Journal of South Asian Federation of Obstetrics and Gynaecology

Register      Login

VOLUME 14 , ISSUE 2 ( March-April, 2022 ) > List of Articles


Current Practices in Management of Placenta Accreta Spectrum in Low-resource Settings

AG Radhika, Sruthi Bhaskaran, Shilpa Singh, Meena Samant, Archana Kumari, Pikee Saxena, Manisha Beck, Ruchi Srivastava, Rachna Chaudhary, Anita Singh, Uma Pandey

Keywords : Abnormally invasive placenta, Morbidly adherent placenta, Placenta accreta spectrum, Placenta increta, Placenta percreta, Placental diseases, Placental disorders

Citation Information : Radhika A, Bhaskaran S, Singh S, Samant M, Kumari A, Saxena P, Beck M, Srivastava R, Chaudhary R, Singh A, Pandey U. Current Practices in Management of Placenta Accreta Spectrum in Low-resource Settings. J South Asian Feder Obs Gynae 2022; 14 (2):172-178.

DOI: 10.5005/jp-journals-10006-2012

License: CC BY-NC 4.0

Published Online: 21-06-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Background: Placenta accreta spectrum (PAS) is characterized by abnormal trophoblast invasion of part or entire placenta into the myometrium due to defects in the endometrial–myometrial interface following surgeries involving the uterine cavity, uterine curettage, or uterine infection. Cesarean section is an important risk factor for PAS. A global increase in Cesarean section has resulted in an exponential increase in the PAS. Objective: To examine the prevailing practices for the management of PAS in India and to formulate readily translatable practical management algorithms for low-resource settings. Materials and methods: This cross-sectional study was conducted from April 2019 to March 2020 across nine tertiary care centers in India. Ethics clearance was obtained for the study. Patient details were noted in predesigned pro forma. Risk factors, investigations for antenatal diagnosis and treatment options, and outcomes were recorded. Analysis data were analyzed using the statistical software Statistical Package for the Social Sciences (SPSS) version 16 (IBM, Armonk, New York, USA). The qualitative variables were reported as numbers and percentages. The association of surgery type (elective/emergency) and technique with qualitative variables and risk factors was analyzed using Chi-square/Fisher's exact test. The quantitative variables are reported as the median and interquartile range and were tested with the Mann–Whitney U-test between the two groups. The Kruskal–Wallis test was applied to compare the quantitative variables among the three groups. A p-value less than 0.05 was considered significant. Result: The prevalence of PAS was 0.12%, and previous Cesarean scarring was the most important risk factor. There were almost 43% of women unbooked at the tertiary centers though they were being supervised by lower healthcare facilities during the antenatal period. Ultrasound (USG) diagnosis of PAS was established in 51.3% of cases only. Cesarean-hysterectomy and interval hysterectomy were undertaken in 84% and 8% women respectively. Intraoperative hemorrhage and urological injury were the most common complications. Based on the findings of the study, a simple, user-friendly algorithm for clinical practice and management was formulated. Conclusion: Identification of antenatal clinical factors for PAS risk stratification in low-resource settings is important to enable timely referral to tertiary care. The availability of USG and the necessary skills for detection of PAS are important factors for the diagnosis and management of PAS. Therefore, both radiologists and obstetricians should be adequately trained for the condition to prevent maternal morbidity and mortality. PAS-complicated Cesarean is best carried out at tertiary facilities with multidisciplinary planning and preparation.

