Patients with high-risk pregnancies due to placenta accreta spectrum (PAS) are at high risk of morbidity and mortality, which may increase risk for childbirth related mental health sequelae including postpartum post-traumatic stress disorder (PTSD) and trauma symptoms. However, there has been limited investigation into these patients’ mental health needs. We aimed to use qualitative data to understand PAS patients’ mental health experiences through their obstetric course, and to generate recommendations for the delivery of mental health support to these patients. This exploratory study used a focus group format with patients who had a history of PAS. General questions about patient’s pregnancies, births, and postpartum experiences were asked by mental health professionals. Using a rapid qualitative analysis approach, transcriptions of these focus groups were coded by three psychiatrists and core themes were extracted. We conducted four focus groups with a total of 22 women. Major emotional themes included fear and isolation during the antepartum period, and grief, anxiety, and trauma in the postpartum period. Both periods were associated with a negative emotional impact on relationships with family members. Sadness depression were less prominent among participants’ experiences. Participants felt that mental health care resources needed to be integrated with their obstetric care, extend further into the postpartum period, and should be as specific as possible to their medical condition. Based on the results of these focus groups, we propose that patients with high-risk pregnancies and/or a history of traumatic birth should have access to expert mental health care that is integrated with their obstetric care. These patients may benefit from extended obstetric follow-up. Mental health screening in these populations should focus on anxiety and trauma symptoms rather than only screening for depression. Future studies should continue to examine these factors in a broader group of women with high-risk pregnancies beyond PAS.

Placenta accreta spectrum (PAS) disorder poses significant risks to maternal health, given the complexities of screening, diagnosis, and management. To address these challenges, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) hosted a workshop on June 10–11, 2024, bringing together expert health care professionals, researchers, stakeholders, and patient advocates to identify knowledge gaps, with an overarching goal of informing future research and best practices for PAS. Key discussions revolved around the resources and infrastructure needed to advance screening, diagnosis, and clinical management of PAS, alongside ways to enhance collaboration across disciplines. Participants considered strategies to optimize existing research resources and explored opportunities to strengthen partnerships between the NICHD and key stakeholders to achieve mutual objectives. The workshop—attended by representatives from the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Pan-American Society for the Placenta Accreta Spectrum, the National Accreta Foundation, the American Institute of Ultrasound in Medicine, and the Society of Gynecologic Oncology—aimed to foster consensus on essential PAS topics and to identify clinical and research priorities in all phases of PAS care. Additionally, a critical focus of the workshop was to enhance understanding of patient experiences and needs, recognizing that patient perspectives are essential for informing future research and improving outcomes.

Placenta accreta spectrum (PAS) disorder poses significant risks to maternal health, given the complexities of screening, diagnosis, and management. To address these challenges, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) hosted a workshop on June 10-11, 2024, bringing together expert health care professionals, researchers, stakeholders, and patient advocates to identify knowledge gaps, with an overarching goal of informing future research and best practices for PAS. Key discussions revolved around the resources and infrastructure needed to advance screening, diagnosis, and clinical management of PAS, alongside ways to enhance collaboration across disciplines. Participants considered strategies to optimize existing research resources and explored opportunities to strengthen partnerships between the NICHD and key stakeholders to achieve mutual objectives. The workshop-attended by representatives from the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Pan-American Society for the Placenta Accreta Spectrum, the National Accreta Foundation, the American Institute of Ultrasound in Medicine, and the Society of Gynecologic Oncology-aimed to foster consensus on essential PAS topics and to identify clinical and research priorities in all phases of PAS care. Additionally, a critical focus of the workshop was to enhance understanding of patient experiences and needs, recognizing that patient perspectives are essential for informing future research and improving outcomes.

