Emory Healthcare · Clinical Protocol
Placenta Accreta
Spectrum
Invasive Placental Disease Management
ACOG Consensus No. 7
SMFM 2023
Emory Healthcare 2026
Effective Date: 02/12/2026 · Applicable Facilities: EDH, EJCH, EUHM
Section 1 · Overview
Scope & Purpose
- 🎯Applies to all inpatient and outpatient obstetric and perioperative teams
- 🔬Covers suspected or confirmed PAS — accreta, increta, and percreta
- 📅From prenatal identification through postpartum care
- 🏥Optimize outcomes via multidisciplinary team approach
Section 1 · Definition
What is PAS?
A spectrum of abnormal placental adherence and invasion into the uterine wall.
Formerly known as morbidly adherent placenta.
🔵
Accreta
Villi attach to
myometrium
🟣
Increta
Villi invade
myometrium
🔴
Percreta
Villi penetrate
through serosa
ACOG/SMFM Obstetric Care Consensus No. 7 (2018) · Emory Healthcare Policy (2026)
Section 1 · Depth of Invasion
Placenta Accreta
Definition
Chorionic villi attach directly to the myometrium without invasion. No intervening decidua basalis.
Clinical Significance
Most common form (~75–78%). Placenta does not separate normally at delivery.
Section 1 · Depth of Invasion
Placenta Increta
Definition
Chorionic villi invade the myometrium but do not penetrate the uterine serosa.
Clinical Significance
~17% of PAS cases. Greater risk of hemorrhage than accreta alone.
Section 1 · Depth of Invasion
Placenta Percreta
Definition
Villi penetrate through the uterine serosa and may invade adjacent organs (bladder, bowel).
Clinical Significance
~5% of PAS. Highest morbidity. Requires urology/colorectal surgical involvement.
Section 1 · Pathophysiology
Etiology & Pathophysiology
- 🔬Defect of the endometrial–myometrial interface
- ⚠️Failure of normal decidualization in the area of a uterine scar
- 🔗Allows abnormally deep placental anchoring villi and trophoblast infiltration
- 📈Rising incidence driven by increasing rates of cesarean delivery
ACOG/SMFM Obstetric Care Consensus No. 7 (2018)
Section 1 · Epidemiology
Rising Incidence
1 in 272
Current US rate
(National Inpatient Sample, 2016)
1 in 533
Rate from
1982–2002
1 in 2,510
Rate in
1970s–1980s
ACOG/SMFM Obstetric Care Consensus No. 7 (2018)
Section 2
Risk Factors &
Diagnosis
Identifying patients at risk and confirming the diagnosis antenatally
Section 2 · Risk Factors
Primary Risk Factor:
Prior Cesarean Delivery
| Prior Cesarean Deliveries |
PAS Risk (with Placenta Previa) |
| 0 | 3% |
| 1 | 11% |
| 2 | 40% |
| 3 | 61% |
| ≥4 | 67% |
ACOG/SMFM Obstetric Care Consensus No. 7 (2018)
Section 2 · Risk Factors
Additional Risk Factors
Uterine History
Prior uterine surgeries, curettage, or Asherman syndrome
Maternal Factors
Advanced maternal age, multiparity
Placental Location
Placenta previa is a major independent risk factor
ACOG/SMFM Obstetric Care Consensus No. 7 (2018)
Section 2 · Diagnosis
Antenatal Diagnosis
- ✅Highly desirable — outcomes are optimized when delivery is planned before labor or bleeding
- 🔊Primary modality: obstetric ultrasonography
- 👩⚕️Evaluate by providers with experience and expertise in PAS diagnosis
- ⚠️Absence of ultrasound findings does not preclude PAS — clinical risk factors remain crucial
ACOG/SMFM Obstetric Care Consensus No. 7 (2018)
Section 2 · Ultrasound
Ultrasound Features
Gray-Scale Findings
Multiple vascular lacunae within placenta
Loss of normal hypoechoic zone
