417 A difficult to tell reality: care improvement opportunities for fatal cases of placenta accreta spectrum

Almost all cases of maternal death (MD) due to postpartum hemorrhage (PPH) are preventable. Placenta Accreta Spectrum (PAS) is a common cause of massive PPH. Few studies analyze PAS cases that result in MD. This paper aims to identify “delays” in the care of patients who died because of PAS in Latin America. We conducted a retrospective, descriptive, observational multicentric study in Latin American hospitals. We analyzed the care of patients who died from PAS, under The California Pregnancy-Associated Mortality Review Committee model, and take into account management standards of centers of excellence in PAS. The information was collected through a predesigned survey and discussed by telephone contact between the principal investigators and each local team. Thirty-four patients in eight Latin American countries (Colombia, Guatemala, Paraguay, Bolivia, Peru, Ecuador, Brazil and Venezuela) were included. Delays were identified in all cases (Table 1). The most prevalent type of delay was associated with health providers (97%), followed by health institutions (94%) and related to patients (76.5%). The principal cause of death was PPH (31 cases), followed by sepsis (2 cases) and pulmonary thromboembolism (1 case). Most delays were associated with the quality of health services, identifying as the main factors associated with death: failure to diagnose PAS with prenatal ultrasounds (35.3%) and underestimation of risk on suspicion of PAS (35.3%). The analysis groups defined maternal deaths as avoidable in all cases and determined that the interventions needed to change the outcome would have low, moderate, and high difficulty in 29, 50, and 21% of cases, respectively In all cases of PAS related to maternal death, we identify multiple improvement opportunities. All maternal deaths due to PAS were preventable, most of them with low to moderate complexity interventions.