Association of Implementing a Multidisciplinary Team Approach in the Management of Morbidly Adherent Placenta With Maternal Morbidity and Mortality

Real-world study: Impact of multidisciplinary management of apalutamide-associated adverse events in prostate cancer

OBJECTIVE

To analyse the adverse events (AEs) associated with apalutamide and the impact of a multidisciplinary team (MDT) protocol on its management at a tertiary care hospital in a real-world setting.

METHODS

This was an observational, prospective, cohort study based on real-world evidence at the Hospital Clínic de Barcelona. Includes patients diagnosed with metastatic hormone-sensitive prostate cancer (mHSPC) or high-risk nonmetastatic castration-resistant prostate cancer (nmCRPC) and who started treatment with apalutamide between May 2019 and March 2023 in a real-world clinical setting.

RESULTS

Of the 121 patients treated with apalutamide, 52.1% experienced an AE, 19.8% experienced temporarily interruption or a reduction in the dose of apalutamide, and 13.2% discontinued treatment due to AEs. Without MDT protocol (49 patients), 24.5% of patients had to temporarily interrupt or reduce the dose of apalutamide due to AEs, with a median time from the start of treatment of 10.1 months, and 24.5% discontinued apalutamide due to AEs, with a median time from the start of treatment of 3.1 months. Meanwhile, whit MDT protocol (72 patients), 16.7% of patients had to temporarily interrupt or reduce the dose of apalutamide due to AEs, with a median time from the start of treatment of 1.6 months, and 5.6% discontinued apalutamide due to AEs, with a median time from the start of treatment of 4 months. The risk reduction associated with treatment discontinuation was statistically significant (p-value = 0.003).

CONCLUSIONS

This study highlights the importance of MDT management of AEs associated with apalutamide to reduce treatment discontinuation.

Development and implementation of a pregnancy heart team at a Southeastern United States tertiary hospital: a qualitative study

BACKGROUND

The United States has seen a significant rise in maternal mortality and morbidity associated with cardiovascular disease over the past 4 decades. Contributing factors may include an increasing number of parturients with comorbid conditions, a higher rate of pregnancy among women of advanced maternal age, and more patients with congenital heart disease who survive into childbearing age and experiencing pregnancy. In response, national medical organizations have recommended the creation of multidisciplinary obstetric-cardiac teams, also known as pregnancy heart teams, to provide comprehensive preconception counseling and coordinated pregnancy management that extend through the postpartum period.

OBJECTIVE

We sought to describe the development and implementation of a pregnancy heart team for parturients with cardiac disease at a southeastern United States tertiary hospital.

STUDY DESIGN

This was a qualitative study that was conducted among healthcare team members involved during the pregnancy heart team formation. Semi-structured interviews were conducted between April and May 2022, professionally transcribed, and the responses were thematically coded for categories and themes using constructs from The Consolidated Framework for Implementation Research.

RESULTS

Themes identified included intentional collaboration to improve outpatient and inpatient coordination through earlier awareness of patients who meet the criteria and via documented care planning. The pregnancy heart team united clinicians around best practices and coordination to promote the success and safety of pregnancies and not only to minimize maternal health risks. Developing longitudinal care plans was critical among the pathway team to build on collective expertise and to provide clarity for those on shift to reduce hesitancy and achieve timely, vetted practices without additional consults. Establishing a proactive approach of specialists offering their perspectives was viewed as positively contributing to a culture of speaking up. Barriers to the successful development and sustainability of the pregnancy heart team included unmet administrative needs and clinician turnover within a context of shortages in staffing and high workload.

CONCLUSION

This study described the process of developing and implementing a pregnancy heart team at 1 institution, thereby offering insights for future multidisciplinary care for maternal cardiac patients. Establishing pregnancy heart teams can enhance quality care for high-risk patients, foster learning and collaboration among physician and nursing specialties, and improve coordination to manage complex maternal cardiac cases.

Anesthesia and postpartum pain management for placenta accreta spectrum: The healthcare provider perspective

OBJECTIVE

To explore the management and experiences of healthcare providers around anesthetic care in placenta accreta spectrum (PAS).

METHODS

This descriptive survey study was carried out over a 6-week period between January and March 2023. Healthcare providers, both anesthesiologists and those involved in operative care for women with PAS, were invited to participate. Questions invited both quantitative and qualitative responses. Qualitative responses were analyzed using content analysis.

RESULTS

In all, 171 healthcare providers responded to the survey, the majority of whom were working in tertiary PAS referral centers (153; 89%) and 116 (70%) had more than 10 years of clinical experience. There was variation in the preferred primary mode of anesthesia for PAS cases; 69 (42%) used neuraxial only, but 58 (35%) used a combined approach of neuraxial and general anesthesia, with only 12 (8%) preferring general anesthesia. Ninety-nine (61%) were offering a routine antenatal anesthesia consultation. Content analysis of qualitative data identified three main themes, which were "variation in approach to primary mode of anesthesia", "perspectives of patient preferences", and "importance of multidisciplinary team care". These findings led to the development of a decision aid provided as part of this paper, which may assist clinicians in counseling women on their options for care to come to an informed decision.

CONCLUSIONS

Approach to anesthesia for PAS varied between healthcare providers. The final decision for anesthesia should take into consideration the clinical care needs as well as the preferences of the patient.

Anesthesia and postpartum pain management for placenta accreta spectrum: The patient perspective and recommendations for care

OBJECTIVE

Placenta accreta spectrum (PAS) is a high-risk complication of pregnancy, which often requires complex surgical intervention. There is limited literature on the patient experience during the perioperative period and postpartum pain management for PAS. Therefore, this study aims to explore the patient perspective of anesthesia care.

METHODS

Ethical approval was granted by the hospital ethics committee (EC02.2023). This was a descriptive survey study, including women with a history of pregnancy complicated by PAS who were members of two patient advocacy groups. The survey, consisting of both open and closed questions, was performed over a 6-week period between January and March 2023. Content analysis was performed on qualitative data to identify themes, and recommendations for care are suggested.

