.RIL IMMUNE --
>> IHI WE'RE JUST STARTING
INFLAMINTORYRYATHWAY WITH THE
BER DEPOSITION AND THEHE ROLE OF
ACCRETA.
I THINK THI TO HER POINT PWE'RE
LOOKING --N THE FOURTH
TRIMESTER, WE'RE LOOKING AFTER R
LIVERY, SO WHAT I THINK WOULD
BE GREAT IS HELPING TO TO
UNDERSTAND TTAT PATHWAY DURING
GESTATION ORVEN PREGESTATION
AN
FIGUREGU OUT WHEUT CAN WE
BLOCK IT.
WE HAVE A MICRO ARRAY,AY
INFLAMMATORY MICRY ARRAYRR O
AG BN, THERE ALL T ALL AES BUT B
TRIMESTERR SAMPLES.
SO TRE T ARE A PEOPLE W W HAVE
DE TS TMENT, YOU GIVEIV
PRETTY HIGHH POTENCY
NFLAMMATORY TOAN THEHE MOUSEOU
MODEL AND SEE WHAT W HAPPENS WH
R SOME OTHER ANIMAL MEL..
SO YES, Y PEOPLE ARE START STA S
T THAT, IT'ST' NOT WHERE OUR
URFO
URFO B W I KNOW YOU'VE B
LOOKT IT A LITTLE BIT, THE
LE OF INFORMATION.
-- CAREANS FOR PGNANCY,
IT
HPENS LOCALLY.
THIS IS -- YOU KNOW,ERSUS IN
THAT SCOTT ALLUDED TO WERE INDI
MATERNAL SERUM.
BUT THE CHANGES THAT PEOPLE AT
THE SCRIBE AT THE IMMUNE LEVEL
ARE LITERALLY THE MACROPHAGES
AND VILLI SO IT'S AS A VERY V LL
EFFECT VESE VERSUS SYSTE SC EFF,
SO YES THEORETICALLY B A L
MOREORK HAS TOE DONE TO
THINK ABO SYSTEMIC
CONSEQUENCES OF SUCH A LOCAL
DULATOR.
>> JUST TO AT ON THAT,UR
TRIMESTER WTEE MUCH MORE MRD T T
INVOLVED IN THO IMMUNOMODULAR
PAWAYS WHEREAS IN SECOND
SEMESTERRE MOR ANGIOGENIC --
POTTIALLY BE MODULATED TO
PRENT ACCRETARE BUT -- -->> W SM
SAMPLES AS WELL, LOOK AT
MIC PLATFORMS,MSHERE'S A
SHIFT INN EXPRESSION, THE
ESTI IS WHY.
>>
ABS LUTELY.
>> DR.AADE..
>> SOOO GOO BACO TO THE
INCREASING RATE OF ARETA, AS
BOB SAID, WE USED TO T SEE THEST
DEFECTDEIN THE T PAS,ND THERE
S NO ACCRETA, BUT INBURDER TO
HAVE AN AC AETA, YOU HAVE TOE
EHAVE THE T IMPLANTATION ON THEE
INCISION, S---- THE QUESTION WAS
ASISED, IS THE INCREASED RATE
OF
CORRELATE WITH MATER MAT AGE AND
MI,MIMI THE T MORE LOWYINGYI D
RE ACCRETA E EOU'RE GOING TO
HAVE.
THE OTHER OTY YOU COULDCO IT,T,
THE INCIS IN ON THE THE T LOWERR
CLOWSER OWD CLOSER TO THE CG C P
FUNDUS, SO TIGHER THE
IN
SION, THE MORE LIKELY THE
PLACENTA IS GOING TO NGACH THAT
INCISION.
OF THESE SHOSED BE
IN
STINATED ALONG WITH THE
TECHNIQUE AND T AND CLORE.
DR. FOX.
>> COULDN'T AGREE MORE M WH
NEEDING TO T KNOW WHERE KUTTING
AR.
IT'S INTERESTING TO HEAR THE
DIFFERENT HYPOT HYES.
I HEAR SOME SAY LOWER L BECAUSE
YOU T T B BTTERLY DERP
ONES ANDESIGHER -- YOU KNOW,
THERE'S DIFFERENT RISKS AND IT
PACTS RUPTURE.
