Summary of current recommendations from selected international guidelines
| RCOG (2018)40 | ACOG/SMFM/SGO (2018)9 | FIGO (2018)8 | SOGC (2019)10 | IS-AIP (2019)25 | |
| Team and location | Placenta accreta spectrum should be cared for by a multidisciplinary team with expertise in complex pelvic surgery in a specialist center with logistic support for immediate access to blood products, adult, and neonatal intensive care | ||||
| Timing of delivery | 35–36+6 (GPP) | 34–35+6 (1A) | No formal recommendation. | 34–36 (II-3B) | 34–36+0 (Level 5) |
| Anesthesia | The choice of anesthesia technique should be made by the anesthetist conducting the procedure in consultation with the patient in advance (GPP) | No comment on this issue | Insufficient evidence to support the use of one technique over the other. | Regional epidural anesthesia is considered safer in most cases (III-B) | No comment on this issue |
| Ureteric stents | Insufficient evidence to recommend routine use (Grade C) | Value is unclear, left to case-by-case evaluation | Insufficient evidence to recommend routine use | Insufficient evidence to recommend routine use | Insufficient evidence to recommend routine use (Level 5) |
| Tranexamic acid | No comment on this issue | Insufficient evidence to recommend routine use | Where available, prior to skin incision (High and Strong) | To be administered at the commencement of surgery (I-A) | Should be administered whenever massive hemorrhage occurs (Grade A) |
| Skin incision | No comment on this issue | Left to operator judgment | Midline skin incision (Low and Weak) | Midline skin incision (III-B) | Individualized on a case-by-case basis (Grade D) |
| Hysterotomy | High without incising through the placenta | ||||
| Manual placental removal | No attempt should be made to remove the placenta if it shows no signs of separation | ||||
| Uterotonics | Insufficient evidence to recommend giving or withholding uterotonic drugs after delivery of the fetus | Not to be given routinely | |||
| Interventional radiology techniques | There is insufficient evidence to recommend routine interventional radiology techniques such as embolization or placement of an arterial segment balloon (Grade D) | ||||
| IIA ligation | No comment on this issue | Insufficient evidence to recommend routine use | Role is currently unclear (Low and Strong) | Insufficient evidence to recommend routine use (II-1C) | In case of persistent pelvic bleeding following hysterectomy (Grade D) |
| Hysterectomy type | No comment on this issue | Total | Total (Low and Strong) | Total | Individualized on a case-by-case basis (Grade C) |
| Cell salvage | Recommended (Grade D) | Recommended if available | Recommended if available (Low and Strong) | Recommended if available (II-3A) | Should be available for all elective procedures as a minimum |
| Uterus-preserving surgery | Uterus-preserving surgery may be appropriate if the extent of the placenta accreta spectrum is limited in depth and surface area, and the entire placental implantation area is accessible (GPP) | Consider for selected cases after detailed counseling about risks, uncertain benefics, and efficacy and should be considered investigational (Grade 2C) | Option for women who desire to preserve their fertility and agree to continuous long-term monitoring in centers with adequate expertise (Moderate and Strong) | Focal central disease may be amenable to wedge resection, with complete removal of the placenta and repair of the uterus (II-3B) | In selected cases, local resection appears to be reasonably successful (Level 2b) |
| Methrotrexate | Adjuvant therapy should not be used for expectant management as it is of unproven benefit and has significant adverse effects (Grade C) | ||||
ACOG, American College of Obstetricians and Gynecologists; FIGO, International Federation of Gynecology and Obstetrics; GPP, Good Practice Point; IS-AIP, International Society for Abnormally Invasive Placenta; RCOG, Royal College of Obstetricians and Gynaecologists; SGO, Society of Gynecologic Oncology; SMFM, Society for Maternal-Fetal Medicine; SOGC, Society of Obstetricians and Gynecologists of Canada.