RESULTS

A total of 347 participants responded to the survey; 76% (n = 252) had a cesarean hysterectomy (n = 252), and general anesthesia was the most common primary mode of anesthesia (39%, n = 130). We identified two overarching themes: experiences of anesthesia and experience of postpartum pain management. Under experiences of anesthesia, three subthemes were identified, namely "communication with the anesthesiologist", "deferring to the expertise of the team", and "consequences of decision around the mode of anesthesia." Under postpartum pain management, two subthemes emerged: "support of specialist PAS team" and "poor pain management following PAS surgery".

CONCLUSIONS

Women want to be involved in decisions around their care, but do not always understand the consequences of their decision-making, such as missing the birth of their child. An antenatal anesthesiology consultation is important to provide women with information, explore preferences, and develop a plan of care for the birth.

Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care

The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.

Placenta Accreta Spectrum Disorders - The Impact of the Creation of a Multidisciplinary Team on Maternal Outcomes in Portugal

OBJECTIVE

 To describe a cohort of placenta accreta spectrum (PAS) cases from a tertiary care institution and compare the maternal outcomes before and after the creation of a multidisciplinary team (MDT).

METHODS

 Retrospective study using hospital databases. Identification of PAS cases with pathological confirmation between 2010 and 2021. Division in two groups: standard care (SC) group - 2010-2014; and MDT group - 2015-2021. Descriptive analysis of their characteristics and maternal outcomes.

RESULTS

 During the study period, there were 53 cases of PAS (24 - SC group; 29 - MDT group). Standard care group: 1 placenta increta and 3 percreta; 12.5% (3/24) had antenatal suspicion; 4 cases had a peripartum hysterectomy - one planned due to antenatal suspicion of PAS; 3 due to postpartum hemorrhage. Mean estimated blood loss (EBL) was 2,469 mL; transfusion of packed red blood cells (PRBC) in 25% (6/24) - median 7.5 units. Multidisciplinary team group: 4 cases of placenta increta and 3 percreta. The rate of antenatal suspicion was 24.1% (7/29); 9 hysterectomies were performed, 7 planned due to antenatal suspicion of PAS, 1 after intrapartum diagnosis of PAS and 1 after uterine rupture following a second trimester termination of pregnancy. The mean EBL was 1,250 mL, with transfusion of PRBC in 37.9% (11/29) - median 2 units.

CONCLUSION

 After the creation of the MDT, there was a reduction in the mean EBL and in the median number of PRBC units transfused, despite the higher number of invasive PAS disorders.

The role of transvaginal ultrasound in the third-trimester evaluation of patients at high risk of placenta accreta spectrum at birth

BACKGROUND

Transvaginal ultrasound imaging has become an essential tool in the prenatal evaluation of the lower uterine segment and anatomy of the cervix, but there are only limited data on the role of transvaginal ultrasound in the management of patients at high risk of placenta accreta spectrum at birth.

OBJECTIVE

This study aimed to evaluate the role of transvaginal sonography in the third trimester of pregnancy in predicting outcomes in patients with a high probability of placenta accreta spectrum at birth.

STUDY DESIGN

This was a retrospective analysis of prospectively collected data of patients presenting with a singleton pregnancy and a history of at least 1 previous cesarean delivery and patients diagnosed prenatally with an anterior low-lying placenta or placenta previa delivered electively after 32 weeks of gestation. All patients had a least 1 detailed ultrasound examination, including transabdominal and transvaginal scans, within 2 weeks before delivery. Of note, 2 experienced operators, blinded to the clinical data, were asked to make a judgment on the likelihood of placenta accreta spectrum as a binary, low or high-probability of placenta accreta spectrum, and to predict the main surgical outcome (conservative vs peripartum hysterectomy). The diagnosis of accreta placentation was confirmed when one or more placental cotyledons could not be digitally separated from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens.

RESULTS

A total of 111 patients were included in the study. Abnormal placental tissue attachment was found in 76 patients (68.5%) at birth, and histologic examination confirmed superficial villous attachment (creta) and deep villous attachment (increta) in 11 and 65 cases, respectively. Of note, 72 patients (64.9%) had a peripartum hysterectomy, including 13 cases with no evidence of placenta accreta spectrum at birth because of failure to reconstruct the lower uterine segment and/or excessive bleeding. There was a significant difference in the distribution of placental location (X2=12.66; P=.002) between transabdominal and transvaginal ultrasound examinations, but both ultrasound techniques had similar likelihood scores in identifying accreta placentation that was confirmed at birth. On transabdominal scan, only a high lacuna score was significantly associated (P=.02) with an increased chance of hysterectomy, whereas on transvaginal scan, significant associations were found between the need for hysterectomy and the thickness of the distal part of the lower uterine segment (P=.003), changes in the cervix structure (P=.01), cervix increased vascularity (P=.001), and the presence of placental lacunae (P=.005). The odds ratio for peripartum hysterectomy were 5.01 (95% confidence interval, 1.25-20.1) for a very thin (<1-mm) distal lower uterine segment and 5.62 (95% confidence interval, 1.41-22.5) for a lacuna score of 3+.

CONCLUSION

Transvaginal ultrasound examination contributes to both prenatal management and the prediction of surgical outcomes in patients with a history of previous cesarean delivery with and without ultrasound signs suggestive of placenta accreta spectrum. Transvaginal ultrasound examination of the lower uterine segment and cervix should be included in clinical protocols for the preoperative evaluation of patients at risk of complex cesarean delivery.

Radiomics-based prediction of FIGO grade for placenta accreta spectrum

BACKGROUND

Placenta accreta spectrum (PAS) is a rare, life-threatening complication of pregnancy. Predicting PAS severity is critical to individualise care planning for the birth. We aim to explore whether radiomic analysis of T2-weighted magnetic resonance imaging (MRI) can predict severe cases by distinguishing between histopathological subtypes antenatally.

METHODS

This was a bi-centre retrospective analysis of a prospective cohort study conducted between 2018 and 2022. Women who underwent MRI during pregnancy and had histological confirmation of PAS were included. Radiomic features were extracted from T2-weighted images. Univariate regression and multivariate analyses were performed to build predictive models to differentiate between non-invasive (International Federation of Gynecology and Obstetrics [FIGO] grade 1 or 2) and invasive (FIGO grade 3) PAS using R software. Prediction performance was assessed based on several metrics including sensitivity, specificity, accuracy and area under the curve (AUC) at receiver operating characteristic analysis.