I HAVE TO AGREE AITEEWHAT YOU
SAID, BOB, A NOT NOT HAVGHE
LOITUDAL DATA, BECAUSE I HAVEAV
TO WONDER ALSOR THERE ARE P ANY
OF WOMEN WOM MAY HAVE SYMOMSS
OF A CAREAN SCAR NICHE BUT ITTT
NDND OF GOES UNDERRECOGNIZED.
LITTLE BITLE TL OF TROUBLEUBLEE
INTRAMENTRRUAL -- I- DO THIO T
HAVING SOME MORE LONG-STONDIST
WE DO TO U OURATIENTS WOULD BETA
REALLY, REAY HELPFUL,,OT JUST
FROM AN ACCRETA PERSPECTIVE BUT
A CECTION A - A
A>> IT SOUNDS LIKE WE REALLYY D
SOMESO RCTs WITHH LONG-TERM
LLOW-UP AND I'M SUI' THEY
YWOULD BE DELHTED TO T FUND THIS
CRITICALLY IMPORTANT ISSUE
THAT'S JUST SUCH A FUNDAMEUNAL
ASPECT OF OBSTE OICS THAT' T
STILLST SO S POORLY UNDERSTOOD.
>> THE OER THING I'LL ADD TO
THAT IS I THINK I'MNKNK REALLY
D THAT WE HAD -- THATTE
HAVEVE HEREE GYNECOLOGICOL
ONCOLOGISTLO
THINK THE OTHER PLACE THAT THIS
COMESME UP ISS WITH OUR REI
COLLEAGUES.
OUR REI COLLEAGUES MANAGE NICHES
COMPLETEMP SEPARATELY THE WAYE
FERTILITY.Y. RELATEDEL TO
- TOLLTODIFFERENT THAN ALL
OF OUR O SOCIETYTY GUIDELINES, I
THINK THIN ISUGH TO T -- THEHE
STAKEHSTDEEHGROUP KEEPSEP WIDENG
WHO WEE N TOET ACCESS TO, TO
GROUPS OOU PEOPLE ORE IORTA., LE
>> DR. R DERTS.
>> THIS MAY BE AN
UNCOMFORCOBLE -- THIS IS --
ROBERTS, TRTS MAY BE ---- I IAS
REALLY TAK BY YOUR IMAGES OF
THE SR PREGNANCY AND PICKING
THAT UP EARLY.
HAVIN BEENNVOLVED IN ONE OF
QUESTIQUTI WHICH IS, IF W SAYNGI
WE'RE GOING TO TRYRYRY A G
, PARTICULAR PEOPLE THATHA
HAVE HAD CESAREAN SECONEC EARLY
IMAGING,AGHEG, THEUESTN
HAPPENS WITH THOSE PATIENTS IN I
TEXAS, WXARE YOU SEE THEEE'S
T HAS ATCAR
PREGNANCY, YOUR FEAR IS TT TT
COMES ACCRETCR AND YET Y Y
THING ABOUT IT OTHIT
THAN MAYBE SEND THEM TO T
R --
>> SEND THEM TO CALIFORALA.
>>N, IT'S DIFFICULTFI
THOUGH, BEC,SE I THINK WE
SHOULD BEOING EAR
TRASOUND, I I WLD FEEL
STRONGLY THAT PEOPLE FOR
CESAREAN SECTIONS, THES,SHOULD
HAVE IHA EAR E.
BUT THENHETAISES THE ISSUE OF
WHAT HAPPENS NEXT.
>> I'D LOVE TO HEAR WHA ALFRED
S TO SAY BECAUSE I THINK HE'S
T ABOUT THIS AS MUCH M
ANYBODY.
THERE'S NO N CORRECT ANSWERNSRNI
THINK THOSE ARE CRITICALLY
IMPORTANT ISSUES, MANY BEYDY
THE SCOPE OF WHAT WE CO WD DO,
BUT I WOULD ADVOCATE F A
UPHINGS.
IS, I TNK THENK EARLIEROU
AGNO THIS, THE BETTER OFFFF
THE PATIENTS WILL BE, ANDND I
CORRECT.AT'S PROBABLY MEDICALLY
NU
ER TWO I WHATEVER TVE
LOGISTICALSTICALSTS ARE, THEY
BE LESS EARLIER IN
PREGNANCY, SO I THINK TRYING TO
DO WHAT'S MEDICALLY BESTT A A
THEN FIGING OUT THE BEST WE
CAN DOCAITH THE LOGWETICS ISS
PROBABLY A BETTER STRAT SY S THN
NOT DONOG WHAT' W MEDICALED BEST
BECAUSEUS OF LOGISTICALCA HASSL.
