FIGO classification for the clinical diagnosis of placenta accreta spectrum disorders

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: Introduction.

Objective To estimate the prevalence and incidence of placenta previa complicated by placenta accreta spectrum (PAS) and to examine the different criteria being used for the diagnosis. Design Systematic review and meta-analysis. Data sources PubMed, Google Scholar, ClinicalTrials.gov and MEDLINE were searched between August 1982 and September 2018. Eligibility criteria Studies reporting on placenta previa complicated by PAS diagnosed in a defined obstetric population. Data extraction and synthesis Two independent reviewers performed the data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with difference agreed by consensus. The primary outcomes were overall prevalence of placenta previa, incidence of PAS according to the type of placenta previa and the reported clinical outcomes, including the number of peripartum hysterectomies and direct maternal mortality. The secondary outcomes included the criteria used for the prenatal ultrasound diagnosis of placenta previa and the criteria used to diagnose and grade PAS at birth. Results A total of 258 articles were reviewed and 13 retrospective and 7 prospective studies were included in the analysis, which reported on 587 women with placenta previa and PAS. The meta-analysis indicated a significant (p Conclusions The high heterogeneity in qualitative and diagnostic data between studies emphasises the need to implement standardised protocols for the diagnoses of both placenta previa and PAS, including the type of placenta previa and grade of villous invasiveness. PROSPERO registration number CRD42017068589

https://bmjopen.bmj.com/content/bmjopen/9/11/e031193.full.pdf

Epidemiology of placenta previa accreta: a systematic review and meta-analysis.

This study was conducted in order to establish the joint Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) guidelines on placenta accreta spectrum (PAS) disorders and propose strategies to standardize image acquisition, interpretation, and reporting for this condition with MRI. The published evidence-based data and the opinion of experts were combined using the RAND–UCLA Appropriateness Method and formed the basis for these consensus guidelines. The responses of the experts to questions regarding the details of patient preparation, MRI protocol, image interpretation, and reporting were collected, analyzed, and classified as “recommended” versus “not recommended” (if at least 80% consensus among experts) or uncertain (if less than 80% consensus among experts). Consensus regarding image acquisition, interpretation, and reporting was determined using the RAND–UCLA Appropriateness Method. The use of a tailored MRI protocol and standardized report was recommended. A standardized imaging protocol and reporting system ensures recognition of the salient features of PAS disorders. These consensus recommendations should be used as a guide for the evaluation of PAS disorders with MRI. • MRI is a powerful adjunct to ultrasound and provides valuable information on the topography and depth of placental invasion.
 • Consensus statement proposed a common lexicon to allow for uniformity in MRI acquisition, interpretation, and reporting of PAS disorders.
 • Seven MRI features, namely intraplacental dark T2 bands, uterine/placental bulge, loss of low T2 retroplacental line, myometrial thinning/disruption, bladder wall interruption, focal exophytic placental mass, and abnormal vasculature of the placental bed, reached consensus and are categorized as “recommended” for diagnosing PAS disorders.

Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) joint consensus statement for MR imaging of placenta accreta spectrum disorders.

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

Objective To characterize fellowship training experiences in the 11 Canadian minimally invasive gynaecologic surgery (MIGS) programs and compare the surgical exposure of fellows in these programs to that of the American Association of Gynecologic Laparoscopists (AAGL) accredited fellowship in MIGS (FMIGS). Methods In this cross-sectional study, 2017 and 2018 MIGS fellowship graduates across Canada were given a web-based survey via SurveyMonkey software to evaluate 5 key components of postgraduate fellowship curricula: 1) surgical exposure; 2) teaching and evaluation methods; 3) research experience; 4) clinical responsibilities; and 5) pursuit of other academic endeavours. Interest in creating a national standardized curriculum and seeking accreditation for MIGS fellowships were also examined. Results The survey attained a 91% (20/22) response rate of the target population. All Canadian MIGS programs met the minimum standards for at least 62% (8/13) of the surgical competencies listed by the AAGL, with office hysteroscopy being the procedure with the largest discordance. Half of respondents (10/20) attended a program with an established curriculum, and 75% (15/20) believed there would be a benefit to standardizing training nationwide. Seventy percent (14/20) had published at least one manuscript during their fellowship and 60% (12/20) pursued postgraduate degrees. The majority (55%; 11/20) felt certain that MIGS should become a credentialed fellowship in Canada. Conclusion Canada has made meaningful progress in MIGS training over the past decade with 11 well-established fellowship programs. Although this survey identifies a general interest in standardized training and accreditation for Canadian MIGS programs, more research is needed on how best to accomplish this.

Jessica Papillon Smith

Papers

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

Understanding Minimally Invasive Gynaecologic Surgery Fellowship Training in Canada: A National Survey of Recent Graduates.

Internal iliac artery ligation-a contemporary simplified approach.