Evidence-Based Perioperative Management of Placenta Accreta Spectrum Disorder.

Placenta accreta spectrum (PAS) disorder, characterized by failure of the abnormally adherent placenta to detach from the uterus after delivery, is a leading cause of severe maternal morbidity. Despite its relatively low incidence, disproportional contributions to perinatal hemorrhage, massive transfusion, and emergency hysterectomy underscore the critical need for development of evidence-based surgical management strategies for PAS. There is clear benefit to preoperative management of anemia, as well as preparation for intraoperative resuscitation with blood products and cell salvage. Several tenets of normal cesarean delivery should be maintained in PAS delivery such as the use of neuraxial anesthesia until delivery, prophylactic antibiotics, mechanical thromboprophylaxis intraoperatively, and administration of tranexamic acid if excessive bleeding occurs. Elements of surgical management distinctive to PAS and accepted as best practice include the following: planning delivery at centers with experienced teams when PAS is suspected antenatally, global intraoperative uterine and pelvic survey on entry into the abdominal cavity to assess for anatomic distortion or abnormal vascularity, selection of hysterotomy site for delivery well away from the placental margin, and direct visual assessment of the placental relationship with the myometrium after neonatal delivery and during the start of uterine involution. Other morbidity-reducing strategies such as routine cystoscopy with or without ureteral stent placement, unconventional transverse abdominal entry, hysterotomy extension with surgical staplers, and endovascular hemorrhage reduction tactics involving aortic or iliac balloon occlusion and multivessel arterial embolization remain experimental and require further research.