RESULTS

Forty-one women met the inclusion criteria. At univariate analysis, 0.64 sensitivity (95% confidence interval [CI] 0.0-1.00), specificity 0.93 (0.38-1.0), 0.58 accuracy (0.37-0.78) and 0.77 AUC (0.56-.097) was achieved for predicting severe FIGO grade 3 PAS. Using a multivariate approach, a support vector machine model yielded 0.30 sensitivity (95% CI 0.18-1.0]), 0.74 specificity (0.38-1.00), 0.58 accuracy (0.40-0.82), and 0.53 AUC (0.40-0.85).

CONCLUSION

Our results demonstrate a predictive potential of this machine learning pipeline for classifying severe PAS cases.

RELEVANCE STATEMENT

This study demonstrates the potential use of radiomics from MR images to identify severe cases of placenta accreta spectrum antenatally.

KEY POINTS

• Identifying severe cases of placenta accreta spectrum from imaging is challenging. • We present a methodological approach for radiomics-based prediction of placenta accreta. • We report certain radiomic features are able to predict severe PAS subtypes. • Identifying severe PAS subtypes ensures safe and individualised care planning for birth.

Surgical Techniques for the Management of Placenta Accreta Spectrum

The surgical management of placenta accreta spectrum (PAS) is often challenging. There are a variety of techniques and management options described in the literature ranging from uterine sparing to cesarean hysterectomy. Following the inaugural meeting of the Pan-American Society for Placenta Accreta Spectrum a multidisciplinary group collaborated to describe collective recommendations for the surgical management of PAS. In this manuscript, we outline individual components of the procedure and provide suggested direction at key points of a cesarean hysterectomy in the setting of PAS. KEY POINTS: · The surgical management of PAS requires careful planning and expertise.. · Multidisciplinary team care for pregnancies complicated by PAS can decrease morbidity and mortality.. · Careful surgical techniques can minimize risk of significant hemorrhage by avoiding pitfalls..

Global variation and outcomes of expectant management of CSP

The incidence of Cesarean scar pregnancies (CSPs) is rising globally. Ultrasound criteria for the diagnosis of CSPs have been described by the International Society of Ultrasound in obstetrics and gynecology and appear to be well used in various centers around the world. There is no guidance on best practices for expectant management of CSP, and there is considerable variation in how this is offered globally. Many studies have reported significant maternal morbidity in cases of CSP with fetal cardiac activity managed expectantly, largely relating to hemorrhage and cesarean hysterectomy from placenta accreta spectrum. However, high live birth rates are also reported. Literature describing the diagnosis and expectant management of CSP in low-resource settings is lacking. Expectant management in selected cases where no fetal cardiac activity is present is a reasonable option and can be associated with good maternal outcomes. Standardization in reporting different types of CSPs and correlating these with pregnancy outcomes will be an important next step in developing guidance for expectant management of this high-risk pregnancy with a high burden of complications.

Living with a diagnosis of Placenta Accreta Spectrum: Mothers' and Fathers' experience of the antenatal journey and the birth

OBJECTIVE

Much research into Placenta Accreta Spectrum (PAS) has focussed on the associated maternal morbidity and mortality. However, mothers' and fathers' lived experiences of the aftermath of a diagnosis of PAS up to the birth and beyond has received little attention. Therefore, the aim of this study was to increase our understanding of the psychological consequences of PAS on women and their partners during pregnancy, up to and including the birth.

METHODS

In-depth interviews were conducted with 29 participants; 6 couples were interviewed together (n = 12), 6 couples were interviewed separately (n = 12), and 5 women were interviewed without their partner. Data from the antenatal and intrapartum periods are presented. Couples were eligible for inclusion if they had a diagnosis of PAS within the previous 5 years. An Interpretative Phenomenological Analysis approach was used to gather and analyse data. Virtual interviews were conducted over a 3-month period from February to April 2021.

RESULTS

Themes emerged relating to two distinct timepoints, the antenatal period and birth. The antenatal period had two main themes: the first antenatal main theme was "Living with PAS", which had two sub-themes: "Lack of knowledge of PAS" and "Experiences of varied approaches to care". The second antenatal main theme was "Coping with uncertainty", which had two sub-themes of "Getting on with it", and "Emotional toll". Relating to birth, two main themes emerged. The first main theme was "A traumatic experience", with three sub-themes of "Saying goodbye", "Experiencing trauma" and the "Witnessing of trauma" (by fathers). The second main theme which emerged was "Feeling safe in the hands of experts", with two subthemes of "Safety in expert team" and "Relief at surviving".

CONCLUSIONS

This study highlights the significant psychological consequences a diagnosis of PAS has on mothers and fathers, how they try to come to terms with the diagnosis and the experience of a traumatic birth, and how management within a specialist team can alleviate some of these fears.

Use of an aortic balloon to achieve uterine conservation in a case of placenta accreta spectrum: A case report

Placenta accreta spectrum (PAS) is a rare complication of pregnancy associated with a high risk of massive haemorrhage and caesarean hysterectomy. This is a case report of abdominal aortic balloon occlusion, using intravascular ultrasound, to achieve uterine conservation in a case of severe PAS. The patient was a 34-year-old woman, G2P1, with one prior caesarean section. Antenatal imaging, consisting of transabdominal and transvaginal ultrasound, and magnetic resonance imaging, showed features of PAS. The risk of caesarean hysterectomy with PAS was explained, but the patient declared a desire to retain fertility. Following multi-disciplinary discussion, it was considered appropriate to attempt uterine conservation using en-bloc myometrial and placental resection. An elective caesarean delivery was performed at 36 weeks of gestation. An aortic balloon was inserted prior to surgery using intravascular ultrasound, which allowed for radiation-free, point-of-surgery, accurate balloon sizing, by measuring the aortic diameter, and correct placement of the balloon in the abdominal aorta below the renal vessels. Intraoperative findings confirmed PAS, and a myometrial resection was performed. There were no intraoperative complications. Estimated blood loss was 1000 mL and the patient had an uncomplicated postoperative course. This case demonstrates how the use of an intravascular intraoperative aortic balloon can facilitate uterine conservation in a case of severe PAS.

