Placenta accreta spectrum: management update

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 5 – A N T E N ATA L C A R E

Placenta Accreta Spectrum: Management Update Walker SP, Weale N, Elhodaiby M. Placenta accreta spectrum: management update. TOG 2025;27:286–298. doi:10.1111/tog.70008

0.07% 4 ~35% GLOBAL MEDIAN PAS PREVALENCE PAS MATERNAL DEATHS, MBRRACE 2023 (2019– POSSIBLE-PAS PREGNANCIES NEEDING 21) EMERGENCY CD

DO N' T-M IS S FA C TS

  1. Manage in a specialised regional PAS centre with full MDT (NHS England mandate since 2020); deliver electively around 34–36+6 weeks

  2. Unexpected intraoperative PAS → close the abdomen without incising the uterus, transfer to/seek support from a specialist centre (NICE)

  3. Planned CH: never attempt placental delivery; conserve ovaries; total hysterectomy if intracervical hypervascularity or cervical invasion

  4. Uterine conservation feasible if ≥2 cm healthy myometrium above cervix and <50% of axial circumference affected

  5. Bleeding is usually from sector S2 (colpouterine arteries) — IIL and B-Lynch 1 often fail; use LUS transverse compression suture / B-Lynch 2, colpouterine ± uterine artery ligation, REBOA or IMAC

  6. Balloons and compression sutures need contractile muscle — excise deficient myometrium (focal resection or hysterectomy)

  7. Placenta left in situ: 28.1% infection, 10.8% secondary PPH, 10.8% delayed hysterectomy, one maternal death (n=167) — not widely practised

  8. Anaesthesia: large-bore access + arterial line before induction, rapid infuser, cross-matched blood, cell salvage, point-of- care coagulation, fibrinogen replacement + tranexamic acid

THEATRE SET-UP CHECKLIST

Supine, 15° left lateral tilt Modified Lloyd–Davies, stirrups Under-buttock bag Pneumatic compression garments

Rapid infuser Two cell salvage circuits Ward manoeuvre — avoid transecting placenta

Don't trust a normal primary survey

ABBREVIATION KEY

PAS — placenta accreta spectrum IIL — internal iliac artery ligation

CD — caesarean delivery REBOA — resuscitative endovascular balloon occlusion of the aorta

CH — caesarean-hysterectomy IMAC — internal manual aortic compression

MDT — multidisciplinary team APH / PTL — antepartum haemorrhage / preterm labour

MOH — massive obstetric haemorrhage NA / GA — neuraxial anaesthesia / general anaesthesia

LUS — lower uterine segment SITM — Special Interest Training Module

OSCS — one-step conservative surgery COS — complex obstetric surgery

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — doi:10.1111/tog.70008

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