Updates on the management of placenta accreta spectrum

Abstract

Placenta accreta spectrum (PAS) disorders is a multifactorial process that encompasses a heterogeneous group of conditions characterized by an abnormal invasion of trophoblastic tissue through the myometrium and uterine serosa. PAS is associated with a high burden of adverse maternal outcomes including severe life-threatening hemorrhage, need for blood transfusion, damage to adjacent organs, and death. Prenatal screening of PAS is mandatory so that women may be counselled about the severity of this condition to plan management with a multidisciplinary team and delivery in a specialized center. Ultrasound during the second and third trimester is the primary tool in diagnosing PAS, while magnetic resonance imaging is generally performed to confirm the diagnosis and to delineate the topography of placental invasion. Cesarean hysterectomy with placenta left in situ between 34 and 35 weeks of gestation is currently the gold standard surgical management of PAS disorders. Conservative management, such as uterine conservation with the placenta left in situ, or "Triple-P" procedure, should be restricted to a limited number of patients who desire to preserve fertility, after an extensive counselling regarding the high maternal morbidity and mortality risks. Finally, endovascular interventional radiology has been suggested to reduce the amount of blood loss, improve visualization of the operative field and reduce surgical complications, and its use is increasing in specialized centers.