Ultrasonographic Prediction of Placental Invasion in Placenta Previa by Placenta Accreta Index

This study aimed to investigate the diagnostic accuracy of the placenta accreta index (PAI) for predicting placenta accreta spectrum (PAS) in women with placenta previa. We analyzed 33 pregnancies with placenta previa at Keio University Hospital. The PAI was assessed in the early third trimester, and PAS was diagnosed histologically or clinically defined as retained placenta after manual removal attempts. The PAI and incidence of PAS were analyzed. Ten women (30%) were diagnosed with PAS and had higher volumes of perioperative bleeding (p = 0.016), higher rate of requiring uterine artery embolization (p = 0.005), and peripartum hysterectomy (p = 0.0002) than women without PAS. A PAI > 2 was the most useful cut-off point for predicting PAS and was more sensitive than prediction values using traditional evaluation (history of cesarean section and placental location). Post-hoc analysis revealed a higher rate of previous history of cesarean delivery (30% vs. 4.4%, p = 0.038), severe placental lacunae (≥grade2) (70% vs. 8.7%, p = 0.0003), thin myometrial thickness (90% vs. 22%, p = 0.0003), anterior placenta (100% vs. 30%, p = 0.0002), and presence of bridging vessels (30% vs. 0%, p = 0.0059) in PAS women. PAI could help predict the outcomes of women with placenta previa with and without a history of cesarean delivery to reduce PAS-induced perinatal complications.

Two-dimensional ultrasound signs as predictive markers of massive peri-operative blood loss in placenta previa suspicious for placenta accreta spectrum (PAS) disorder

OBJECTIVE

To evaluate certain two-dimensional (2D) ultrasound signs as predictors of massive peri-operative blood loss (PBL) in pregnant women with placenta previa suspicious of PAS disorder.

MATERIALS AND METHODS

A single center retrospective study was done in pregnant women who had undergone prenatal diagnosis with 2D ultrasound grey scale and color Doppler using the EW-AIP (which has been changed to IS-PAS (International Society for the Placenta Accreta Spectrum)) criteria between January 2007 and May 2021. The patients were divided into 2 groups, non-massive hemorrhage with PBL ≤ 2500 mL and massive PBL >2500 mL. All PAS cases had pathological confirmation. Ultrasound signs and hemorrhagic outcomes were compared between the two groups. A PAS scoring system to predict massive PBL was constructed and a receiver operating characteristic (ROC) curve was calculated to evaluate the efficacy of the scoring system.

RESULTS

Of 534 women, 146 (28.3%) had PBL > 2500 mL and 388 (71.7%) had PBL ≤ 2500 mL. In the massive PBL group, 101 (69.2%) were diagnosed as PAS and 45 (30.8%) as placenta previa alone. From 10 evaluated 2D ultrasound signs, 3 had the highest odds ratios (ORs) associated with massive PBL, 'focal exophytic mass' OR 8.17 (p = 0.024), 'placental bulge' OR 2.47 (p = 0.011), and 'placental lacunae feeder vessels' OR 2.38 (p = 0.01). When using the PAS scoring system, the AUC to predict massive PBL was 0.80 (95% CI, 0.76-0.85,).

CONCLUSION

Our PAS scoring system based on 2-dimensional ultrasound signs combined with grey scale and color Doppler is useful to predict massive PBL and can help optimize pre-operative management in cases of previa suspicious of PAS.

Separation sign: novel ultrasound sign for ruling out diagnosis of placenta accreta spectrum

OBJECTIVE

To assess the performance of the 'separation sign' as a predictor of normal placental separation in a large cohort of women at risk for placenta accreta spectrum (PAS) and in a high-risk subgroup with placenta previa or anterior low-lying placenta and at least one previous Cesarean delivery.

METHODS

This was a prospective study of women at risk for PAS referred to a specialist clinic at between 22 and 38 weeks' gestation. All women underwent ultrasound assessment for the presence of the separation sign, which detects the difference in elasticity between the myometrium and the placenta, characterized by different rates of rebound after an ultrasound probe is used to apply pressure over the uteroplacental interface. When the sign is positive, the placenta appears to move relative to the myometrium, leading to the appearance or enhancement of the clear zone. The predictive performance of the separation sign for normal spontaneous placental separation at delivery was assessed.

RESULTS

Of the 194 included women, 163 had a positive separation sign, all of whom went on to have normal placental separation at delivery. Of the 24 women with a negative separation sign, three (12.5%) had normal placental separation and 21 (87.5%) were diagnosed with PAS. This yielded a sensitivity of 98.2% (95% CI, 94.8-99.6%) and specificity of 100% (95% CI, 83.9-100%). In the high-risk cohort (n = 35), a positive separation sign remained a reliable predictor of normal placental separation, with a positive predictive value of 100%, sensitivity of 88.9% (95% CI, 65.3-98.6%) and specificity of 100% (95% CI, 80.5-100%).

CONCLUSIONS

The separation sign could be a useful tool in women considered to be at risk for PAS, as it can facilitate the prediction of normal placental separation at delivery. This may prevent overtreatment, the associated iatrogenic morbidity and unnecessary allocation of clinical resources. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Living beyond placenta accreta spectrum: parent's experience of the postnatal journey and recommendations for an integrated care pathway

BACKGROUND

Placenta Accreta Spectrum is associated with significant clinical maternal morbidity and mortality, which has been extensively described in the literature. However, there is a dearth of research on the lived experiences of pregnant people and their support partners. The aim of this study is to describe living beyond a pregnancy and birth complicated by PAS for up to four years postpartum. Participants experiences inform the development of an integrated care pathway of family centered support interventions.

METHODS

An Interpretative Phenomenological Analysis approach was applied to collect data through virtual interviews over a 3-month period from February to April 2021. Twenty-nine participants shared their stories; six people with a history of PAS and their support partners were interviewed together (n = 12 participants), six were interviewed separately (n = 12 participants), and five were interviewed without their partner. Pregnant people were eligible for inclusion if they had a diagnosis of PAS within the previous 5 years. This paper focuses on the postnatal period, with data from the antenatal and intrapartum periods described separately.

