Placenta Accreta Spectrum: Planning a Safer Multidisciplinary Birth

Placenta accreta spectrum (PAS) describes abnormal placental attachment, ranging from superficial adherence to invasion through the uterine wall and into nearby organs. It is a major cause of severe obstetric haemorrhage, particularly when placenta praevia overlies a previous caesarean scar. Outcomes improve when the diagnosis is suspected antenatally and the birth is planned before labour, membrane rupture or an emergency bleed.

For Australian maternity services, planning means more than booking an operating theatre. It involves choosing the right hospital, confirming blood and intensive care capacity, coordinating anaesthetic and surgical expertise, preparing the newborn team, and making a clear plan that the patient and family can understand. The principles are relevant to tertiary hospitals in Sydney, Melbourne, Brisbane, Perth, Adelaide and beyond, as well as regional services arranging transfer to a higher-level centre.

Recognising The Clinical Risk

The probability of PAS rises with the number of previous caesarean births, especially when the placenta is low-lying or praevia. Previous uterine surgery, curettage, myomectomy, adenomyosis and assisted reproductive treatment may add risk. A history of postpartum haemorrhage should heighten vigilance, although it does not diagnose abnormal placentation by itself.

Ultrasound is the primary assessment tool. Findings can include placental lacunae, loss of the clear zone behind the placenta, irregular bladder-wall interface, bridging vessels and marked vascularity at the uterovesical region. The absence of classic signs does not exclude disease, particularly when imaging is performed early, the placenta is posterior, or expertise is limited.

The spectrum is also a surgical planning problem. Suspected increta or percreta may involve the cervix, bladder, parametria or pelvic sidewall, with consequences for ureteric identification and urinary tract repair. Magnetic resonance imaging can help answer specific anatomical questions, but it should complement expert ultrasound rather than delay referral or create false reassurance.

Building A Reliable Antenatal Assessment

A practical pathway starts with early review of the dating scan and placental location, followed by targeted imaging at a specialist service. Serial assessment may be appropriate when the diagnosis or extent remains uncertain. The report should describe the likely depth and topography of invasion, the relationship to the bladder and cervix, and any features that could alter the incision or surgical approach.

Maternal health also needs attention. Anaemia should be identified and treated promptly with oral or intravenous iron according to severity, gestation and local protocols. Blood pressure, diabetes, thyroid disease and other comorbidities can affect timing, anaesthesia and postoperative recovery; background reading on maternal thyroid outcomes is relevant when broader pregnancy risks are being reviewed.

Counselling should be specific without being alarmist. Discuss planned caesarean hysterectomy, possible bladder or bowel surgery, transfusion, intensive care, preterm birth, loss of fertility and the possibility of an unplanned emergency procedure. Some patients may choose to preserve fertility, but conservative management is highly specialised, carries risks such as delayed haemorrhage and infection, and requires prolonged follow-up in a service equipped to respond quickly.

Bringing The Right Team Together

A dedicated PAS meeting should include a maternal-fetal medicine specialist, experienced obstetric and gynaecological surgeons, anaesthetists, neonatologists, haematology or transfusion specialists, theatre nursing staff and, where indicated, urology or interventional radiology. A clinical governance lead, social worker, interpreter and perinatal mental health clinician can make the plan safer and more usable for the family.

The patient should know who is coordinating care and how to contact the service after hours. Written information should explain where to present for bleeding, contractions or reduced fetal movements. In Australia, a woman living outside a metropolitan area may need planned accommodation near the hospital, help with travel costs and an agreed retrieval pathway rather than informal advice to “come in if worried”.

Hospitals such as the Royal Women’s Hospital in Melbourne, Westmead Hospital in Sydney and Mater Mothers’ Hospital in Brisbane illustrate the type of tertiary environment often required: advanced obstetric surgery, blood banking, adult ICU and neonatal intensive care on the same campus or within a coordinated network. Local arrangements differ, so the referral decision should be based on capability, case complexity and timely access to expertise.

Research discussions may also touch on future regenerative and translational approaches; resources covering cell and gene therapy belong in that wider scientific context, not as a current substitute for established PAS surgery or haemorrhage management.

