Table 4

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 locationPlacenta 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 delivery35–36+6 (GPP)34–35+6 (1A)No formal recommendation.34–36 (II-3B)34–36+0 (Level 5)
AnesthesiaThe 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 issueInsufficient 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 stentsInsufficient evidence to recommend routine use (Grade C)Value is unclear, left to case-by-case evaluationInsufficient evidence to recommend routine useInsufficient evidence to recommend routine useInsufficient evidence to recommend routine use (Level 5)
Tranexamic acidNo comment on this issueInsufficient evidence to recommend routine useWhere 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 incisionNo comment on this issueLeft to operator judgmentMidline skin incision (Low and Weak)Midline skin incision (III-B)Individualized on a case-by-case basis (Grade D)
HysterotomyHigh without incising through the placenta
Manual placental removalNo attempt should be made to remove the placenta if it shows no signs of separation
UterotonicsInsufficient evidence to recommend giving or withholding uterotonic drugs after delivery of the fetusNot to be given routinely
Interventional radiology techniquesThere is insufficient evidence to recommend routine interventional radiology techniques such as embolization or placement of an arterial segment balloon (Grade D)
IIA ligationNo comment on this issueInsufficient evidence to recommend routine useRole 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 typeNo comment on this issueTotalTotal (Low and Strong)TotalIndividualized on a case-by-case basis (Grade C)
Cell salvageRecommended (Grade D)Recommended if availableRecommended if available (Low and Strong)Recommended if available (II-3A)Should be available for all elective procedures as a minimum
Uterus-preserving surgeryUterus-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)
MethrotrexateAdjuvant 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.