RESULTS

One superordinate theme "Living beyond PAS" emerged from interviews, with 6 subordinate themes as follows; "Living with a different body", "The impact on relationships", "Coping strategies", "Post-traumatic growth", "Challenges with normal care" and recommendations for "What needs to change". These themes informed the development of an integrated care pathway for pregnant people and their support partners to support them from diagnosis up to one year following the birth.

CONCLUSION

Parents described the challenges of the postnatal period in terms of the physical and emotional impact, and how some were able to make positive life changes in the aftermath of a traumatic event. An integrated care pathway of simple supportive interventions, based on participant recommendations, delivered as part of specialist multidisciplinary team care may assist pregnant people and their support partners in alleviating some of these challenges.

Planned versus Unplanned Delivery for Placenta Accreta Spectrum

OBJECTIVE

Women with placenta accreta spectrum (PAS) having an unplanned delivery may have worse outcome compared with women with a planned delivery. The primary objective of this study was to compare severe maternal morbidity among women with PAS who had a planned scheduled delivery versus an unplanned delivery. Secondary objective was to compare neonatal outcomes.

STUDY DESIGN

Retrospective cohort study at two tertiary centers (January 2009 to June 2019) of all women who underwent a hysterectomy with a histologic proven PAS. Primary outcome was severe maternal morbidity which defined as any of the following: transfusion of ≥4 RBC units or ureter/bowel injury. Neonatal outcome was a composite neonatal morbidity defined as any of the following: Apgar score's < 5 at 5 minutes, mechanical ventilation, or respiratory distress syndrome. Maternal demographic, clinical, and sonographic characteristics were compared between the two groups (planned vs. unplanned). Descriptive statistics were used as appropriate, and a statistical significance was established if p-value was < 0.05.

RESULTS

Of 109 women who underwent cesarean hysterectomy for PAS, 41 (37.6%) had an unplanned delivery. There was no significant difference in the number of previous cesarean deliveries or ultrasound findings between the two groups. Women with an unplanned delivery were more likely to bleed during pregnancy than those that had a planned delivery (p = 0.04). Women with unplanned delivery had lower gestational age at delivery (30.3 vs. 33.8 weeks, p = 0.001) had a 75% higher rate of the primary outcome (63 vs. 36%, p = 0.007) and had a higher rate of intensive care unit admissions (39 vs. 17.7%, p = 0.01) compared with women with a planned delivery. The neonatal morbidity did not differ between the two groups.

CONCLUSION

Since unplanned cesarean hysterectomy among women with PAS occurs in 40% and is associated with significantly higher morbidity, interventions are needed to mitigate the rate of adverse outcomes.

KEY POINTS

· Only 60% of women with PAS reached planned delivery at 34 weeks.. · PAS unplanned delivery is associated with high morbidity.. · Some women with PAS may need a scheduled earlier delivery..

Pregnancy-Related Hysterectomy for Peripartum Hemorrhage: A Literature Narrative Review of the Diagnosis, Management, and Techniques

Postpartum hemorrhage is a life-threatening situation, in which hysterectomy can be performed to prevent maternal death. However, it is associated with high rates of maternal morbidity and mortality and permanent infertility. The incidence of pregnancy-related hysterectomy varies across countries, but its main indications are the following: uterine atony and placenta spectrum (PAS) disorders. PAS disorder prevalence is rising during the last years, mainly due to the increased number of cesarean sections. As a result, obstetricians should be aware of the difficulties of this emergent condition and improve its accurate antenatal diagnosis rates, as well as its modern management strategies. Of course, special skills are required during a pregnancy-related hysterectomy, so these patients should be referred to centers of excellence in antenatal care, where a multidisciplinary team approach is followed. This study is a narrative review of the literature of the last 5 years (PubMed, Cochrane) regarding postpartum hemorrhage to offer obstetricians up-to-date knowledge on this pregnancy-related life-threatening issue. However, there is a lack of available high-quality data, because most published papers are retrospective case series or observational cohorts.

Accuracy and Interobserver Reliability of Magnetic Resonance Imaging for Placenta Accreta Spectrum Disorders

OBJECTIVE

This study aims to define the accuracy, predictive value, and interobserver reliability of magnetic resonance imaging (MRI) in the diagnosis of placenta accreta spectrum (PAS) disorders.

STUDY DESIGN

Two experienced radiologists independently interpreted the MRI studies of patients with possible PAS from two referral centers. Radiologists were blinded to sonographic and clinical information. We calculated diagnostic testing characteristics and kappa statistics of interobserver reliability for MRI findings of PAS.

RESULTS

Sixty-eight MRI cases were evaluated. Confirmed PAS and severe PAS were present in 44 (65%) and 20 (29%) cases. For the diagnosis of any PAS, MRI had a sensitivity 66%, specificity 71%, positive predictive value (PPV) 81%, negative predictive value (NPV) 53%, and accuracy 68%. For the diagnosis of severe PAS (percreta), MRI had a sensitivity 85%, specificity 79%, PPV 63%, NPV 93%, and accuracy 81%. The accuracy of individual signs of PAS was lower (44-65%). Interobserver agreement was almost perfect for previa; substantial for myometrial interruptions, PAS, severe PAS, and placental bulging/balling; and moderate to slight for other signs of PAS.

CONCLUSION

Although the interobserver reliability of MRI for a diagnosis of PAS is substantial, the accuracy and predictive value are modest and lower than previously reported.

Complicated placenta accreta spectrum: identifying a high-risk cohort

OBJECTIVE

To assess differences in the perioperative complication rate between patients with placenta accreta spectrum (PAS) with and without complicating factors.

METHODS

This retrospective cohort study included subjects who underwent cesarean hysterectomy with histology-proven PAS between 23 0/7 and 42 0/7 weeks gestational age (GA) from 1 July 2008 to 11 April 2017. Perioperative outcomes were compared between those with uncomplicated PAS and "complicated PAS," defined as PAS subjects who experienced ≥2 bleeding episodes, preterm premature rupture of membranes (PPROM), or premature contractions requiring tocolysis.

