https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/1471-0528.15306

Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a.

Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta.

FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management.

For	more	than	half	a	century	after	the	first	case	series	of	placenta accreta was reported in 1937,1 the main and often only approach to management was a cesarean hysterectomy. This approach had the advantage of reducing the immediate risks of major hemorrhage associated with accreta placentation at a time when there was no
access to blood transfusion.

Over	the	last	two	decades,	a	variety	of	conservative	options	for the management of placenta accreta spectrum (PAS) disorders have evolved, each with varying rates of success, and peripartum and secondary complications.2–4 In a recent systematic review and meta- analysis of the outcome of placenta previa accreta diagnosed prenatally, 208
out	of	232	(89.7%)	cases	had	an	elective	or	emergent	cesarean	hysterectomy.5 As a result of a lack of randomized clinical trials, the optimal management of PAS disorders remains undefined and is determined by the capacity to diagnose invasive placentation preoperatively, local expertise, depth of villous invasion, and presenting symptoms.4

In	cases	of	high	suspicion	for	PAS	disorders	during	cesarean delivery, the majority of members of the Society for Maternal- Fetal Medicine (SMFM) proceed with hysterectomy and only 15%–32% report conservative management.6,7

However,	there	is	considerable practice variation reported on aspects of care aroun delivery and hysterectomy by both obstetricians and maternal- fetal medicine
specialists.6,8

There	is	also	wide	variation	between	high-	incomecountries and low- and middle- income countries owing to limited or no access to specialist care and essentia additiona treatment, such as blood products for transfusion. Hysterectomy remains the definitive surgical treatment for PAS disorders, especially for its invasive forms, and a primary elective cesarean hysterectomy is the safest and most practical option for most low- and middle- income countries where diagnostic, follow- up, and additional treatments are not available. In this chapter, we review the evidence- based data onnonconservative surgery (i.e. cesarean hysterectomy) for the management of PAS disorders.

Obstetricia FIGO consensus guidelines on placenta accreta spectrum disorders: nonconservative surgical management

