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Addressing Diagnosis, Management, and Complication Challenges in Placenta Accreta Spectrum Disorder: A Descriptive
Marfy Abousifein1, Anna Shishkina2, Nicholas Leyland2
1Health Sciences Department, McMaster University, Hamilton, ON L8S 4L8, Canada.
Insights
Diagnosing placenta accreta spectrum (PAS) disorder early is crucial for maternal and neonatal health. This case series highlights diagnostic challenges and emphasizes implementing clinical guidelines for better outcomes.
Area of Science:
- Obstetrics and Gynecology
- Maternal-Fetal Medicine
Background:
- Increasing cesarean section rates correlate with a rising incidence of placenta accreta spectrum (PAS) disorder.
- Despite existing clinical guidelines, antepartum diagnosis of PAS remains a significant challenge.
- Delayed diagnosis of PAS can lead to adverse maternal and neonatal health outcomes.
Observation:
- This case series presents two high-risk patients with PAS who were diagnosed late, following antenatal hemorrhage.
- Patient 1, with three prior cesarean sections, developed placenta percreta with bladder invasion, requiring hysterectomy and ureteric reimplantation.
- Patient 2, with two prior cesarean sections, experienced antepartum hemorrhage due to placenta previa and attachment issues, necessitating a hysterectomy.
Findings:
- Both patients presented with risk factors and imaging findings suggestive of PAS but were diagnosed only after significant complications arose.
- Complex surgical interventions, including hysterectomy and management of related complications like vesicovaginal fistula, were required.
- The cases underscore the difficulties in diagnosing PAS even with risk factors and suggestive imaging.
Implications:
- Implementing clinical guidelines for PAS diagnosis at non-tertiary centers is vital.
- Radiologists and antenatal care providers should be educated on early PAS detection to improve patient and neonatal outcomes.
- Timely diagnosis and access to specialized care in tertiary centers are essential for managing PAS effectively.
Introduction:
In light of increased cesarean section rates, the incidence of placenta accreta spectrum (PAS) disorder is increasing. Despite the establishment of clinical practice guidelines offering recommendations for early and effective PAS diagnosis and treatment, antepartum diagnosis of PAS remains a challenge. This ultimately risks poor mental health and poor physical maternal and neonatal health outcomes.
Case Descriptions:
This case series details the experience of two high-risk patients who remained undiagnosed for PAS until they presented with antenatal hemorrhage, leading ultimately to necessary, complex surgical interventions, which can only be optimally provide in a tertiary care center. Patient 1 is a 37-year-old woman with a history of three cesarean sections, which elevates her risk for PAS. She had placenta previa detected at 19 weeks, and placenta percreta diagnosed upon hemorrhage. During a hysterectomy, invasive placenta was found in the patient's bladder, leading to a cystotomy and right ureteric reimplantation. After discharge, she was diagnosed with a vesicovaginal fistula, and is currently awaiting surgical repair. Patient 2 is a 34-year-old woman with two previous cesarean sections. The patient had complete placenta previa detected at 19- and 32-week gestation scans. She presented with antepartum hemorrhage at 35 weeks and 2 days. An ultrasound showed thin myometrium at the scar site with significant vascularity. A hysterectomy was performed due to placental attachment issues, with significant blood loss. Both patients were at high risk for PAS based on past medical history, risk factors, and pathognomonic imaging findings.
Discussion:
We highlight the importance of the implementation of clinical guidelines at non-tertiary healthcare centers. We offer clinical-guideline-informed recommendations for radiologists and antenatal care providers to promote early PAS diagnosis and, ultimately, better patient and neonatal outcomes through increased access to adequate care.
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