Designing The Day Of Birth

The timing of delivery balances the risk of spontaneous labour and bleeding against prematurity. Many planned cases are scheduled in the late preterm or early term period according to imaging, bleeding history, contractions, comorbidities and local protocol. The date should allow the full team to attend and should include a contingency for earlier admission if symptoms develop.

The theatre plan should specify the preferred uterine incision, patient positioning, surgical sequence and equipment. A fundal or high transverse incision may be considered when the placenta occupies the lower segment, but ultrasound mapping must guide the decision. After delivery, the placenta is generally left undisturbed and a planned hysterectomy proceeds; attempting manual removal can trigger catastrophic haemorrhage.

Anaesthesia should be discussed antenatally, including the role of regional, general or combined techniques and the possibility of conversion. Large-bore intravenous access, arterial monitoring, rapid infusion equipment, warming measures and cell salvage should be considered. Urology input is particularly valuable when imaging suggests bladder invasion, although routine stent placement remains a case-by-case decision rather than an automatic step.

Preparing For Major Haemorrhage

The transfusion plan must be written, rehearsed and visible. It should identify the blood bank contact, available red cells, fresh frozen plasma, platelets, cryoprecipitate or fibrinogen support, massive transfusion activation criteria and laboratory turnaround times. Australian services commonly work with Australian Red Cross Lifeblood guidance, but the local protocol and stock levels govern what can be delivered on the day.

Point-of-care coagulation testing may help guide replacement during rapid blood loss. Calcium, temperature, acid-base status and fibrinogen deserve active management, since coagulopathy can develop quickly. A patient-specific plan should also document antibody status, venous access difficulties, religious or personal preferences about blood products, and consent for hysterectomy and organ repair.

Postoperative care is part of the haemorrhage plan. Some patients need a planned admission to ICU or high-dependency care, while others can be monitored in a specialist obstetric unit if stable. Analgesia, thromboprophylaxis, antibiotics, urinary drainage, wound review and mobilisation should be coordinated with the risk of ongoing bleeding and reoperation.

Protecting Maternal And Newborn Recovery

A planned PAS birth may still result in preterm delivery, transfusion, urinary tract injury or a prolonged hospital stay. The neonatal team should attend because respiratory support, thermoregulation, glucose monitoring and feeding assistance may be needed. Families benefit from hearing where the baby will go, whether skin-to-skin contact is possible, and how a parent’s ICU admission could affect early bonding.

Neonatal jaundice is not specific to PAS, but prematurity, bruising and feeding difficulties can increase surveillance needs. Clear guidance on neonatal jaundice follow-up can support discharge education and communication between the hospital, newborn service and local GP or child health nurse.

Emotional recovery also deserves deliberate care. Emergency fears, loss of fertility, pain, a traumatic birth or separation from the newborn can affect both parents. Offer debriefing after the operation, access to perinatal mental health support and a documented follow-up appointment. Future pregnancy counselling should cover recurrence risk, contraception and the implications of uterine surgery.

The broader fetal assessment should remain clinically focused. Where neurological concerns or associated findings arise, specialist fetal neurosonography assessment may be appropriate, but it should not distract from the immediate placental and maternal surgical priorities.

Turning The Plan Into Action

A written checklist reduces variation between the antenatal clinic, ward, theatre and blood bank. It should be updated after every significant scan, admission or episode of bleeding. Simulation can test whether the team can activate blood products, reach the operating room, summon urology and communicate with the neonatal unit without delay.

For regional and rural families, practical details matter as much as clinical language. Confirm accommodation, transport, childcare, interpreter access and the route to hospital. If heavy bleeding, faintness or severe abdominal pain occurs, the local emergency number in Australia is 000; the maternity service should also provide direct instructions for less severe symptoms.

• Refer suspected PAS early to a centre with complex obstetric surgery, blood bank and critical care capacity.
• Record placental mapping, surgical intent, transfusion arrangements and escalation contacts in one accessible plan.
• Treat iron deficiency and anaemia before birth, and review haemoglobin after any antenatal bleeding.
• Include the patient, support person, interpreter and neonatal team in a documented briefing.
• Debrief the family and review the case through local morbidity, mortality and quality-improvement processes.

A well-rehearsed plan gives the team time to make careful decisions before an emergency develops. Review suspected PAS with the appropriate tertiary service, involve the family early, and use local Australian protocols to turn antenatal concern into coordinated, safe care.