Antenatal Planning for Placenta Accreta Spectrum (PAS)
For patients at risk of PAS (previa with prior cesarean, multiple prior cesareans, low-lying placenta, prior accreta),
anticipate major hemorrhage and plan delivery at an experienced center.
1. Identification & Diagnosis
- Screen patients with risk factors: placenta previa/low-lying placenta, prior cesarean or myomectomy, IVF, multiparity.
- Perform targeted ultrasound for placental location and features suspicious for PAS.
- Consider MRI if ultrasound findings are equivocal or to define depth of invasion and topography.
- Document level of suspicion (e.g., low / moderate / high) and communicate to the care team.
2. Referral & Site Selection
- Refer suspected PAS cases to a center with:
- Experienced MFM and obstetric surgery team
- 24/7 anesthesia and blood bank with massive transfusion capacity
- Interventional radiology (if part of local protocol)
- ICU / high-dependency unit
- Confirm transfer and acceptance early in the third trimester when feasible.
- Provide comprehensive records and imaging to the referral center.
3. Delivery Timing & Mode
- Target planned delivery before onset of labor or bleeding, typically 34–36+ weeks depending on guideline and patient factors.
- Mode of delivery: usually scheduled cesarean (often cesarean hysterectomy) for confirmed/suspected PAS.
- Avoid attempts at manual placental removal when accreta is suspected; plan for leaving placenta in situ with hysterectomy as indicated.
4. Multidisciplinary Preoperative Planning
- Hold a planning conference (OB/MFM, anesthesia, urology, IR, blood bank, neonatology, ICU, nursing).
- Define:
- Primary surgeon and backup
- Anesthetic plan (regional vs general vs combined)
- Massive transfusion strategy
- Use of ureteric stents, cell salvage, pelvic artery balloon catheters (if part of local practice)
- Ensure blood products are reserved/available (RBC, FFP, platelets, cryoprecipitate).
- Prepare for significant operative time and potential ICU admission.
5. Intraoperative Considerations
- Experienced surgical team present at incision time.
- Midline vertical laparotomy or other approach providing optimal exposure.
- Delivery of fetus via incision away from placenta (e.g., fundal or high transverse uterine incision when appropriate).
- Plan for cesarean hysterectomy without attempting placental separation for confirmed accreta.
- Continuous communication with anesthesia regarding blood loss, hemodynamics, and lab values.
6. Postoperative Care & Counseling
- Post-op monitoring in ICU/step-down as indicated.
- Monitor for ongoing bleeding, infection, thromboembolic events, and organ dysfunction.
- Provide counseling regarding loss of fertility (if hysterectomy), emotional support, and future pregnancy risks if uterus preserved.
This outline is intended as a structured reminder and should be aligned with national guidelines and your institutional PAS care pathway.