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Antenatal Planning for Placenta Accreta Spectrum

Structured checklist for suspected PAS (accreta/increta/percreta) to reduce hemorrhage morbidity.

Core principle For patients at risk (e.g., placenta previa/low-lying placenta with prior cesarean; multiple prior cesareans; prior accreta), anticipate major hemorrhage and plan delivery at an experienced center with a multidisciplinary team.
1

Identification & diagnosis

  • Screen patients with risk factors (previa/low-lying placenta, prior cesarean or uterine surgery, prior PAS, multiparity; IVF may increase risk in some cohorts).
  • Perform targeted ultrasound for placental location and PAS features; document degree of suspicion (low / moderate / high).
  • Consider MRI when ultrasound is equivocal or to help define invasion/topography for surgical planning.
  • Communicate findings clearly to the delivering team and ensure imaging/consult notes are available at point of care.
2

Referral & site selection

  • Refer suspected PAS cases early to a center with:
    • Experienced MFM + obstetric surgery capability for PAS
    • 24/7 anesthesia + blood bank with massive transfusion capacity
    • ICU/high-dependency unit and neonatal services appropriate to GA
    • Urology/gynecologic oncology/back-up surgical support per local staffing model
    • Interventional radiology if used in your local pathway (practice varies)
  • Confirm transfer/acceptance and schedule delivery planning in the early 3rd trimester when feasible.
  • Send complete records: prenatal course, operative reports, imaging, labs, transfusion history, and anesthesia considerations.
3

Delivery timing & planned mode

  • Plan delivery before onset of labor or significant bleeding whenever possible (exact GA range depends on guideline and patient factors; align with your institutional PAS pathway).
  • Mode: typically scheduled cesarean delivery with planned cesarean hysterectomy for confirmed/suspected PAS.
  • Avoid attempts at manual placental removal when PAS is suspected; plan to leave placenta in situ if proceeding to hysterectomy.
  • Ensure neonatal and anesthesia planning reflects the anticipated GA and hemorrhage risk.
Practical scheduling notes
  • Schedule as a daytime, full-team case when possible (surgeon/anesthesia/blood bank/OR staffing).
  • Coordinate pre-op labs and ensure blood product availability aligned with expected hemorrhage.
  • Confirm backup surgeon coverage and ICU bed plan.
4

Multidisciplinary preoperative planning

  • Hold a planning conference (OB/MFM, anesthesia, urology as needed, IR if used, blood bank, neonatology, ICU, nursing).
  • Define roles and contingency plan:
    • Primary surgeon + backup
    • Anesthesia approach (regional vs general vs combined) and hemorrhage monitoring plan
    • Massive transfusion strategy; consider early fibrinogen replacement plan
    • Use of ureteral stents, cell salvage, pelvic balloon catheters (if part of local practice; evidence/practice varies)
  • Ensure blood products are reserved/available (RBC, plasma, platelets, cryoprecipitate or fibrinogen concentrate per local availability).
  • Plan for prolonged OR time and potential ICU admission.
5

Intraoperative considerations

  • Experienced surgical team present at incision time; confirm equipment readiness (rapid infuser, warmer, suction, cell-saver if used).
  • Choose an approach that provides optimal exposure (incision choice individualized).
  • Deliver fetus via incision away from placenta (e.g., high transverse/fundal as appropriate).
  • For confirmed PAS: proceed with cesarean hysterectomy without placental separation attempt.
  • Continuous communication with anesthesia: blood loss, hemodynamics, labs, calcium, temperature, acid-base status.
6

Postoperative care & counseling

  • Post-op monitoring in ICU/step-down as indicated; manage anemia and coagulopathy.
  • Monitor for ongoing bleeding, infection, thromboembolic events, and organ dysfunction.
  • Provide counseling: recovery expectations, emotional support, lactation planning, and (if hysterectomy) loss of fertility.
  • If uterus preserved: discuss future pregnancy risks and need for early referral and planned delivery.

UPDATED: 2025 • This outline is a structured reminder. Align with national guidelines and your institutional PAS pathway.