| Low prenatal diagnostic performance of PAS |
Insufficient knowledge of the disease by prenatal control personnel. Nonreferral of women with RF. |
Screening for PAS in high-risk populations |
| Insufficient knowledge of the disease by obstetricians who perform basic ultrasonography. No active search in population with RF. |
Periodic webinars about PASVirtual continuous support to sonographers by MFM specialists |
| Insufficient availability of MFM specialists. Not timely access to specialized evaluation of patients with RF. |
Periodic education for professionalsPatients with PAS RF prioritization for access to MFM specialist |
| End of pregnancy with more than 36 weeks of gestation |
Insufficient availability of neonatal ICU |
Administrative and economic efforts to expand the number of neonatal ICU bedsSchedule in advance the birth of these babies to have on notice to the neonatal ICUVisibility of PAS and search for private companies or government support, seeking greater availability of ICU beds (economic support) |
| Insufficient opportunity for an operating room due to the high number of daily cesarean section births |
Recognition of the risk of severe maternal and neonatal morbidity in late emergent surgerySchedule in advance these surgeries to have "on notice" to the operation room |
| Late catchment of the patients |
PAS RF patients active search by a specialized centerEarly identification of the disease |
| Lack of an interdisciplinary group |
The “mother-child” nature of the hospital |
Assessment of the adequacy of this hospital modelSupport from nearby hospitals in scheduled surgeriesRemote support of interdisciplinary groups to adapt the protocol to the available personnel |
| Difficulties for agile hiring of additional personnel for specific procedures |
Administrative effort focused on facilitating the necessary hiring |
| Lack of collaborative work with neighboring private hospitals |
Creation of regional groups for academic discussion and assistance support around PAS |
| Absence of a “PAS team” |
Identification of leaders interested in PAS in each specialty (anesthesiology, pediatrics, obstetrics, intensive care, nursing, surgical instrumentation, etc.) |
| Lack of contact with groups in other cities or countries |
Use of telemedicine and participation in regional (LatAm PAS study group) and international (IS-PAS, PAS2) academic groups |
| Absence of feedback on histological study results |
Insufficient availability of pathology services in the region linked to the public health system |
Administrative effort focused on facilitating the necessary hiring |
| Absence of pathology service within the hospital |
Administrative effort focused on facilitating the necessary hiring |
| Lack of institutional messaging system to transfer surgical piece to pathology service |
Administrative effort focused on facilitating the safe remission of surgical pieces |
| Lack of communication with pathologists from another institution |
Inclusion of local or regional pathologists in interdisciplinary groups |
| High frequency of normal reports of cases with apparent PAS in the macroscopic examination during surgery. It may be related to the fact that surgeons always detach the placenta after surgery to confirm the presence of PAS in the face of the low frequency of histological studies. |
Avoid placental delivery in the operating room by surgical group, provided that histological processing is ensured to clarify the diagnosis. |
| Limited capacity for massive transfusion |
Absence of a blood bank inside the hospital |
Administrative effort focused on facilitating the necessary hiring |
| Variable response to the emerging request for blood components other than RBCU |
Administrative effort focused on facilitating the agile and sufficient supply of blood components from external blood banks |
| Absence of intraoperative cell recovery system (“cell saver”) |
Hospital economic investment for the acquisition of the equipmentRequest to nongovernmental organizations to donate this equipment (for example Jehovah's witnesses) |
| High frequency of “emergent” surgeries (with vaginal bleeding or uterine activity) or at night |
Surgeries scheduling between 34–36 weeks |
Construction, disclosure, and supervision of compliance with institutional protocol for PAS |
| Lack of prioritization of patients with PAS RF (previous cesarean section and placenta previa) in surgical programs |
Recognition of the risk for severe maternal and neonatal morbidity in late emergent surgery |
