Orris

Give answer to write in exam on Recent advances in treament of placenta accreta spectrum:MS OBG short notes

Reading File
Reading File
Finding Sources
Searching the Web

Placenta accreta spectrum recent advances management conservative endovascular REBOA guidelines 2024 2025

Searching PubMed

"placenta accreta" AND management

Finding Sources
Reading Article

PMID: 39884567

Reading Article

PMID: 38969992

Reading Web Page

https://www.acog.org/clinical/clinical-guidance/obstetric-ca…

Reading File
Finding Sources

Recent advances in treatment of Placenta Accreta Spectrum (PAS)

Placenta accreta spectrum includes accreta, increta and percreta, in which chorionic villi are abnormally adherent to or invade the myometrium and sometimes adjacent organs. The objective of modern treatment is to prevent massive obstetric hemorrhage, minimize urinary tract injury and, in selected women, preserve fertility.

1. Planned multidisciplinary management

The greatest advance is antenatal recognition and planned delivery in a PAS referral centre rather than emergency surgery.
  • Targeted ultrasound with colour Doppler is the first-line modality.
  • MRI is useful when posterior placenta, obesity, equivocal ultrasound, or suspected parametrial/bladder invasion is present.
  • Delivery is planned in a Level III/IV centre with a multidisciplinary PAS team: maternal-fetal medicine specialist, experienced pelvic surgeon/gynaecologic oncologist, anaesthetist, urologist, interventional radiologist, ICU team, neonatologist and blood bank.
  • Delivery is generally planned at 34+0 to 35+6 weeks, after antenatal corticosteroids, unless bleeding, labour, rupture of membranes or maternal/fetal compromise mandates earlier delivery.
  • Preoperative optimisation includes correction of anaemia, large-bore venous access, arterial line, cross-matched blood and activation of a massive transfusion protocol.

2. Improved haemorrhage-control strategies

  • Massive transfusion protocols using packed cells, fresh frozen plasma and platelets in balanced ratios, with fibrinogen replacement guided by coagulation testing.
  • Point-of-care coagulation testing, such as thromboelastography/ROTEM, helps targeted replacement of fibrinogen and blood products.
  • Intraoperative cell salvage with a leukocyte-depletion filter is increasingly used in anticipated massive blood loss.
  • Uterotonics are used for atony of uninvolved uterus. Tranexamic acid is used early for established postpartum haemorrhage; routine prophylaxis in PAS remains under evaluation.
  • Planned midline laparotomy and a fundal/classical uterine incision away from the placenta avoid transecting the placenta and provoking torrential bleeding.

3. Planned caesarean hysterectomy: standard definitive treatment

For extensive PAS, especially increta/percreta, the accepted definitive treatment remains:
  1. Deliver fetus through an incision away from placenta.
  2. Clamp and divide the cord.
  3. Do not attempt manual placental separation.
  4. Leave placenta in situ.
  5. Perform total caesarean hysterectomy, often with urological assistance if bladder/ureteric involvement is suspected.
Attempted placental removal can cause catastrophic haemorrhage. Current ACOG guidance continues to support caesarean hysterectomy with placenta left in situ as the usual approach, undertaken by an experienced multidisciplinary team in a high-level centre (ACOG PAS guidance).

4. Conservative and fertility-preserving treatment

This is an important recent area of development. It should be offered only to carefully selected, haemodynamically stable women who strongly desire uterine preservation, after detailed counselling and with facilities for prolonged follow-up and emergency hysterectomy.

A. Expectant management

  • Fetus is delivered and the placenta is left completely in situ.
  • Umbilical cord is cut short and uterus is closed.
  • Placenta is allowed to undergo gradual resorption over weeks to months.
  • Serial clinical review, ultrasound, haemoglobin and infection surveillance are required.
Complications: secondary haemorrhage, sepsis/endometritis, DIC, delayed hysterectomy, readmission and need for uterine artery embolisation.

B. Conservative surgery

Appropriate mainly for focal, accessible disease:
  • Local myometrial resection with placenta and reconstruction of uterine wall.
  • Segmental uterine resection and repair.
  • Compression sutures, such as B-Lynch, and intrauterine balloon tamponade may be adjuncts in selected focal cases.
A 2025 systematic review/meta-analysis found lower blood loss and fewer genitourinary injuries with conservative approaches than caesarean hysterectomy, but the evidence is mainly observational and subject to selection bias (Hessami et al., 2025, PMID 39884567). Hence, conservative treatment is not suitable for extensive percreta, uncontrolled bleeding or unstable patients.

5. Interventional radiology and endovascular techniques

These techniques aim to reduce pelvic blood flow and surgical blood loss:
  • Prophylactic balloon occlusion of internal iliac arteries.
  • Uterine artery balloon occlusion or embolisation.
  • Aortic balloon occlusion and REBOA (resuscitative endovascular balloon occlusion of the aorta) in selected severe PAS/percreta cases.
Potential benefits include reduced blood loss and transfusion in experienced centres. However, evidence is inconsistent and complications include arterial thrombosis, vessel injury, limb ischaemia and radiation exposure. Therefore, routine prophylactic balloon catheter placement is not universally recommended; it should be individualized and performed only by an experienced interventional radiology/endovascular team.

6. Urological advances

  • Preoperative cystoscopy and selective prophylactic ureteric stenting may help identify ureters in suspected bladder invasion.
  • Early urologist involvement is important in percreta with bladder or parametrial invasion.
  • Planned partial cystectomy and bladder repair may be required. Routine stenting for every PAS case is not recommended.

7. Role of methotrexate

Methotrexate was previously used to accelerate resorption of retained placenta. It is not recommended, because term placental tissue has little proliferative activity and methotrexate may cause serious maternal toxicity, including bone marrow suppression and sepsis.

Conclusion

The key advance in PAS treatment is planned, team-based management in a specialised centre with availability of massive transfusion, critical care, urology and interventional radiology. Planned caesarean hysterectomy with placenta left in situ remains the safest standard treatment for extensive PAS. Uterus-preserving surgery, placenta left in situ, arterial embolisation and REBOA are promising selected-case options, but require expert teams, informed consent and close follow-up because delayed haemorrhage, infection and secondary hysterectomy remain possible.
This is a shared conversation. Sign in to Orris to start your own chat.