I THI THERE'S ONE MORE POINT
THAT YOU DIDN'T RAISE BECAUSE
YOU WERE BEING POLITE BUT I
THINK IT'SK MPORTANT TO RAISE,AI
AND THAT IS, FOR USS
OBSTETRICIANRI AAN FOR
RADIOLOGISTSOG WHO ARE NOTXPE
EXPERTS, IT CAN BE RLLY TRICKY
TO DIAOSIA A CESEANEAEACAR.
THE SCARIEST DIAGNOSIS IS
SOMEBODY IN I A SMALL SMAMUNITY
HO
ITAL SAYING OH, THISHI IS LIKE
A MISS KAIRNL THAT'S GOING TO
BECAUSE THERE'S A FUNNY
G SAC IN THE LOWER UTE RUN
SEGMENT.
SO I THINK IFF WF START DNG
IS, IT'S AITO GOING TO REQUIRE
UCATINUCAND TRAINING PEOPLE
WHO DO EARLY URASOUNDS,
ESPECIALLY IN N-TERTIARY CARE
S.NT
SHOULD.NMAPEOPLEOPHINKS ABOUTRWE
>>
WAS GOING TO GO BACK TO THE
HESURGICAL AICROACIC
I TINK TTT COULD BE TRICKY.
I THINK THERE ARE SOME CASEE
THATAT ARE CLEARLY EASY T
DIAGNOSE BUT THERE ARE SOMEE THT
ARE NOT.
YOU HAV HAVLOWER SEGMENT
IM
ANTATION, TIE SAC ISAC
LITTLE BIT CROOKED TETHERED
S THEHE SCAR, THE PLAHENTA
IS MAYBE A BIT TOWDSOWHE
RELATIVELY NORMAL PGNANCY.E A
SO THERE WILL BE A LOT OF
THAT, BUT I TRULY BLYIEVE THA
WE WILL GET TO A POINT WHERE THT
RSTRS TRIME TERME ULTRASOUNDSOOD
PLAY A BIGIG ROLE INN ETA
DIS.
BUT THBUREASON I SAY IT'AYVERY
TRICKY BECAUSE WESEAVE SEEN
SSION IN THE MARKERS THAT
WE SEE FROM FIRST TO SECOO AND
THIRD AND I SHOW THE CASE HOW
SICK THAT PIENT BECAME WITH
JUST THE VERY V SUBTLE FINDINGIN
THE FIRST ULTRASOUND,SOO WE NEED
DTO BEEALLYYOOD ATAKINGIN
THESE DIAGNOSIS AND WE NEED TEEE
START LOOKING AT A THE FIRSTST R
OUND TRYIN T TO FIND MORE
SUBTLE SIGNS TIGN JUST A LOWER
SEGMENT IMPNTMPION.
SOSO THINK THERE'S A LOT OF WORK
RKBUT I'M HOPEFUL THEIRST
TRIMESTER ULTRASOUND HAVE BIGGER
ROLE TO TLA IN THE DIAGN DIS
EARLY.
BECAUSE IF WE'RE DOING
BIOMARBIRS AND THE VALUE OF
BIOMARKERSKE EARLY IN I PREGNANY
HAVING THE COMPLEMENTARY
ULTRASOUND BECOMES REALLY
IM
RTANT IN THAT SETTING.NG
I WAND TO GO BACK TO THE
SURGICAL APPROACH BSE THOSE
OF YOU THAT POINTED OUT WE'VE
BEEN DOING THISHI FOR A LONG TIE
DEIDT SEE S THAT HIGH RATE
OF ACCRETAS IN THE T P P P, WE T
NT TO GIVE THE IMPRESSION THAT
WE WEREE SO SYSTEMATICALLY
ORGANIZED AND WE DID CESAREAN
SECTIONS AND W AE ALL FLOWEDLO O
THIRD YEAR, THE SECOND YEARHE T
WOULD TRAIN THE TIRST YEAR AND
IT W HAPHAZARD AND IT WAS ALL
OVER.
