Placenta accreta spectrum (PAS) disorders represent a critical challenge in maternal health, characterized by abnormal adherence of the placenta to the uterine wall, often resulting in severe complications during delivery. As cesarean deliveries (CD) continue to rise globally, so does the incidence of PAS, necessitating robust clinical practice guidelines (CPGs). A recent study published in JAMA Network Open underscored significant gaps in these guidelines, particularly between high-income countries and low- and middle-income countries (LMICs).
Scientific and Clinical Evidence: What the Data Tell Us
The systematic review analyzed CPGs from January 2014 to January 2024, focusing on PAS and related CD recommendations. Researchers identified 18 relevant articles: 14 primarily dealing with PAS and four addressing CD or postpartum hemorrhage management. The findings revealed discrepancies across guidelines, including risk factor identification, screening protocols, and management strategies.
Epidemiology and Risk Factors
Cesarean delivery emerges as the most significant risk factor for PAS, with each additional CD compounding the risk. An odds ratio of 1.96 was noted for PAS in patients with prior CD compared to those without. Other risk factors, such as placenta previa and uterine surgeries, were documented but with varying levels of evidence. Surprisingly, inconsistent data were reported for multiparity, smoking, and anemia.
Screening Practices
Ultrasonography was unanimously recommended as the first-line screening tool for PAS, boasting sensitivity and specificity rates of 90.7% and 96.9%, respectively. However, disagreement persisted regarding the optimal timing for screening, with most guidelines favoring second-trimester initiation.
Management Approaches
Antenatal management guidelines demonstrated an agreement rate of 88.9%, emphasizing the need for a multidisciplinary approach involving obstetrics, maternal-fetal medicine, surgical oncology, and other specialties. However, consensus on hospitalization timing and surveillance protocols remained elusive.
Limitations in Current Evidence
The study highlighted critical gaps in evidence, particularly in LMIC-specific recommendations. For example, only one guideline addressed these settings, underscoring the need for context-specific strategies.
Correct Health Practices and Practical Recommendations
Given these findings, healthcare providers should prioritize early identification of risk factors, employ ultrasonography as the first screening modality, and adopt a multidisciplinary approach to management. For patients in resource-limited settings, tailored strategies that consider local constraints are essential.
Expert Insights and Commentary
Dr. Anne Smith, a maternal-fetal medicine specialist, emphasizes, “Standardized guidelines are vital for managing PAS effectively. We must bridge the gap between evidence and practice, particularly in LMICs where resources and training may be limited.”
Conclusion
As PAS incidence rises, globally applicable and comprehensive guidelines are imperative. Addressing these gaps through targeted research and collaboration can significantly improve outcomes for affected patients.
References
1. Bonanni G, Lopez-Giron MC, Allen L, et al. Guidelines on placenta accreta spectrum disorders: A systematic review. JAMA Netw Open. 2025;8(7):e2521909. doi:10.1001/jamanetworkopen.2025.21909 .2. Shamshirsaz AA, Fox KA, Salmanian B, et al. Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach. Am J Obstet Gynecol. 2015;212(2):218.e1-9. doi:10.1016/j.ajog.2014.08.019 IF: 8.4 Q1 .
