What are the recommended delivery plans for patients diagnosed with placenta accreta spectrum to minimize maternal and fetal risks?

For patients diagnosed with placenta accreta spectrum (PAS), the recommended delivery plans focus on multidisciplinary care and a planned caesarean birth to minimise maternal and fetal risks NICE NG192.

• Initial Assessment and Referral: If a routine 20-week ultrasound scan shows placenta praevia or a low-lying placenta in a patient with a previous caesarean or uterine scar, a greyscale ultrasound scan with colour doppler should be performed to assess for PAS NICE NG192. If PAS is suspected, the patient should be referred to a specialist placenta accreta spectrum centre for ongoing care and management NICE NG192. An MRI scan may be considered to complement ultrasound findings for surgical planning, with discussion about the procedure and the lack of long-term evidence regarding risks to the baby NICE NG192.
• Discussion of Birth Options: A senior obstetrician should discuss birth options with the patient, including the timing of birth, potential operative interventions (such as the possibility of hysterectomy), and the need for blood transfusion NICE NG192. General discussions about the benefits and risks of both caesarean and vaginal birth should also occur, acknowledging that precise numerical risk estimates cannot be given for individual women NICE NG192.
• Multidisciplinary Team Planning for Caesarean Birth: When planning a caesarean birth for a patient suspected of having PAS, a multidisciplinary team must agree on which other healthcare professionals need to be consulted or present, such as specialists in gynaecological surgery, interventional radiology, colorectal surgery, urology, or vascular surgery, depending on the nature of the PAS NICE NG192. The team should also define the responsibilities of each member NICE NG192.
• Requirements During Planned Caesarean Birth: During the planned caesarean birth, a consultant obstetrician, a consultant gynaecologist, and a consultant anaesthetist must be present in the operating theatre NICE NG192. A paediatric or neonatal registrar or consultant should be present to provide immediate care for the baby NICE NG192. A haematology registrar or consultant should be available for advice NICE NG192. It is also crucial to ensure a critical care bed is available for the patient and a critical care neonatal cot for the baby, although emergency surgery should not be delayed while waiting for a bed NICE NG192. Sufficient cross-matched blood and blood products must be readily available if acceptable to the patient NICE NG192.
• Development of Protocols: Specialist placenta accreta spectrum centres and their supporting local maternity units should develop protocols for the diagnosis, assessment, and management of PAS across their network NICE NG192. These protocols should also cover the care and management of PAS identified late in pregnancy or during labour, including how specialist units can support emergency care in local maternity units NICE NG192.