OBJECTIVE:To evaluate the comparative efficacy of two of the most commonly used second-line uterotonics-methylergonovine maleate and carboprost tromethamine. METHODS:We conducted a double-blind randomized trial at two large academic perinatal centers in patients undergoing nonemergency cesarean delivery with uterine atony refractory to oxytocin, as diagnosed by the operating obstetrician. The intervention included administration of a single dose of intramuscular methylergonovine or carboprost intraoperatively at diagnosis. The primary outcome, uterine tone on a 0-10 numeric rating scale 10 minutes after study drug administration, was rated by operating obstetricians blinded to the drug administered. Secondary outcomes included uterine tone score at 5 minutes, administration of additional uterotonic agents, other interventions for uterine atony or hemorrhage, quantitative blood loss, urine output, postpartum change in serum hematocrit, transfusion, length of hospital stay, adverse drug or transfusion reactions, and postpartum hemorrhage complications. A sample size of 50 participants per group was planned to detect a 1-point difference (with estimated within-group SD of 1.5) in the mean primary outcome with 80% power at a two-sided α level of 0.05 while accounting for potential protocol violations. RESULTS:A total of 1,040 participants were enrolled, with 100 randomized to receive one of the study interventions. Mean±SD 10-minute uterine tone scores were 7.3±1.7 after methylergonovine and 7.6±2.1 after carboprost, with an adjusted difference in means of -0.1 (95% CI, -0.8 to 0.6, P =.76). Additional second-line uterotonics were required in 30.0% of the methylergonovine arm and 34.0% in the carboprost arm (adjusted odds ratio 0.72, 95% CI, 0.27-1.89, P =.505), and geometric mean quantitative blood loss was 756 mL (95% CI, 636-898) and 708 mL (95% CI, 619-810) (adjusted ratio of geometric means 1.06, 95% CI, 0.86-1.31, P =.588), respectively. No differences were detected in the occurrence of other interventions for uterine atony or postpartum hemorrhage. CONCLUSION:No difference was detected in uterine tone scores 10 minutes after administration of either methylergonovine or carboprost for refractory uterine atony, indicating that either agent is acceptable. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov , NCT03584854.

In patients with a prior cesarean delivery, some propose the risk of placenta accreta spectrum (PAS) is influenced by uterine factors such as cesarean scar defect size, remaining myometrial scar thickness, and defective decidua.1,2 We sought to evaluate PAS risk factors associated with prior surgical procedures and wound healing to optimize triage and counseling in pregnancies at the highest risk for PAS, specifically in patients with placenta previa and prior cesarean delivery.

INTRODUCTION:The aim of this study is to document the distribution of classic versus non-classic presentation of Placenta Accreta Spectrum (PAS) disorders as well as grading categories by the Society for Pediatric Pathology (SPP) and FIGO systems in an institutional cohort of gravid hysterectomies. We also document the prevalence of uterine scar as a histologic correlate for uterine scar dehiscence, a phenomenon raised by some as central to PAS pathogenesis. METHODS:PAS cases were assigned grade and designated as classic (anterior lower uterine segment implantation, prior C-section) or non-classic (implantation away from anterior lower uterine segment and/or no prior C-section). Features of dehiscence (uterine window, histologic evidence of scar) were recorded. RESULTS:Sixty-two patients were included: 76 % had prior C-section; 55 % had other forms of uterine instrumentation. Classic PAS was recorded in 52 % patients; notably, 48 % had non-classic presentation; of these, all but one had prior instrumentation (curettage, myomectomy, laparoscopy). Uterine window was described in 53 % classic and 23 % non-classic PAS. Scar was demonstrated in 31 % classic and 23 % non-classic PAS; trichrome/reticulin stains were confirmatory. 32 % cases were SPP grade 1, 18 % grade 2, 18 % grade 3a and 32 % grade 3d. Grade 3 was significantly more common in classic (72 %) than non-classic (27 %) PAS. DISCUSSION:While most PAS patients have classic presentation, a large subset does not; in addition, scar tissue is not identified histologically in most PAS hysterectomies; in these settings, PAS cannot be fully attributed to scar dehiscence. Uterine instrumentation often precedes non-classic PAS reinforcing the concept of decidual disruption as central to PAS pathogenesis. PAS grading as defined correlates with presentation (classic vs non-classic).

Placenta Accreta Spectrum (PAS) patient outcomes are significantly improved under the care of multidisciplinary teams. Currently, hysterectomies for PAS management are billed under the same codes as benign non-obstetric abdominal hysterectomies, though we hypothesized that more surgeon resources are used for the former. We compared the required operating room times and number of attending OBGYNs between hysterectomies for PAS and benign gynecologic (GYN) indications. Hysterectomies performed between 2015-2023 at a single institution were included. GYN hysterectomies included scheduled cases with procedure codes for abdominal hysterectomy (total or supracervical). Laparoscopic and robotic hysterectomies as well as those including other unrelated procedures were excluded. PAS hysterectomies included cesarean hysterectomies with pathology-confirmed PAS. Wilcoxon rank sum and Chi-squared analyses were used for continuous and categorical variables, respectively. Three-hundred twenty-three hysterectomies were included, 147 PAS and 176 GYN. Cases of PAS comprised of 54 grade 1 (36.7%) and 93 grade 2 or above (63.3%). PAS hysterectomies were significantly more likely to require >1 attending OBGYN than GYN hysterectomies (29.9% vs 3.98%, OR 10.3 [4.48-23.8]). Compared to GYN hysterectomies (median 184 min, IQR 156, 235), attending OBGYN time in the operating room (OR) was similar when compared to all PAS hysterectomies (median 198 min, IQR 160, 240, p=0.78). However, this time was significantly greater for PAS hysterectomies grade 2 or above (median 214 min, IQR 167, 252, p=0.02) and those with placenta previa (median 222 min, IQR 192, 256, p< 0.01). PAS hysterectomies are more likely to require multiple attending OBGYNs, and in cases with placenta previa or invasive PAS, longer time in the OR. As multidisciplinary delivery care is now the standard of care for PAS management, reimbursement rates for PAS hysterectomies should better reflect the resources and personnel required to care for these complex patients.

