Passing through the Past to Future of Placenta Accreta Spectrum (PAS): Unraveling the Complexities and Hidden Facets of PAS

Placenta accreta spectrum (PAS), including placenta accreta, placenta increta, and placenta percreta, is the consequence of an excessive adhesion of the placenta within the myometrium or beyond, resulting in a complex and challenging pregnancy-related life-threatening disease.[1] The incidence of this disorder has risen 10-fold due to the significant increase in cesarean deliveries in recent decades, a major risk factor for PAS.[1] This situation is expected to worsen in the coming years as the consequences of the increased rate of cesarean delivery may take years to manifest.

Antenatal diagnosis of PAS is crucial for effective management, and various measures can be taken to reduce associated risks. The American College of Obstetricians and Gynecologists has recommended that cesarean hysterectomy should be performed between 34 and 36 weeks of gestation to ensure optimal neonatal development and reduce the likelihood of maternal bleeding. Prior to delivery, it is recommended that women consider being transferred to a Placenta Accreta Center of Excellence or a level-3 or -4 center to enhance the chances of better outcomes. Evaluation and/or delivery at these facilities has been shown to improve outcomes due to the availability of a large, multidisciplinary team.[2] [3]

There are debates surrounding the best ways to manage PAS, including when to deliver the baby, which surgical approach to use, whether to use additional interventions, and whether to use conservative treatment that preserves the uterus for fertility preservation. In this series, we examine the risk factors, diagnosis, management, and contentious issues related to PAS. Furthermore, there is a need for a lot of resources for the PAS center and ancillary team that are highlighted and discussed in this PAS series.

We are fortunate to have a stellar multidisciplinary group of contributors to this symposium. Care of PAS requires teams of individuals with diverse skills and areas of expertise. Too often, there is focus on one aspect of care such as surgical technique or prenatal diagnosis, rather than the coordination of team efforts to optimize outcomes. These papers address the full spectrum of care for families with PAS. The authors include obstetrician gynecologists, maternal fetal medicine specialists, gynecologic oncologists, surgeons, anesthesiologists, pathologists, radiologists, intensivists, PhD researchers, psychiatrists, psychologists, and advocates. In addition, the authors comprise some of the most experienced and innovative clinicians, researchers, and thought leaders in the field.

Of course, there are chapters on imaging and prenatal diagnosis. Excellent care for PAS starts with antenatal identification of the condition. This allows for planned delivery under optimal circumstances in a PAS center of excellence. Our ability to diagnose the condition continues to improve as we standardize imaging techniques, definitions, and reproducibility. There is also a critical paper on presurgical evaluation. This allows optimal planning for timing of delivery, surgical approach, anesthesia, counseling, and person-centered decision-making. Multidisciplinary conferences to discuss upcoming PAS deliveries are a great way to facilitate this process.

Several articles outline details regarding the nuts and bolts of safe PAS delivery. These include focus on surgical techniques, anesthesia considerations, and critical care medicine. These pieces will help clinicians become familiar with cutting edge techniques and protocols to optimize outcomes. They also highlight current controversies regarding management of PAS. The anesthesia and critical care manuscripts are especially important since these aspects of PAS care are often neglected and are integral to maternal health.

Of note, several chapters focus on topics that have received relatively less attention such as mental health. PAS can be a traumatic experience for mothers and their loved ones and emotional support and mental health care is just as important as surgical technique. Another paper discusses strategies for training more clinicians to care for pregnancies with PAS. As more and more gynecologic surgery is performed using minimally invasive and robotic techniques, fewer practitioners are trained in complex open pelvic surgery. Simulation and other types of training are also useful to facilitate multidisciplinary teamwork, especially for cases that are somewhat uncommon. Accordingly, training programs targeted for PAS are needed to provide adequately trained physicians. Finally, a manuscript highlights the remaining knowledge gaps in PAS. At times it seems as though there is more “gap” than knowledge given controversies and uncertainties regarding optimal management and surgical technique. Even the pathophysiology is evolving, and current theories dramatically differ from dogma held even a few years ago. This paper paints the way forward toward improved outcomes for everyone affected by PAS.

We hope that you will enjoy these papers as much as we do. They serve as a terrific introduction to the condition and can serve as a reference when details are useful for specific management questions or issues. We are indebted to the efforts of our authors, editors, and publishers. With gratitude.

Publication History

Article published online:
19 June 2023

• References

• 1 Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. J Matern Fetal Neonatal Med 2011; 24 (11) 1341-1346
• 2 Shamshirsaz AA, Fox KA, Salmanian B. et al. Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach. Am J Obstet Gynecol 2015; 212 (02) 218.e1-218.e9
• 3 Silver RM, Fox KA, Barton JR. et al. Center of excellence for placenta accreta. Am J Obstet Gynecol 2015; 212 (05) 561-568