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

      Abstract

      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

      • 1
        The 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.
      • 2
        Placenta 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.
      • 3
        Ultrasound 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.
      • 4
        Magnetic 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.
      • 5
        Placenta accreta spectrum disorders are potentially life-threatening and demand regional interdisciplinary team-based care to deliver the safest outcomes for mothers and infants.

      Recommendations

      • 1
        Pregnant 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).
      • 2
        Women 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).
      • 3
        Protocol-based interdisciplinary care from diagnosis to surgery will optimize both intraoperative and postoperative outcomes (II-3A).
      • 4
        Antenatal 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).
      • 5
        For 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).
      • 6
        Regional 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).
      • 7
        Intravenous tranexamic acid should be administered at the commencement of surgery because it reduces intraoperative blood loss (I-A).
      • 8
        Surgery 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).
      • 9
        Presently there is insufficient evidence to recommend giving or withholding uterotonic drugs after delivery of the fetus (III-C).
      • 10
        Presently 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).
      • 11
        Focal 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).
      • 12
        Classical 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).
      • 13
        Women 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).
      • 14
        Prenatal 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).
      • 15
        Though 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).

      Key Words

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