Guidelines on Placenta Accreta Spectrum Disorders: A Systematic Review

Abstract

Importance: Placenta accreta spectrum (PAS) is a complex, life-threatening condition that demands a multidisciplinary approach involving obstetrics, maternal-fetal medicine, and various surgical and medical specialties. Effective management relies on multispecialty collaboration and consensus, supported by standardized protocols, to optimize outcomes, guide informed clinical decisions, and mitigate the risks associated with PAS.

Objective: To examine clinical practice guidelines for PAS inclusive of high-income countries and low- to middle-income countries (LMICs) identifying areas of consensus and gaps in guidance.

Evidence review: A comprehensive search of PubMed, GIN Library, and ECRI Guidelines Trust identified all PAS-related clinical practice guidelines published from January 1, 2014, to January 31, 2024. Additional searches included professional societies' designated websites and cited references. Two independent reviewers screened the guidelines, resolving conflicts through cross-referencing. Initially, 2 independent reviewers provided structured review and feedback to refine, correct, or highlight areas of consensus, disagreement, or insufficient evidence. Any instances of nonagreement were adjudicated by majority panel agreement, arising from a panel of 15 to 18 experts, all authors of PAS guidelines. Agreement scores for each recommendation area (eg, epidemiology, diagnosis, and antenatal management) were categorized as high agreement (≥75%), poor consensus (<50% or ≥30% insufficient evidence), and high levels of insufficient evidence (≥50% of recommendations with insufficient evidence) based on a priori score criteria.

Findings: A total of 14 guidelines from 18 articles from national and international societies were included. High agreement was noted in areas such as specialized expertise (100%), antenatal management (88.9%), diagnosis (76.9%), and epidemiology (75.0%). Poor consensus characterized cesarean hysterectomy management (38.5% insufficient evidence and 23.0% disagreement), conservative techniques (33.3% insufficient evidence and 11.1% disagreement), and fertility counseling (30.0% insufficient evidence and 10.0% disagreement). Despite the high risk of anemia, consensus was lacking on iron supplementation strategies. Recommendations for thromboembolism prevention varied, with some guidelines favoring pharmacologic interventions and others advocating for nonpharmacologic measures. Hemorrhage management and postnatal management recommendations, including iron supplementation and thromboembolism prevention, were characterized by high levels of insufficient evidence (55.6% and 57.1%, respectively). Only 1 article (5.6%) specifically addressed LMICs, highlighting substantial underrepresentation.

Conclusions and relevance: This systematic review of PAS guidelines identified significant discrepancies and insufficient evidence in key aspects of care. The findings underscore the urgent need for further research and quality measures to enhance standardized approaches and improve patient outcomes. The limited availability of recommendations applicable to LMICs highlights the critical need for tailored guidance that accounts for resource constraints and clinical access challenges unique to these settings.

Figure 1.. PRISMA Flow Diagram of the Study Selection Process

Figure 2.. Epidemiology and Prenatal Diagnosis and Management

ACOG indicates American College of Obstetricians and Gynecologists; ACR, American College of Radiology; AIUM, American Institute of Ultrasound in Medicine; AWMF, Association of Scientific Medical Societies in Germany; CD, cesarean delivery; CNGOF, Collège National des Gynécologues et Obstétriciens Français; FECOLSOG, Federación Colombiana de Obstetricia y Ginecología; FIGO, Fédération Internationale de Gynécologie et d’Obstétrique; GOHO, Gottesfeld-Hohler Memorial Foundation; ICU, intensive care unit; IOG, Institute of Obstetricians and Gynaecologists; IS-PAS, International Society for Placenta Accreta Spectrum; MRI, magnetic resonance imaging; MSPE, Medical Student Performance Evaluation; NICE, National Institute for Health and Care Excellence; NICU, neonatal intensive care unit; NWIHP, National Women and Infants Health Programme; PAS, placenta accreta spectrum; PSGO, Polish Society of Gynecologists and Obstetricians; RANZCOG, Royal Australian and New Zealand College of Obstetricians and Gynaecologists; RCOG, Royal College of Obstetricians and Gynaecologists; SMFM, Society of Maternal-Fetal Medicine; SOGC, Society of Obstetricians and Gynaecologists of Canada; TAS, transabdominal ultrasonography; TV, transvaginal.

Figure 3.. Surgical Treatment and Postnatal Management

ACOG indicates American College of Obstetricians and Gynecologists; ACR, American College of Radiology; AIUM, American Institute of Ultrasound in Medicine; AWMF, Association of Scientific Medical Societies in Germany; CD, cesarean delivery; CNGOF, Collège National des Gynécologues et Obstétriciens Français; FECOLSOG, Federación Colombiana de Obstetricia y Ginecología; FIGO, Fédération Internationale de Gynécologie et d’Obstétrique; GOHO, Gottesfeld-Hohler Memorial Foundation; ICU, intensive care unit; IOG, Institute of Obstetricians and Gynaecologists; IS-PAS, International Society for Placenta Accreta Spectrum; MSPE, Medical Student Performance Evaluation; NICE, National Institute for Health and Care Excellence; NWIHP, National Women and Infants Health Programme; PAS, placenta accreta spectrum; PSGO, Polish Society of Gynecologists and Obstetricians; RANZCOG, Royal Australian and New Zealand College of Obstetricians and Gynaecologists; RCOG, Royal College of Obstetricians and Gynaecologists; SMFM, Society of Maternal-Fetal Medicine; SOGC, Society of Obstetricians and Gynaecologists of Canada; VD, vaginal delivery.