OBJECTIVE:To evaluate the comparative efficacy of two of the most commonly used second-line uterotonics-methylergonovine maleate and carboprost tromethamine.METHODS:We conducted a double-blind randomized trial at two large academic perinatal centers in patients undergoing nonemergency cesarean delivery with uterine atony refractory to oxytocin, as diagnosed by the operating obstetrician. The intervention included administration of a single dose of intramuscular methylergonovine or carboprost intraoperatively at diagnosis. The primary outcome, uterine tone on a 0-10 numeric rating scale 10 minutes after study drug administration, was rated by operating obstetricians blinded to the drug administered. Secondary outcomes included uterine tone score at 5 minutes, administration of additional uterotonic agents, other interventions for uterine atony or hemorrhage, quantitative blood loss, urine output, postpartum change in serum hematocrit, transfusion, length of hospital stay, adverse drug or transfusion reactions, and postpartum hemorrhage complications. A sample size of 50 participants per group was planned to detect a 1-point difference (with estimated within-group SD of 1.5) in the mean primary outcome with 80% power at a two-sided alpha level of 0.05 while accounting for potential protocol violations.RESULTS:A total of 1,040 participants were enrolled, with 100 randomized to receive one of the study interventions. Mean +/- SD 10-minute uterine tone scores were 7.3 +/- 1.7 after methylergonovine and 7.6 +/- 2.1 after carboprost, with an adjusted difference in means of -0.1 (95% CI, -0.8 to 0.6, P=.76). Additional second-line uterotonics were required in 30.0% of the methylergonovine arm and 34.0% in the carboprost arm (adjusted odds ratio 0.72, 95% CI, 0.27-1.89, P=.505), and geometric mean quantitative blood loss was 756 mL (95% CI, 636-898) and 708 mL (95% CI, 619-810) (adjusted ratio of geometric means 1.06, 95% CI, 0.86-1.31, P=.588), respectively. No differences were detected in the occurrence of other interventions for uterine atony or postpartum hemorrhage.CONCLUSION:No difference was detected in uterine tone scores 10 minutes after administration of either methylergonovine or carboprost for refractory uterine atony, indicating that either agent is acceptable.CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, NCT03584854.

Study Objective: To investigate the incidence, predictors, and clinical implications of placenta accreta spectrum (PAS) in pregnancies after hysteroscopic treatment for Asherman syndrome (AS).Design: This is a retrospective cohort study, conducted through a telephone survey and chart review.Setting: Minimally invasive gynecologic surgery center in an academic community hospital.Patients: Database of 355 patients hysteroscopically treated for AS over 4 years. We identified patients who achieved preg-nancy past the first trimester and evaluated the incidence and predictors for PAS as well as associated clinical implications.Interventions: Telephone survey.Measurements and Main Results: We identified 97 patients meeting the inclusion criteria. Among these patients, 23 (23.7%) patients had PAS. History of cesarean delivery was the only variable statistically significantly associated with having PAS (adjusted odds ratio 4.03, 95% confidence interval 1.31-12.39). PAS was diagnosed antenatally in 3 patients (14.3%), with patients having placenta previa more likely to be diagnosed (p <.01). Nine patients (39.13%) with PAS required cesarean hysterectomy, which is 9.3% of those with a pregnancy that progressed past the first trimester. Factors associated with cesarean hysterectomy were the eti-ology of AS (dilation and evacuation after the second trimester pregnancy or postpartum instrumentation, p <.01), invasive placenta (increta or percreta, p <.05), and history of morbidly adherent placenta in previous pregnancies (p <.05). Two patients with PAS (9.5%) had uterine rupture, and another 2 (9.5%) experienced uterine inversion.Conclusion: There is a high incidence of PAS and associated morbidity in pregnancies after hysteroscopic treatment for AS. There is a low rate of antenatal diagnosis as well as a lack of reliable clinical predictors, which both stress the importance of clinical awareness, careful counseling, and delivery planning. Journal of Minimally Invasive Gynecology (2023) 30, 192 -198.(c) 2022 AAGL. All rights reserved.

