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Guidelines on Placenta Accreta Spectrum Disorders: A Systematic Review
Giulia Bonanni1,2, Maria C Lopez-Giron3, Lisa Allen4,5
1Fetal Care and Surgery Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
Insights
Clinical practice guidelines for placenta accreta spectrum (PAS) show consensus on diagnosis and antenatal management but lack guidance on cesarean hysterectomy and conservative treatments, highlighting a need for more research.
Area of Science:
- Obstetrics and Gynecology
- Maternal-Fetal Medicine
- Surgical Specialties
Background:
- Placenta accreta spectrum (PAS) is a life-threatening obstetric complication requiring multidisciplinary management.
- Standardized protocols and consensus are crucial for optimizing outcomes and mitigating risks in PAS.
- Effective management necessitates collaboration among obstetrics, maternal-fetal medicine, and surgical/medical specialists.
Purpose of the Study:
- To systematically review clinical practice guidelines for PAS.
- To identify areas of consensus and gaps in guidance for PAS management.
- To include guidelines from both high-income and low- to middle-income countries (LMICs).
Main Methods:
- A comprehensive search of PubMed, GIN Library, and ECRI Guidelines Trust was conducted for PAS guidelines (2014-2024).
- Two independent reviewers screened guidelines, with conflicts resolved by expert panel consensus.
- Agreement scores were categorized as high agreement (≥75%), poor consensus (<50%), or high insufficient evidence (≥50%).
Main Results:
- Fourteen guidelines were included, showing high agreement on specialized expertise, antenatal management, diagnosis, and epidemiology.
- Poor consensus and insufficient evidence were found in cesarean hysterectomy, conservative techniques, and fertility counseling.
- Significant gaps exist in recommendations for hemorrhage management, postnatal care, iron supplementation, and thromboembolism prevention, with limited focus on LMICs.
Conclusions:
- Significant discrepancies and insufficient evidence exist in current PAS clinical practice guidelines.
- There is an urgent need for further research and quality measures to standardize PAS care and improve patient outcomes.
- Tailored guidance for LMICs is critical, addressing resource constraints and unique clinical access challenges.
Importance:
Placenta accreta spectrum (PAS) is a complex, life-threatening condition that demands a multidisciplinary approach involving obstetrics, maternal-fetal medicine, and various surgical and medical specialties. Effective management relies on multispecialty collaboration and consensus, supported by standardized protocols, to optimize outcomes, guide informed clinical decisions, and mitigate the risks associated with PAS.
Objective:
To examine clinical practice guidelines for PAS inclusive of high-income countries and low- to middle-income countries (LMICs) identifying areas of consensus and gaps in guidance.
Evidence Review:
A comprehensive search of PubMed, GIN Library, and ECRI Guidelines Trust identified all PAS-related clinical practice guidelines published from January 1, 2014, to January 31, 2024. Additional searches included professional societies' designated websites and cited references. Two independent reviewers screened the guidelines, resolving conflicts through cross-referencing. Initially, 2 independent reviewers provided structured review and feedback to refine, correct, or highlight areas of consensus, disagreement, or insufficient evidence. Any instances of nonagreement were adjudicated by majority panel agreement, arising from a panel of 15 to 18 experts, all authors of PAS guidelines. Agreement scores for each recommendation area (eg, epidemiology, diagnosis, and antenatal management) were categorized as high agreement (≥75%), poor consensus (<50% or ≥30% insufficient evidence), and high levels of insufficient evidence (≥50% of recommendations with insufficient evidence) based on a priori score criteria.
Findings:
A total of 14 guidelines from 18 articles from national and international societies were included. High agreement was noted in areas such as specialized expertise (100%), antenatal management (88.9%), diagnosis (76.9%), and epidemiology (75.0%). Poor consensus characterized cesarean hysterectomy management (38.5% insufficient evidence and 23.0% disagreement), conservative techniques (33.3% insufficient evidence and 11.1% disagreement), and fertility counseling (30.0% insufficient evidence and 10.0% disagreement). Despite the high risk of anemia, consensus was lacking on iron supplementation strategies. Recommendations for thromboembolism prevention varied, with some guidelines favoring pharmacologic interventions and others advocating for nonpharmacologic measures. Hemorrhage management and postnatal management recommendations, including iron supplementation and thromboembolism prevention, were characterized by high levels of insufficient evidence (55.6% and 57.1%, respectively). Only 1 article (5.6%) specifically addressed LMICs, highlighting substantial underrepresentation.
Conclusions And Relevance:
This systematic review of PAS guidelines identified significant discrepancies and insufficient evidence in key aspects of care. The findings underscore the urgent need for further research and quality measures to enhance standardized approaches and improve patient outcomes. The limited availability of recommendations applicable to LMICs highlights the critical need for tailored guidance that accounts for resource constraints and clinical access challenges unique to these settings.