Retroplacental myometrial thickness <1 mm
Abnormal uterine serosa–bladder interface
Doppler Findings
Turbulent lacunar blood flow (most common)
Increased subplacental vascularity
Gaps in myometrial blood flow
Vessels bridging placenta to uterine margin
SMFM PAS Ultrasound Marker Task Force (2021) · ACOG/SMFM Consensus No. 7 (2018)
Section 2 · Imaging
MRI: Adjunct Imaging
When to Consider MRI
Posterior placenta previa · Indeterminate ultrasound · Suspected percreta with organ invasion
Limitations
More expensive · Less available · Expertise limited · Does not clearly improve on ultrasound in most cases
ACOG/SMFM Obstetric Care Consensus No. 7 (2018)
Section 3
Care Coordination &
Planning
Multidisciplinary team assembly and pre-operative preparation
Section 3 · Care Coordination
Core Care Team
🤱 Nursing
Clinical coordination lead
👩⚕️ MFM
Maternal-Fetal Medicine specialist
💉 Anesthesia
Neuraxial or general anesthesia planning
👶 NICU
Neonatal intensive care unit
🩸 Blood Bank
Massive transfusion protocol readiness
Consultation by second trimester or as soon as diagnosis is made · Emory Healthcare Protocol (2026)
Section 3 · Care Coordination
Augmented Care Team
🔬 Gyn-Oncology
Retroperitoneal dissection support
🏥 ICU
Postoperative critical care planning
🩻 Interventional Radiology
Rare adjunct procedures (selective use)
🫀 Urology
Suspected bladder/ureteral involvement
🔪 Trauma / General / Colorectal Surgery
Suspected bowel involvement
Section 3 · Facility Requirements
Level of Care
ACOG/SMFM Recommendation
Delivery at a Level III or IV maternal care facility. Continuously available staff with PAS expertise.
Required Infrastructure
Interdisciplinary critical care team · Blood bank with massive transfusion protocol · Strong nursing leadership
ACOG SMFM Obstetric Care Consensus No. 7 (2018)
Section 3 · Delivery Planning
Timing of Delivery
34–35+6
Weeks of gestation
Recommended delivery window
- 📋Scheduled delivery before onset of labor or bleeding
- 🚫Avoid placental disruption at time of delivery
- 💊Antenatal corticosteroids per RCOG Green-top Guideline 27a at 34–35+6 weeks
ACOG/SMFM Consensus No. 7 (2018) · RCOG Green-top Guideline 27a (2018)
Section 3 · Care Timeline
Antenatal Care Timeline
1
1st TrimesterIdentify risk factors; early ultrasound evaluation
2
2nd TrimesterMultidisciplinary team consultation; confirm diagnosis
3
3rd TrimesterSchedule OR; obtain consent; pre-op assessment
4
34–35+6 wksPlanned cesarean hysterectomy
5
PostpartumICU / recovery; surveillance if conservative management
Section 3 · Consent
Informed Consent
- Cesarean hysterectomy
- Possible cystotomy and/or ureteral injury
- Possible bowel injury
- Blood transfusion (including cell salvage)
- Interventional radiology procedures
- ICU admission
- Conservative options (retained placenta in situ, uterine-sparing) — only when appropriate expertise available
Emory Healthcare Protocol (2026)
Section 4
Intraoperative
Management
Surgical approach, hemorrhage preparedness, and goal-directed therapy
Section 4 · Surgical Approach
General Surgical Approach
Standard Approach
Planned cesarean hysterectomy with placenta left in situ after fetal delivery. Avoid attempted placental removal.
Conservative Management
Uterus-sparing strategies only in highly selected cases at centers with specific expertise and with informed consent.