RESULTS

Overall, 26 complicated PAS and 27 uncomplicated PAS cases were compared; no difference in the rate of perioperative complications was identified. An increased proportion of complicated PAS cases required blood product transfusion before delivery: 2 (40%), 3 (27.3%), and 2 patients (20%) for those with PPROM, preterm contractions, and ≥2 bleeding episodes respectively, compared to patients with uncomplicated PAS, having no transfusions (p = .001). Time of delivery was earlier for patients with complicated compared to uncomplicated PAS (median GA 30.9 [Q1 = 27.9; Q3 = 31.9] and 34.9 [Q1 = 32.1; Q3 = 35.7], p < .001). Median birthweights were lower (p < .0144) and maternal length of stay longer (p < .0012) for complicated PAS.

CONCLUSION

Patients with complicated PAS were not at higher risk for perioperative complications but were associated with earlier delivery, required more antenatal blood transfusions, and had a longer LOS.

Safer outcomes for placenta accreta spectrum disorders: A decade of quality improvement

OBJECTIVE

To describe the evolution and evaluation of protocol-based multidisciplinary quality improvement (QI) in women undergoing cesarean hysterectomy for radiologically suspected and pathologically confirmed placenta accreta spectrum (PAS) disorders.

METHODS

A single-center, retrospective cohort study was conducted of all patients undergoing cesarean hysterectomy for PAS disorders between March 2009 and June 2018. Two distinct periods were defined to compare outcomes: 2009-2011 (initial period) and 2017-2018 (current period). Primary outcomes included blood loss and administration of blood products. Secondary outcomes included perioperative levels of hemoglobin, adverse events and complications, time to mobilization, and length of hospitalization.

RESULTS

Among the 105 consecutive patients identified, there were 26 in the initial period and 32 in the current period. With the implementation of all QI care bundles, median estimated surgical blood loss halved from 2000 ml in the initial period to 1000 ml in the current period, and fewer patients required allogenic blood transfusion (61.5% vs 25%). Patients in the current period demonstrated improved postoperative levels of hemoglobin compared to those in the initial period (101 g/L vs 89 g/L) and had a shorter median postoperative hospital stay (3 days vs 5 days).

CONCLUSION

These results support the implementation of a multifaceted QI and patient care initiative for women with PAS disorders.

Quality of life and sexual function after a pregnancy complicated by placenta accreta spectrum

BACKGROUND AND AIMS

Little is known about the impact of Placenta Accreta Spectrum (PAS) on quality of life (QoL). This study aims to explore QoL and sexual function after a pregnancy complicated by PAS.

METHODS

Women who experienced a pregnancy complicated by PAS were invited to complete an online survey. Two validated surveys were completed: Short Form 36 (SF-36) and Female Sexual Function Index (FSFI). The mean scores were calculated and were compared between women by pregnancy outcomes. Continuous variables were presented as mean (standard deviation (SD)) and were compared to assess for significance between groups using independent t-test and one-way analysis of variance. Categorical variables were compared using χ² test.

RESULTS

A total of 142 women responded to the survey. For the SF-36, physical health was significantly higher for women at 24-36 months postpartum compared to those from 0-6 months postpartum for physical functioning (mean difference 21.9 (95% confidence interval (CI) 10.2, 33.5), role limitation due to physical function (mean difference 32.1 (95% CI 9.4, 54.7)) and pain (mean difference 15.5 (95% CI 3.4, 30.9)). For the mental health domains, only vitality improved at 24-36 months compared to the first six months postpartum (mean difference 12.8 (95% CI 0.2, 25.5)). The mean FSFI score was 24.8 (±5.8), lower than the critical score of 26.5 indicating sexual dysfunction, and 56.8% (n = 75), scored less than 26.5.

CONCLUSION

Women after a pregnancy complicated by PAS had high scores on the physical health domains of SF-36. The mental health scores were lower for all women regardless of time since birth.

What we know about placenta accreta spectrum (PAS)

Placenta accreta spectrum (PAS) is an umbrella term for a variety of pregnancy complications due to abnormal placental implantation, including placenta accreta, placenta increta and placenta percreta. During the past several decades, the prevalence of PAS has been increasing, and the clinical importance of this disease is significant because of the severe complications. In this review, we summarized the available evidence-based data for PAS in various aspects: prevalence, risk factors, pathogenesis, clinical presentation and prenatal screening, and clinical management. Meanwhile, we provided a series of prospects in each section for further studies on PAS. Moreover, we first present a visualized workflow for the management of PAS from three steps: predelivery, during delivery and postdelivery.

Maternal morbidity in placenta accreta spectrum following introduction of a multi-disciplinary service compared to standard care: an Irish perspective

AIM

The purpose of this study is to compare maternal outcomes in patients with placenta accreta spectrum (PAS) when managed as part of a multi-disciplinary team (MDT) compared to standard care.

METHODS

Patients in the standard care group were retrospectively identified from pathology records, with patients in the MDT group prospectively collected on an electronic database. Data on maternal demographics, delivery, estimated blood loss (EBL), transfusion requirements, and morbidity were recorded.

RESULTS

Sixty patients were diagnosed with PAS between 2006 and 2019, of whom 32 were part of the standard care group and 28 in the MDT group. Compared to standard care, MDT care was associated with an increase in antenatal diagnosis from 56.3 to 92.9% (p < 0.0001), a significant reduction in EBL (4150 mL (800-19500) vs 1975 (495-8500), p < 0.0001), and transfusion requirements (median 7 (0-30) units of RCC vs 1 (0-13), p < 0.0001).

CONCLUSION

PAS is associated with significant maternal morbidity and warrants management in an MDT setting with specialist input, which is associated with improved outcomes.

Placenta Accreta Spectrum

Placenta accreta spectrum is a term used to describe abnormal adherence and abnormal invasion of the placenta into the uterine wall during pregnancy. The incidence of placenta accreta spectrum has steadily increased over the last 40 years and is most notably linked to rising cesarean birth rates. This condition is associated with increased maternal morbidity and mortality because of the high risk of severe hemorrhage and likely need for hysterectomy at the time of birth. Early diagnosis of abnormal placentation is preferable in order to coordinate birth planning with a interprofessional collaborative team within a high-level perinatal care center. This article describes the case of a woman diagnosed with placenta accreta spectrum and the clinical course of her pregnancy and birth.