Background Placenta accreta spectrum (PAS) disorders are a potentially life-threatening complication of pregnancy that demand coordinated interdisciplinary care to achieve safer outcomes. The rising incidence of this disease is due to a growing number of uterine surgical procedures, including the rising incidence of pregnancy following Caesarean section. Objective To provide current evidence-based guidelines on the optimal methods used to effectively screen, diagnose, and manage PAS disorders. Methods Members of the guideline committee were selected on the basis of their ongoing expertise in managing this condition across Canada and by practice setting. The committee reviewed all available evidence in the English medical literature, including published guidelines, and evaluated diagnostic tests, surgical procedures, and clinical outcomes. Evidence Published literature, including clinical practice guidelines, was retrieved through searches of Medline and The Cochrane Library to March 2018 using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized controlled trials, and observational studies written in English. Searches were updated on a regular basis and incorporated in the guideline to July 2018. Values The quality of evidence in this document was graded using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Results This document reviews the evidence regarding the available diagnostic and surgical techniques used for optimal management of women with suspected PAS disorders, including anaesthesia and practical considerations for interdisciplinary care. Benefits, Harms, and Costs Implementation of the guideline recommendations will improve awareness of this disease and increase the proportion of affected women receiving interdisciplinary care in regional centres. Conclusions Interdisciplinary team-based care providing accurate diagnostic services, coordinated planning, and safer surgery deliver effective care with improved clinical outcomes in comparison with alternative management. Summary Statements 1The incidence of placenta accreta spectrum disorders is steadily rising in many countries, likely due to the increasing proportion of women becoming pregnant following a variety of surgical procedures to the uterus, including multiple Caesarean sections. 2Placenta accreta spectrum disorders in the setting of prior Caesarean section deliveries arises from pregnancy implantation within the niche created by this surgery near the cervicoisthmic junction of the uterus. This early presentation as a "Caesarean section scar pregnancy" may be diagnosed by ultrasound methods. 3Ultrasound may be used to screen for, and to diagnose, pregnancies with anterior placenta previa that are complicated by placenta accreta spectrum disorders. The effectiveness of ultrasound in this context depends upon awareness of clinical risk factors, imaging quality, operator experience, gestational age, imaging modalities, and adequate bladder filling. 4Magnetic resonance imaging may complement multimodal ultrasound in the diagnosis and staging of placenta accreta spectrum disorders, though its effectiveness is currently limited by the relative contraindication to the use of a gadolinium contrast enhancing agent. 5Placenta accreta spectrum disorders are potentially life-threatening and demand regional interdisciplinary team-based care to deliver the safest outcomes for mothers and infants. Recommendations 1Pregnant women with clinical risk factors for placenta accreta spectrum disorders and anterior placenta previa at the 18–20-week fetal anatomical ultrasound should be referred for specialist imaging to diagnose or exclude this disorder (II-2A). 2Women with a diagnosis of placenta accreta spectrum disorder should be referred to a regional centre dedicated to the interdisciplinary management of this condition (II-3A). 3Protocol-based interdisciplinary care from diagnosis to surgery will optimize both intraoperative and postoperative outcomes (II-3A). 4Antenatal admission to a designated regional management centre may be indicated, especially following an antepartum hemorrhage, or based on considerations of geography or transport conditions (III-B). 5For otherwise healthy women with no history of vaginal bleeding, the optimal timing of elective Caesarean section delivery is around 34–36 weeks gestation (II-3B). Surgery should be considered earlier for repeated episodes of antepartum hemorrhage or contractions to reduce the risks of emergent unplanned surgery and should ideally be preceded by a course of corticosteroids to enhance fetal lung maturation if prior to 35+0 weeks gestation (II-2A). 6Regional anaesthesia may be safer than general anaesthesia as it is associated with reduced blood loss and is preferred by patients and their partners (II-2A). A massive transfusion protocol should be in place to respond to significant blood loss (III-B). 7Intravenous tranexamic acid should be administered at the commencement of surgery because it reduces intraoperative blood loss (I-A). 8Surgery should be performed in the modified lithotomy position, using midline access, sufficiently high so as to deliver the fetus without incising through the placenta; preoperative or intraoperative ultrasound can be used to guide the optimal uterine incision (III-B). No attempt should be made to remove the placenta if it shows no signs of separation as this may cause substantial hemorrhage (III-B). 9Presently there is insufficient evidence to recommend giving or withholding uterotonic drugs after delivery of the fetus (III-C). 10Presently there is insufficient evidence to recommend either approach (preoperative balloon placement or intraoperative ligation) designed to arrest blood flow from the internal iliac arteries prior to hysterectomy (II-1C). 11Focal central disease may be amenable to wedge resection, with complete removal of the placenta and repair of the uterus (the triple-P procedure) (II-3B). 12Classical Caesarean section and non-removal of the invasive placenta is an acceptable method of delivery but is associated with a protracted course of recovery and a persistent risk of hysterectomy (II-3B). 13Women who retain their fertility following a diagnosis of placenta accreta spectrum disorder should be instructed to access specialist ultrasound early in any future pregnancy so that all management options are available should a Caesarean section scar pregnancy be found (III-B). 14Prenatal diagnosis of the more severe forms of placenta accreta spectrum disorder, expressed as a Caesarean section scar pregnancy, may permit management using minimally invasive surgical techniques (II-3B). 15Though many women with placenta accreta spectrum disorder in well-resourced countries receive safe care, more research and knowledge translation are needed to effectively deliver all management options at the population-based level (III-B).

No. 383-Screening, Diagnosis, and Management of Placenta Accreta Spectrum Disorders

Purpose: To determine the impact of a structured multi-disciplinary management strategy on clinical outcomes in women with invasive placental disease (IPD).Materials and methods: This was a retrospective cohort study of consecutive women having peripartum hysterectomies with IPD over seven years. For the most recent three years, a structured multidisciplinary team (MDT) reviewed each suspected case, created a management plan, and implemented that plan. Outcomes were compared between cases delivered prior to and after the MDT process was started.Results: There were 47 pregnancies with IPD, of which 31 (66.0%) were suspected antenatally and 40 (85.1%) had a prior uterine surgery. An MDT approach was performed in 19 (40.4%) cases. In the MDT group, there were longer operative times (260 min versus 181 min, p = 0.0001), less blood loss (1200 mL versus 2500 mL, p = 0.009), less administration of blood products (47.4% versus 85.7%, p = 0.005), and higher intraoperative lowest mean arterial pressures (MA...

/pdf/invasive-placental-disease-the-impact-of-a-multi-z6achunjzb.pdf

Amy M. DePuy

Papers

Invasive placental disease: the impact of a multi-disciplinary team approach to management

Palliative care in the emergency department during a COVID-19 pandemic.