SO I'M A LITTLE BIT HESITANT TO
SAY THSAE'S A LOT TO SAY ABOUT
THE SURGICAL APPROACH WITH
GARDS TO WHETHER WEAVE
NICHES OR NO OAND WHETHER THAT
PREGNANCY.T ONHE SECOND
IT'S -- - THE WAYAY WE TINEDAS
CH AN ORGANIZED PROCESS OFES
DOING CESAREAN SECTIONS THAT NOW
WE
ENTEN THE WRONG WAY OR THE
OTHER WAY THAT RESULTED IN THAT
PREVALENCE OF THE DISEASE.AND
I DON'T KNOW.
IT'S JUST SO MUCH TO PUT O T T T
CLOSE THE YR IS RELATING
TO WHETHER THAT RVES IN SUC
HUGE INCREASE IN ACCRETA
GREE 100%.I DON'I THINK TE'RE O
HAVE A SINGLEIN THING.
I THINK WHENEVER ANYTHINNYIS
THIS COMPLICATED AND ALL WEE HAE
ARDEMIOLOGYAR CLUES, WE'RE
ALWAYS LOOKING FOR THAT ONHA
MAGIC MAUE THAT WE
STIFICATION, AND IJU THINK IT'
THINGS.ION OF A THESE T
I WL SAY WE MIGHT HAVE HAD THE
INTERN TEACHING THEIN THIRD YEAR
ME
ME STUDENT HOW TO DO D IT, B WE
WAYS DID A TWO-LAYER CLOSURE.
HINK EACH ONE OF THE THINGS
DERVDESTUDY.
AN RCT OF CONSERVATIVE
MANAGEMENT OF ACCRE ARE A IS VEY
HARD BECAUSE IT'S RARE, A LOT OF
PEOPLE DON'TON HAVE H HCK PO EQT
WE SHOULD BE ABLE TO DO RCTs
OF CESAR CN TECHNIQUE BECAUSE WE
CERTAINLY DO ENODOH OF THEM.
>> I THINK YOU HIT ON WHAT I WAT
SECTION, WE TRIED DNG IT IN
N DATA ADA IT'S REALLY
HARD, ESPECIALLY IF PE ILE ARE
COMING FROM ANOTHERNOTER, A
VAST MVAORITY OF PEOPLEEO
DELIVERING IN SMALLER COMMUNITYI
OU JUST GET THEIR
DICTATION AND WHETHERHETT WASNE
LAYER, TWO L TER LANERHOW THEY
REALLY DID IT BECOMES VERY HARDD
TOEASEEA OUT. O
WASWA IT THE LAST C-SECTION OROE
FIRST C-SECTIONCTHAT CAUSED THE
PROBLEM.
>> I THINK THANKS A GREAT POINT,
JUST THROWN OUT BECAUSEEC
SEWE'RE GOING GOINALK ABOUT
RESEARCH TOMORROWOR, WE AREAR DD
LE OUT, LET'S'S GETASTG, WE SENU
200 ACCRETAS AND FIGURE OUT WHAT
GEANALL THESE VARIABLES, ANDNDDN
TH
COUN'OU DO D I.
USTT REALLY HARD TEXTRACT
TTHAT DTHA, BUT YOU COULD DO A
PROSPECTIVE OBSVATIAL COHORT
WHERE YOU COLLECTED THOSE
DATA AND IT WOULD TAKE TAK SAKE
MONEY BECAUSE YOU HAD TO FOLLOWW
THEM FOR A FEW F FRS BUT I B
ULD STILD BE RELATIVELY
INEXPENSIVE AND MAYBE EASIER TO
DO THAN RCT, SO S THOSESE ARE AL
THINGSTHHAT WE SHOULDUL ALL THIK
ABOUT.
T.>> LOOKSKS LE WE NEED TO HAVEA
C
KEKONAC-SECTION REGISTRY, WHRYP
HAVE THEIRECOND OR THIRD T
HAPPENED IN THAN LABOR AAB THIS
SURGERY.
IT WOULD BE A H AE NUMBER
PEOPLEPEYOU COULD FOLLOW WHATHAA
HAPPENS IN SUBSEQUENT
NCIES.
AT'S WHY WE'RE HERE, TO TALK
ABOUTABIGAB PROJECTS.JE
>> THANK YOUNK GUYS.
THANKK Y,,HAWAS ABSOLUTELYLU
AN AMAZINGMA DAY..
