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Placenta accreta spectrum

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of placenta accreta spectrum are prepared by our editorial team based on guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG 2019) and the American College of Obstetricians and Gynecologists (ACOG/SMFM 2018). ...
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Screening and diagnosis

Diagnosis: as per RCOG 2019 guidelines, recognize that antenatal diagnosis of placenta accreta spectrum is crucial in planning its management and has been shown to reduce maternal morbidity and mortality.
B
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Classification and risk stratification

Risk factors
As per RCOG 2019 guidelines:
Recognize that the major risk factors for placenta accreta spectrum are history of accreta in a previous pregnancy, previous Cesarean delivery (rising with the number of previous C-sections) and other uterine surgery, including repeated endometrial curettage.
B
Inform patients requesting elective Cesarean delivery for non-medical indications about the risk of placenta accreta spectrum and its consequences for subsequent pregnancies.
E

Diagnostic investigations

Ultrasound: as per RCOG 2019 guidelines, recognize that ultrasound is highly accurate when performed by a skilled operator with experience in diagnosing placenta accreta spectrum.
B
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  • MRI

Medical management

Setting of care: as per RCOG 2019 guidelines, ensure care of patients with placenta accreta spectrum is provided by a multidisciplinary team in a specialist center with expertise in diagnosing and managing invasive placentation.
E

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  • Expectant management

Therapeutic procedures

Blood product transfusion: as per RCOG 2019 guidelines, discuss additional possible interventions in case of massive hemorrhage, including cell salvage if available.
B

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  • Interventional radiology

  • Setting of delivery

  • Timing of delivery

Perioperative care

Considerations for anesthesia
As per RCOG 2019 guidelines:
Choose anesthetic technique for C-section in patients with placenta accreta spectrum by the anesthetist conducting the procedure in consultation with the patient before surgery.
E
Inform patients that the surgical procedure can be performed safely with regional anesthesia, but it may be necessary to convert to general anesthesia if required and ask to consent to this.
B

Surgical interventions

Cesarean hysterectomy: as per RCOG 2019 guidelines, prefer performing C-section hysterectomy with the placenta left in situ over attempting to separate it from the uterine wall.
B

More topics in this section

  • Uterus-sparing surgery

  • Ureteric stenting

Specific circumstances

Patients with placenta accreta diagnosed intrapartally
As per RCOG 2019 guidelines:
Delay C-section until the appropriate staff and resources have been assembled and adequate blood products are available if at the time of an elective repeat C-section, where both mother and baby are stable, it is immediately apparent that placenta percreta is present on opening the abdomen. Consider closing the maternal abdomen and urgently transferring to a specialist unit for delivery.
E
Leave placenta in situ and perform an emergency hysterectomy if unsuspected placenta accreta spectrum diagnosed after the birth of the baby.
B

Patient education

General counseling
As per RCOG 2019 guidelines:
Ensure that any patients giving consent for C-section understands the risks associated with C-section in general, and the specific risks of placenta accreta spectrum in terms of massive obstetric hemorrhage, increased risk of lower urinary tract damage, the need for blood transfusion and the risk of hysterectomy.
E
Inform patients that the surgical procedure can be performed safely with regional anesthesia, but it may be necessary to convert to general anesthesia if required and ask to consent to this.
B