Blood Management Strategies in Placenta Accreta Spectrum

Placenta accreta spectrum (PAS) presents a major challenge in obstetric care because attempted placental separation may result in rapid and life-threatening hemorrhage. As PAS is often suspected before delivery, there is an opportunity to identify correctable risks and prepare for anticipated blood loss. This narrative review examines blood-management strategies throughout the antenatal, intraoperative, and postoperative periods. A targeted narrative search of PubMed and PubMed Central, supplemented by searches of journal and publisher websites, was conducted for literature available through September 2026. Antenatal management focuses on identifying and treating maternal anemia, referring patients to experienced centers, and developing a multidisciplinary delivery plan. Perioperative preparation includes coordination with the transfusion service, timely access to appropriate blood components, clear criteria for activating a major obstetric hemorrhage protocol, and defined responsibilities for each team member. Blood-product preparation should be individualized according to the severity suggested by prenatal imaging and the anticipated anatomical extent of placental invasion, ranging from suspected accreta to increta or percreta. Key intraoperative blood-conservation measures include intraoperative cell salvage and timely administration of tranexamic acid when clinically indicated, particularly during significant hemorrhage. Viscoelastic hemostatic testing, fibrinogen-directed therapy, and selected interventional radiology procedures may also contribute to individualized management. However, evidence supporting these interventions remains inconsistent and is frequently derived from observational studies, expert consensus, or broader obstetric hemorrhage populations rather than PAS-specific randomized trials. Consequently, blood-management plans should reflect the anticipated severity of PAS, the patient's clinical condition, and the expertise and resources available at the treating institution. A structured and individualized approach linking antenatal optimization, multidisciplinary preparation, timely hemorrhage control, and postoperative surveillance may support safer and more efficient care for patients with PAS.