A life changing experience: An interpretative phenomenological analysis of women's experiences of placenta accreta spectrum

BACKGROUND

The incidence of Placenta Accreta Spectrum (PAS) is increasing. This study explores women's personal experience of a pregnancy, birth and early postpartum period complicated by PAS.

METHODS

A qualitative study involving seven women (age range: 33-44 years) following a pregnancy in the previous two years complicated by PAS was conducted. Using an Interpretative Phenomenological Analysis approach data were collected and analysed in 2019 and 2020 through face-to-face interviews. Interviews were transcribed verbatim.

RESULTS

Women described their experience from diagnosis up to two years following the birth and focussed on the strategies they used to cope with an unexpected diagnosis of PAS. Six main themes emerged. In pregnancy, women were focussed on the diagnosis and managing family life from hospital "it's not until you are told", "sad but safe", "relying on others can be unbearable". In terms of the birth a 'fear of dying' related to self and baby was central. Postnatally key themes related to the ongoing consequences of the condition as "no one believed I could be feeling so much pain" and "it's not all over when you go home".

DISCUSSION

Women who have experienced a pregnancy complicated by PAS experience significant challenges associated with long term hospitalization, post-operative pain and many express feelings of being generally worried lasting many months after their pregnancy. This study makes an important contribution to the growing body of research in PAS, namely that of the woman's own voice.

Internal Iliac Artery Balloon Occlusion for Placenta Previa and Suspected Placenta Accreta: A Randomized Controlled Trial

OBJECTIVE

To investigate the effect of intraoperative balloon occlusion of the internal iliac arteries in women with placenta previa and antenatally diagnosed placenta accreta.

METHODS

In this single-center, randomized controlled trial, women with placenta previa and antenatally suspected placenta accreta were randomly assigned to either the balloon occlusion group or to the control group. The perioperative management approach was similar for both groups, other than preoperative balloon catheter placement and intraoperative occlusion of bilateral internal iliac arteries. The primary outcome was the number of packed red blood cell (RBC) units transfused. With a two-sided α of 0.05 and a power of 0.8, a sample size of 48 women per group was calculated to detect a mean reduction of 2 units packed RBCs transfused with an expected SD of 3.5.

RESULTS

From August 2017 to July 2018, we randomized 50 eligible women to the balloon group and 50 to the control group. Demographic, obstetric, and placental imaging characteristics were similar between groups. The number of packed RBC units transfused was not significantly different between groups (5.3±5.3 in the occlusion group vs 4.7±5.4 in the control group, P=.54). Hospitalization costs and incidence of postoperative fever were significantly higher in the balloon group. No significant differences were found in other outcomes.

CONCLUSION

Intraoperative balloon occlusion of the internal iliac arteries did not reduce the number of packed RBC units transfused in women with placenta previa and antenatally suspected placenta accreta.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-IOR-17012244.

Management of abnormal invasive placenta in a low- and medium-resource setting

The purpose of this review is to describe the panorama of placenta accreta spectrum (PAS) disorder management in low- and middle-income countries, providing information that allows for the improvement of maternal and perinatal outcomes in the management of this pathology. This spectrum of disorders is associated with implications of high morbidity and mortality, both maternal and perinatal, which is why clinical practice guidelines based on management are produced in settings where there is a wide range of available resources. This situation often contrasts with what the reality is in low-resource countries. Prenatal diagnosis of placental accreta is essential to carry out adequate surgical planning in centres where multidisciplinary teams are in place, which improve results and reduce complications. These ideal scenarios should be developed in countries with more significant difficulties in the availability of human and technological resources, through teamwork in the different hospital centres and the adequate transfer of patients at higher risk to centres with the best interdisciplinary management skills.

The Real Maternal Risks in a Pregnancy: A Structured Review to Enhance Maternal Understanding and Education

This review sought to use high-level published data sources for system knowledge translation, collaborative enhanced maternal education and understanding, and prospective maternal quality and safety care planning. The goal was to answer the following question: What are the short- and long-term maternal risks ("near misses," adverse events, severe morbidity and mortality) associated with pregnancy and childbirth? A structured analysis of the literature (systematic review, meta-analysis, observational case-control cohort), focusing on publications between 2016 and April 2019, was undertaken using the following key word search strategy: maternal, morbidity, mortality, co-morbidities (BMI, fertility, hypertension, cardiac, chronic renal disease, diabetes, mental health, stroke), preconception, antepartum, intrapartum, postpartum, "near miss," and adverse events. Only large cohort database sources with control comparison studies were accepted for inclusion because maternal mortality events are rare. Systematic review and meta-analysis were not undertaken because of the wide clinical scope and the goal of creating an education algorithm tool. For this educational tool, the results were presented in a counselling format that included a control group of common maternal morbidity from a regional maternity cohort (2017) of 54 000 births and published risk estimates for pre-conception, pregnancy-associated comorbidity, pregnancy-onset conditions, long-term maternal health associations, and maternal mortality scenarios. Because issues related to maternal comorbidities are increasing in prevalence, personalized pre-conception education on maternal pregnancy risk estimates needs to be encouraged and available to promote greater understanding. This maternal morbidity and mortality evaluation tool allows for patient-provider review and recognition of the possible leading factors associated with an increased risk of maternal morbidity: pre-conception risks (maternal age >45 years; pre-existing cardiac or hypertensive conditions) and pregnancy-obstetrical risks (gestational hypertension, preeclampsia, eclampsia; caesarean delivery, whether preterm or term; operative vaginal delivery; maternal sepsis; placenta accreta spectrum; and antepartum or postpartum hemorrhage).

