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

Abstract

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. © The Author(s). 2022.