ACOG/SMFM Consensus No. 7 (2018) · FIGO Consensus Guidelines (2018)
Section 4 · Pre-Incision
Pre-Incision Team Huddle
- Confirm team roles and assignments
- Review anticipated estimated blood loss (EBL)
- Walk through key surgical steps
- Define intraoperative consult criteria
- Verify all equipment is open and counted prior to induction
- Confirm cell saver is connected and ready
- Alert OB Rapid Response Team
Emory Healthcare Protocol (2026)
Section 4 · Pre-operative Labs
Labs & Vascular Access
Laboratory Studies
CBC · CMP · Type and cross for 4 units PRBC
Maintain active T&S / T&C every 72 hours (admitted patients)
Vascular Access
2 large bore IVs · Consider arterial line · Central venous access only as clinically indicated
Emory Healthcare Protocol (2026)
Section 4 · Hemorrhage Preparedness
Hemorrhage Preparedness
🩸 Cell Saver
Connected and used throughout procedure
🌡️ Fluid Warmer
In-line fluid warmer required
⚡ Rapid Infuser
Available in OR; prime if needed
📊 QBL Monitoring
Quantitative blood loss assessment every 30 minutes
🧪 TEG/ROTEM
Goal-directed therapy guided by labs/TEG/ROTEM when available
💊 Uterotonics
Oxytocin, methylergonovine, carboprost, misoprostol, calcium
Emory Healthcare Protocol (2026)
Section 4 · Transfusion Management
Goal-Directed Transfusion Targets
Platelets
> 50,000
per µL
Active transfusion management early for uncontrolled bleeding
Emory Healthcare Protocol (2026)
Section 4 · Pharmacologic Adjuncts
Tranexamic Acid (TXA)
Dosing Protocol
1 g TXA at 1 L blood loss
Repeat dose at 30 minutes if hemorrhage continues
Availability
Ensure TXA is available and accessible in the OR prior to incision
Emory Healthcare Protocol (2026)
Section 5
Adjunct Procedures &
Post-Operative Care
Interventional radiology, ureteral stents, and postoperative planning
Section 5 · Adjunct Procedures
Interventional Radiology (IR)
Not Recommended
Routine pre-op prophylactic balloon occlusion is NOT recommended — evidence does not support routine use
Selective Use
May be considered in suspected percreta with extra-uterine organ invasion at experienced centers after multidisciplinary discussion
Emory Healthcare Protocol (2026) · ACOG/SMFM Consensus No. 7 (2018)
Section 5 · Adjunct Procedures
Ureteral Stents
Not Routinely Recommended
Evidence does not demonstrate reduced ureteral injury with routine use
Consider When
Strong suspicion of bladder or parametrial invasion to facilitate identification, based on surgeon preference and anatomy
Emory Healthcare Protocol (2026)
Section 5 · Conservative Management
Conservative Management
- 🏥Only at centers with specific expertise
- 📋Requires explicit informed consent regarding risks, surveillance, and potential need for delayed hysterectomy
- 👩⚕️After consultation with Maternal-Fetal Medicine
- 📅Assured follow-up plan must be in place
- ⚠️Retained placenta in situ carries risk of delayed hemorrhage and infection
Emory Healthcare Protocol (2026) · FIGO Consensus Guidelines (2018)
Section 5 · Post-Operative
Post-Operative Care
ICU Planning
Pre-planned ICU admission as part of augmented care coordination. Intensivist involvement as indicated.
Monitoring
Continued hemorrhage surveillance · Coagulation monitoring · Wound and organ injury assessment
Emory Healthcare Protocol (2026)
Summary
Key Takeaways
- 🔍Identify early — antenatal diagnosis optimizes outcomes
- 👥Multidisciplinary team assembled by second trimester
- 🏥Level III/IV facility with massive transfusion capability
- 📅Planned delivery at 34–35+6 weeks before labor or bleeding
- ✂️Cesarean hysterectomy with placenta in situ is the standard approach
- 🩸Protocol-driven hemorrhage management — TXA, goal-directed transfusion
References
Evidence Base
| Source |
Year |
Key Contribution |
| ACOG/SMFM Obstetric Care Consensus No. 7 |
2018 |
Diagnosis, delivery timing (34–35+6 wks), cesarean hysterectomy standard |
| SMFM PAS Ultrasound Marker Task Force |
2021 |
Standardized sonographic markers and ultrasound examination approach |
| FIGO Consensus Guidelines on PAS |
2018 |
Conservative and non-conservative surgical management, terminology |
| RCOG Green-top Guideline 27a |
2018 |
Steroid timing at 34–35+6 wks, follow-up imaging |
| Emory Healthcare Invasive Placental Disease Policy |
2026 |
Institutional protocol for EDH, EJCH, EUHM |