PDF Share
  1. Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. Am J Obstet Gynecol 2018;218(1):75–87. DOI: 10.1016/J.AJOG.2017.05.067.
  2. Jauniaux E, Ayres-de-Campos D, Langhoff-Roos J, et al. IFIGO classification for the clinical diagnosis of placenta accreta spectrum disorders,. Int J Gynecol Obstet 2019;146(1):20–24. DOI: 10.1002/IJGO.12761.
  3. Usta IM, Hobeika EM, Abu Musa AA, et al. Placenta previa-accreta: risk factors and complications. Am J Obstet Gynecol 2005;193 (3 Pt 2):1045–1049. DOI: 10.1016/J.AJOG.2005.06.037.
  4. Al-Khan A, Gupta V, Illsley NP, et al. Maternal and fetal outcomes in placenta accreta after institution of team-managed care. Reprod Sci 2014;21(6):761–771. DOI: 10.1177/1933719113512528.
  5. Jauniaux ERM, Alfirevic Z, Bhide AG, et al. placenta praevia and placenta accreta: diagnosis and management: green-top guideline No. 27a. BJOG 2019;126(1):e1–e48. DOI: 10.1111/1471-0528.15306.
  6. Yu FNY, Leung KY. Antenatal diagnosis of placenta accreta spectrum (PAS) disorders. Best Pract Res Clin Obstet Gynaecol 2021;72:13–24. DOI: 10.1016/J.BPOBGYN.2020.06.010.
  7. The DHS Program – India: standard DHS, 2015-16 [Accessed January 19, 2022]. Available from:
  8. Hall T, Wax JR, Lucas FL, et al. Prenatal sonographic diagnosis of placenta accreta—Impact on maternal and neonatal outcomes. J Clin Ultrasound 2014;42(8):449–455. DOI: 10.1002/JCU.22186.
  9. Tinari S, Buca D, Cali G, et al. Risk factors, histopathology and diagnostic accuracy in posterior placenta accreta spectrum disorders: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2021;57(6):903–909. DOI: 10.1002/UOG.22183.
  10. D'Antonio F, Iacovella C, Palacios-Jaraquemada J, et al. Prenatal identification of invasive placentation using magnetic resonance imaging: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2014;44(1):8–16. DOI: 10.1002/UOG.13327.
  11. Jauniaux E, Hussein AM, Fox KA, et al. New evidence-based diagnostic and management strategies for placenta accreta spectrum disorders. Best Pract Res Clin Obstet Gynaecol 2019;61(xxxx):75–88. DOI: 10.1016/j.bpobgyn.2019.04.006.
  12. Cahill AG, Beigi R, Heine RP, et al. Placenta accreta spectrum. Am J Obstet Gynecol 2018;219(6):B2–B16. DOI: 10.1016/j.ajog.2018.09.042.
  13. Allen L, Jauniaux E, Hobson S, et al. IFIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management. Int J Gynecol Obstet 2018;140(3):281–290. DOI: 10.1002/IJGO.12409.
  14. Hussein AM, Dakhly DMR, Raslan AN, et al. The role of prophylactic internal iliac artery ligation in abnormally invasive placenta undergoing caesarean hysterectomy: a randomized control trial. J Matern Fetal Neonatal Med 2019;32(20):3386–3392. DOI: 10.1080/14767058.2018.1463986.
  15. Guleria K, Gupta B, Agarwal S, et al. Abnormally invasive placenta: changing trends in diagnosis and management. Acta Obstet Gynecol Scand 2013;92(4):461–464. DOI: 10.1111/AOGS.12083.
  16. O'Brien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative strategies. Am J Obstet Gynecol 1996;175(6):1632–1638. DOI: 10.1016/S0002-9378(96)70117-5.
  17. Hussein AM, Kamel A, Raslan A, et al. Modified cesarean hysterectomy technique for management of cases of placenta increta and percreta at a tertiary referral hospital in Egypt. Arch Gynecol Obstet 2019;299(3):695–702. DOI: 10.1007/S00404-018-5027-7.
  18. Matsubara S, Kuwata T, Usui R, et al. Important surgical measures and techniques at cesarean hysterectomy for placenta previa accreta. Acta Obstet Gynecol Scand 2013;92(4):372–377. DOI: 10.1111/AOGS.12074.
  19. Selman AE. Caesarean hysterectomy for placenta praevia/accreta using an approach via the pouch of Douglas. BJOG An Int J Obstet Gynaecol 2016;123(5):815–819. DOI: 10.1111/1471-0528.13762.
  20. Matsubara S, Ohkuchi A, Suzuki H, et al. Cesarean hysterectomy: amputation-first technique (Matsubara). Acta Obstet Gynecol Scand 2015;94(5):552–553. DOI: 10.1111/AOGS.12602.
  21. Zuckerwise LC, Craig AM, Newton JM, et al. Outcomes following a clinical algorithm allowing for delayed hysterectomy in the management of severe placenta accreta spectrum. Am J Obstet Gynecol 2020;222(2):179.e1–179.e9. DOI: 10.1016/J.AJOG.2019.08.035.
  22. Pinas-Carrillo A, Bhide A, Moore J, et al. Outcomes of the first 50 patients with abnormally invasive placenta managed using the “Triple P Procedure” conservative surgical approach. Int J Gynecol Obstet 2020;148(1):65–71. DOI: 10.1002/ijgo.12990.
  23. Ghoshal S, Manchanda R, Manjula BC, et al. A unique case of nonradical management of retained placenta accreta. J South Asian Feder Obst Gynaecol 2014;6:195.
  24. Gupta R, Singh B, Kaur B, et al. Morbidly Adherent Placenta managed Conservatively: A Case Series. J South Asian Feder Obs Gynae 2016; 8(4):327–330.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.