Placenta accreta spectrum (PAS) is characterized by abnormal attachment of the placenta to the uterus, and attempts at placental delivery can lead to catastrophic maternal hemorrhage and death. Multidisciplinary delivery planning can significantly improve outcomes; however, current diagnostics are lacking as approximately half of pregnancies with PAS are undiagnosed prior to delivery. This is a nested case–control study of 35 cases and 70 controls with the primary objective of identifying circulating microparticle (CMP) protein panels that identify pregnancies complicated by PAS. Size exclusion chromatography and liquid chromatography with tandem mass spectrometry were used for CMP protein isolation and identification, respectively. A two-step iterative workflow was used to establish putative panels. Using plasma sampled at a median of 26 weeks’ gestation, five CMP proteins distinguished PAS from controls with a mean area under the curve (AUC) of 0.83. For a separate sample taken at a median of 35 weeks’ gestation, the mean AUC was 0.78. In the second trimester, canonical pathway analyses demonstrate over-representation of processes related to iron homeostasis and erythropoietin signaling. In the third trimester, these analyses revealed abnormal immune function. CMP proteins classify PAS well prior to delivery and have potential to significantly reduce maternal morbidity and mortality.

Objective: To identify independent risk factors for placenta accreta spectrum among pregnancies conceived with assisted reproductive technology. Design: Retrospective cohort study. Setting: Tertiary hospital. Patient(s): Individuals who conceived with assisted reproductive technology and reached 20 weeks' gestation or later from 2011 to 2017. Intervention(s): Patient and cycle data was abstracted from hospital records and supplemented with state-level data. Poisson regression was used for multivariate analyses and reported as adjusted relative risks (aRR). Main Outcome Measure(s): Clinical or histologic placenta accreta spectrum. Result(s): Of 1,975 qualifying pregnancies, 44 (2.3%) met criteria for accreta spectrum at delivery. In the multivariate model, significant risk factors included low-lying placenta at delivery (aRR, 15.44; 95% CI 7.76-30.72), uterine factor infertility or prior uterine surgery (aRR, 4.68; 95% CI, 2.72-8.05), initial low-lying placentation that resolved (aRR, 3.83; 95% CI, 1.90-7.73), and use of frozen embryos (aRR, 3.02; 95% CI, 1.66-5.48). When the fresh vs frozen variable was replaced with controlled ovarian hyperstimulation, the fi nal model did not change (aRR, 2.40 for unstimulated cycles, 95% CI, 1.32-4.38). With frozen transfers, the accreta rate was 16% when the endometrial thickness was < 6mm vs 3.8% with thicker endometrium (P1/4.02). Conclusion(s): Among pregnancies conceived with assisted reproductive technology, accreta spectrum is associated with low placental implantation (even when resolved), uterine factor infertility and prior uterine surgery, and the use of frozen embryo transfer or unstimulated cycles. (Fertil Steril Rep (R) 2023;4:279-85. (c) 2023 by American Society for Reproductive Medicine.)

Objective The aim of the study is to evaluate whether pathologic severity of placenta accreta spectrum (PAS) is correlated with the incidence of small for gestational age (SGA) and neonatal birthweight. Study Design This was a multicenter cohort study of viable, non-anomalous, singleton gestations delivered with histology-proven PAS. Data including maternal history, neonatal birthweight, and placental pathology were collected and deidentified. Pathology was defined as accreta, increta, or percreta. The primary outcome was rate of SGA defined by birth weight less than the 10th percentile. The secondary outcomes included incidence of large for gestational age (LGA) babies as defined by birth weight greater than the 90th percentile as well as incidence of SGA and LGA in preterm and term gestations. Statistical analysis was performed using Chi-square, Kruskal–Wallis, and log-binomial regression. Increta and percreta patients were each compared with accreta patients. Results Among the cohort of 1,008 women from seven United States centers, 865 subjects were included in the analysis. The relative risk (RR) of SGA for increta and percreta did not differ from accreta after adjusting for confounders (adjusted RR = 0.63, 95% confidence interval [CI]: 0.36–1.10 for increta and aRR = 0.72, 95% CI: 0.45–1.16 for percreta). The results were stratified by placenta previa status, which did not affect results. There was no difference in incidence of LGA (p = 1.0) by PAS pathologic severity. The incidence of SGA for all PAS patients was 9.2% for those delivered preterm and 18.7% for those delivered at term (p = 0.004). The incidence of LGA for all PAS patients was 12.6% for those delivered preterm and 13.2% for those delivered at term (p = 0.8203). Conclusion There was no difference in incidence of SGA or LGA when comparing accreta to increta or percreta patients regardless of previa status. Although we cannot suggest causation, our results suggest that PAS, regardless of pathologic severity, is not associated with pathologic fetal growth in the preterm period. Key Points