DI
WE NOT S IN THE MORNING IT
S GOING TO BE AMAZING?
THEE SLIDES WERE AMAZING ALL D A
LONG.
SO THANK TOU, EVE,BODY, FOR
UR PRESENTATIONS.
THAT WAS THE EASY PART.
SO WE'RE GOING TOI DISCUSS NOW
WHAT WWHRE HOPG FORG TOMORROW.
YES.
S.>> SO OUR WORKINGORROUPRO GLS,
FIRST OF ALL, YOU'RE ASSIGNED TO
WORKINGKI GROUP BED O O O YOUR
BADGEE COLOR, WHICH WEE WEL GO
BUT THE GTHL OTH EACH WORKING
GROUP IS T T IDENTIFYIFIF REALLT
IS NOT KWNWNBOUT PLACENTA
AC
ETA SPECTRUM WITHIN YOURN
ASSIGNED SECTION.
YOUR MODERATORS HAV KEY
QU
TIONS FOR YOU YOU TO DISCU D AND
THEN THE WORKING GROSRO WILLIL
IDENTIFY THREE TO FIVE FP T
EAS TO INFORM FUTURE RRCH.
AL
INTIFYINGIF BARRIERSER TO
CONDUCTING RESEARCH THATHA WILL
INFORM THESE GAPS AND SUGGESTINN
THE ACTUAL METHODOETGIES AGI
PROBLEMS OF THE CURRENT RESRCH
SUCHSUS SMALLMA SAMPLE SIZE,
INSTITUTIONAL VARIATION, AND
DI
ACQUISITION, AND THEN IT'S ALSO,
I THINK, IMPK,TANT THAT WE
IDENFY WHO THE KEY
STAKEHOLAKEH AREEHITHINN EAC
SE
ION SON WE CAN MAK SIN
THE FUTUE TO INCLUDINTHEM.
SO FO TOMROW, THERE T
GOING TO BE TWO-HOUR TIME
WHERE EACHE WORKI W GROUP WILLE
ABLE TO COMOAND SORT OF WRANGLEA
WITH THESE QSTIONSIONS
INDIVIDUALLY AND A TNK THROUGH
PRIOR PIES THAT WE'RE
HOPING FOR AND THEN TO REPORT
SO WE PVIDED EACHH MODERATOR
WI A TEMPL TE FOREOR A A FEW SLS
TOMORROW AFTER THAT T TIME.
MODERATOR BUT AO AA CO-LEAD TO
TO MAKTO SURE THAT WE SO W OF OE
DEVELOP SOMEOM MORE BEST IDEASDE
HERE
ULTIMATELYMAN ADDITION TO
SUMMARY SLIDE, WIDE, GOING TO
HOPE FORPEN ABOUT AUT MONTH M ME
SORT OF A REPORT FROM EH
INDIVIDUAL WORKINGORROUP TOUP
PAPER.R.GETHER FOR A A AHITE PA
WE'VE PREPARED BOTH A SHORT
RSION AND A LONG L VERON OF
CO
IDERATIONS FOR EACH WORKING
GROUP, SO THE MERATORS HAVE A
LONGERNG VERSION OF DIFRENT
POTENTIAL QUESTIONS THAT COULDLD
DIRECTIVE, SO QUESTIONS WERE
MEANTT TO BE SORTE OF
THOUGHT-PROVOKING RATHERIN TN
DIRECTDIE.
BEST PRACTICES FORORBE SCRNINGND
DIAGNOSIS TO DR. SAADE'S POINT P
ABT WHAT ARE WE TALKING T ABOUT
HER DO WE IMPROVE
OUR GATEST CHALLENGE TO TRY TR ,
GET AT THOSE CASES WE'RE
TALKINTA ABOUT UNDIAGNOSED PRIOR
TO SURGERY.
WHAT ISATHE ROLEE OF UNIVERSNIVE
WHAT IWH O RPONSIBILITY TOANDCR
COMMUNITIES IN TERMS OF THINKING
THROUGH PEOHE WHO ARE DOING
SCREENING OUT G THEHEHE
COMMUNCOIES, HOW CAN WEMPROVE
WHAT IS DONE UVERSALLYLY AT THI
INT,HICH PATIENTS NEED
REFERRAL TO PAS SPECIALTY
CENTERS AND A HOW CAN WE USE U R
UNDERSTANDING OF THE T
PATHOPPASIOLOGSIAND THE SCIENCE
TO INFLUENNFEN SCREENING DIAGNOS
AND PREDICTION.N.