A comparison of recent guidelines in the diagnosis and management of placenta accreta spectrum disorders

Accreta placentation and in particular its invasive forms are impacting maternal health outcomes globally and the prevalence of placenta accreta spectrum (PAS) continues to increase. The Royal College of Obstetricians and Gynaecologists (RCOG) and the American College of Obstetricians and Gynecologists (ACOG) with the Society for Maternal-Fetal Medicine (SMFM) have updated their national guidelines, whereas the Federation International of Gynecology and Obstetrics (FIGO) and the Society of Obstetricians and Gynecologists of Canada (SOGC) have developed new guidelines on the diagnosis and management of PAS. A comparison of these guidelines highlights common strong recommendations on the need to carefully evaluate women at high risk for PAS (e.g. prior uterine surgery presenting with anterior low-lying placenta or placenta previa), using multi-modal ultrasound imaging. For women diagnosed with PAS, multidisciplinary team-based care, with full logistic support structures (immediate access to comprehensive blood products, adult and neonatal intensive care) and established expertise in complex pelvic surgery, is critical to maximise safe outcomes for mothers and newborns.

Up-regulated cytotrophoblast DOCK4 contributes to over-invasion in placenta accreta spectrum

The syndrome of cytotrophoblast invasion beyond the normal boundary (in the superficial myometrium) is collectively termed placenta accreta spectrum. The incidence of this condition is rising. However, little is known about the underlying molecular changes. Global transcriptomic profiling of cytotrophoblasts isolated from these cases, as compared to gestational age-matched controls, revealed numerous changes in gene expression involving diverse pathways, including cell signaling, migration, and immune functions. DOCK4 was the most highly up-regulated mRNA in the cases. Mutations in this gene are mechanistically linked to cancer progression. Overexpression of DOCK4 in primary cytotrophoblasts increased their invasiveness. This study provides molecular insights into the pathways driving placenta accreta spectrum and suggests numerous future directions.

In humans, a subset of placental cytotrophoblasts (CTBs) invades the uterus and its vasculature, anchoring the pregnancy and ensuring adequate blood flow to the fetus. Appropriate depth is critical. Shallow invasion increases the risk of pregnancy complications, e.g., severe preeclampsia. Overly deep invasion, the hallmark of placenta accreta spectrum (PAS), increases the risk of preterm delivery, hemorrhage, and death. Previously a rare condition, the incidence of PAS has increased to 1:731 pregnancies, likely due to the rise in uterine surgeries (e.g., Cesarean sections). CTBs track along scars deep into the myometrium and beyond. Here we compared the global gene expression patterns of CTBs from PAS cases to gestational age-matched control cells that invaded to the normal depth from preterm birth (PTB) deliveries. The messenger RNA (mRNA) encoding the guanine nucleotide exchange factor, DOCK4, mutations of which promote cancer cell invasion and angiogenesis, was the most highly up-regulated molecule in PAS samples. Overexpression of DOCK4 increased CTB invasiveness, consistent with the PAS phenotype. Also, this analysis identified other genes with significantly altered expression in this disorder, potential biomarkers. These data suggest that CTBs from PAS cases up-regulate a cancer-like proinvasion mechanism, suggesting molecular as well as phenotypic similarities in the two pathologies.

Transverse versus vertical skin incision for planned cesarean hysterectomy: does it matter?

BACKGROUND

To investigate differences in perioperative outcomes by type of skin incision, transverse versus vertical, for planned cesarean hysterectomy for placenta accreta spectrum (PAS).

METHODS

A retrospective cohort study of all women who underwent a planned cesarean hysterectomy for abnormal placentation at a single academic medical center over 5 years. The Student's t-test was used for continuous variables and Fisher's exact test compared categorical variables. Continuous data were presented as median and compared using the Wilcoxon-rank sum test.

RESULTS

Forty-two planned cesarean hysterectomies were identified. A transverse skin incision was made in 43% (n = 18); a vertical skin incision was made in 57% (n = 24). Skin incision was independent of BMI (30.3 vs 30.8 kg/m2, p = 0.37), placental location (p = 0.82), and PAS-subtype (p = 0.26). Mean estimated blood loss (EBL) was 2.73 l (L) (range 0.5-20) and was not significantly different between transverse and vertical skin incision (2.6 L vs 2.8 L, p = 0.8). There was significantly shorter operative time with transverse skin incision (180 vs 238 min, p = 0.03), with no difference in intraoperative complications, including cystotomy (p = 0.22) and ureteral injury (p = 0.73). Postoperatively, there was no difference in maternal length of stay (4.8 vs 4.4 days, p = 0.74) or post-operative opioid use (117 vs 180 morphine equivalents, p = 0.31).

CONCLUSION

Transverse skin incision is associated with shorter operative time for patients undergoing planned cesarean hysterectomy. There was no difference in EBL, intraoperative complications, postoperative length of stay, or opioid use. Given an increasing rate of cesarean hysterectomy, we should consider variables that optimize maternal outcomes and resource utilization.

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

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<0.001) heterogeneity between study estimates for the prevalence of placenta previa, the prevalence of placenta previa with PAS and the incidence of PAS in the placenta previa cohort. The median prevalence of placenta previa was 0.56% (IQR 0.39-1.24) whereas the median prevalence of placenta previa with PAS was 0.07% (IQR 0.05-0.16). The incidence of PAS in women with a placenta previa was 11.10% (IQR 7.65-17.35).

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.

New evidence-based diagnostic and management strategies for placenta accreta spectrum disorders

The increasing incidence of caesarean delivery (CD) has resulted in an increase in placenta accreta spectrum (PAS), adversely impacting maternal outcomes globally. Currently, more than 90% of women diagnosed with PAS present with a placenta praevia (praevia PAS). Praevia PAS can be reliably diagnosed antenatally with ultrasound, and it is unclear whether magnetic resonance imaging improves diagnosis beyond what can be achieved by skilled ultrasound operators. Therefore, any screening programme for PAS will require improved training in the diagnosis of placental disorders and development of targeted scanning protocols. Management strategies for praevia PAS vary depending on the accuracy of prenatal diagnosis, findings at laparotomy and local surgical expertise. Current epidemiological data for PAS are highly heterogeneous, mainly due to wide variation in the clinical criteria used to diagnose the condition at birth. This significantly impacts research into all aspects of the condition, especially comparison of the efficacy of different management strategies.