OBJECTIVE:Cesarean hysterectomy is generally presumed to decrease maternal morbidity and mortality secondary to placenta accreta spectrum disorder. Recently, uterine-sparing techniques have been introduced in conservative management of placenta accreta spectrum disorder to preserve fertility and potentially reduce surgical complications. However, despite patients often expressing the intention for future conception, few data are available regarding the subsequent pregnancy outcomes after conservative management of placenta accreta spectrum disorder. Thus, we aimed to perform a systematic review and meta-analysis to assess these outcomes. DATA SOURCES:PubMed, Scopus, and Web of Science databases were searched from inception to September 2022. STUDY ELIGIBILITY CRITERIA:We included all studies, with the exception of case studies, that reported the first subsequent pregnancy outcomes in individuals with a history of placenta accreta spectrum disorder who underwent any type of conservative management. METHODS:The R programming language with the "meta" package was used. The random-effects model and inverse variance method were used to pool the proportion of pregnancy outcomes. RESULTS:We identified 5 studies involving 1458 participants that were eligible for quantitative synthesis. The type of conservative management included placenta left in situ (n=1) and resection surgery (n=1), and was not reported in 3 studies. The rate of placenta accreta spectrum disorder recurrence in the subsequent pregnancy was 11.8% (95% confidence interval, 1.1-60.3; I2=86.4%), and 1.9% (95% confidence interval, 0.0-34.1; I2=82.4%) of participants underwent cesarean hysterectomy. Postpartum hemorrhage occurred in 10.3% (95% confidence interval, 0.3-81.4; I2=96.7%). A composite adverse maternal outcome was reported in 22.7% of participants (95% confidence interval, 0.0-99.4; I2=56.3%). CONCLUSION:Favorable pregnancy outcome is possible following successful conservation of the uterus in a placenta accreta spectrum disorder pregnancy. Approximately 1 out of 4 subsequent pregnancies following conservative management of placenta accreta spectrum disorder had considerable adverse maternal outcomes. Given such high incidence of adverse outcomes and morbidity, patient and provider preparation is vital when managing this population.

Placenta accreta spectrum (PAS) is associated with high morbidity and mortality. Maternal obesity is independently associated with adverse perinatal outcomes and may augment poor obstetrical outcomes. We sought to determine if increasing maternal body mass index (BMI) is associated with worse perinatal outcomes in patients with PAS.

In vitro fertilization (IVF) has been identified as an important risk factor for placenta accreta spectrum (PAS); however, there is a lack of knowledge on how patients with PAS may differ based on the conception method.1 The mechanism of PAS in patients who conceived with IVF may differ from those with classic risk factors, specifically placenta previa and previous cesarean delivery (CD).2 This study aimed to evaluate patient and pregnancy characteristics and delivery outcomes for PAS pregnancies conceived with IVF (IVF-PAS) or PAS pregnancies conceived without IVF (N-PAS), including those with vaginal deliveries and conservative uterine management.

Also available from AJOG MFM, the newest member of the AJOG family of journals -Conservative management for placenta accreta spectrum: questions

The surgical management of placenta accreta spectrum (PAS) is often challenging. There are a variety of techniques and management options described in the literature ranging from uterine sparing to cesarean hysterectomy. Following the inaugural meeting of the Pan-American Society for Placenta Accreta Spectrum a multidisciplinary group collaborated to describe collective recommendations for the surgical management of PAS. In this manuscript, we outline individual components of the procedure and provide suggested direction at key points of a cesarean hysterectomy in the setting of PAS. Key Points

In 2015, national experts published criteria to define placenta accreta spectrum (PAS) centers of excellence with a goal of improving outcomes. We aimed to (1) characterize the incidence of severe morbidity for placenta accreta spectrum (PAS) patients undergoing hysterectomy at referral centers in a contemporary cohort after 2015 and (2) to evaluate trends in morbidity over time.