IF YOU'RE'R BLUE, JOIE, J ME,
DR. PHACS ANDS DR.I RARE RAH
KEY QUESTIOUE TOTART WITH HOW
CAN POPERATIVE STAGING AND
MORBIDITY PREDY TION BE
IMPROVED?
HO
DO WE ADDRESSDD MARKED
RIATION IN MANAGEMENA
DECISION-MAKING INCLUDINGDI
LOCATION, TIMING OMI DELIVERY AD
ANESTHESIA MANAGEMENT?
WE WANTED TTE MAKE IT A PRT RITY
FOR THIS GROUP, AND ANESTHESIA
AMANAGEMENTGE
WHO ELSE IS NEEDED AS AS PART P
THETHTHULDISCIPLINARYLIEAM IN
INTHE PERIOPERATIVE MANAGEMENT.
AND WHATTHER INTERVENTIONSIO
IMPROVE OUTCOMES LIKE TIK ONES
THAT WE STARTED TO TALK ABOUT
TO
Y. GROUP THREE, THIS I
OP
ATIVE MANAGEMENT OF PAS.
THIS I I THEHEED TEAM.
>> ARO AIATELY.
>> DR. WRIR.T, S DEAND -- HOW S.
HOW DW WE STRATIFY PATIENTSIEORE
TARGETED A PIE P-CENTEREDTE
TENAGEMENT OPTIONS, IMMIATE
HYSTERECTOMY, DRAIDRAYSTERECTOMY
VERSUSVE RESECTION AND PLACENTAA
IN SITIN
HOW DO WE DEVELOP INSTITUTIONAL
CAPACITY FOR MULTIPLETIANEEMENTM
OPTIONS AND ARERE
INTRAOPERATIVE TECVE TUES THATHA
IMPROVIM OUTCOMES.
THEN GROUP FOR IN YELLOW,
THIS ISIS DR. CARUSI ANDI BARTE.
WHAT ARE THE FRONTIERS OF PAS
IDENTIFICATION ANDREVENTION.
ACCRETA RESEARCH AND WHATT WE'T
AT ARE THE TYPHE O SPECIMENSCID
TECHNOLOGIES AND RESEARCH
APPROACHESCH ESSEN EAL FOR
EFFECTIVE BIIVARKERS FOR PAS.
WHAT IS THE IMPACT ON PAS ON THE
GYN HEALTH BUTRONGED MENEDLTERM
HEALTHHEWHAT DO YOU NEED TOEEO
TO EMOTOONALLY SUPPORT WOM
UNDERGUNNG THENGNG DECISIONS AND
AT ARE OUR OPPORTUNITIES TO T
MITIGATEHAT IMPACT.
>> OKAY.
SO WE'VE W REACHED THE END.
RIGHT?HT
CERTAINLY IF YOUIFAVEIF QUESTION
NEED ANYTHING FRO ELSE, FEEL
FREE TO REACHUT TO CHRISTINA
WHAT THE GROUPSRO A A SUPPOSEDPO
BE
DOING.NG
IF THE MODERATORS WANT TAN CHAT
AS
ELL, WE'RE HAPPY TO DO THAT.
WE'RE GOING TOI HEAD OVER THERE
PRETTY SOONOOO YOU'REITED TOO
DRINKS, LIGHTHT FOOD, FOME
SATION, WOULD LOVE TO TEE
CERTAINLRTTHIS IS NOT S QUIREDQU
LLY OPTIO OL B OLOVE TO SO
IT.
MORE MINUT M, M WE GET TO THE ED
THAT A WE TAKE A PTURE
ALLALOGETHER.
THANK YOU. Y Y
>> MAYBE NOT WITH THE DRINKS IN
THE BACKGROUND.
AND JUST A THANK YOU Y TO THE
NICHD FOR PUTTING TTISTI TOGETHE
TO IMIN WITH, BECA BEG B WITH.
WE THANK YOU SO MUCHO OUR
PASSION PROJECT, A INHEHEHE ROOM
HAVE DONE FOR ACCRETA
MANAGEMENT, SO THANK YOU A Y SO
OMUCH.