“Placenta accreta spectrum” (PAS) is a rare but serious pregnancy condition where the placenta abnormally adheres to the uterine wall and fails to spontaneously release after delivery. When it occurs, PAS is associated with high maternal morbidity and mortality—as PAS management can be particularly challenging. This two-part review summarizes current evidence in PAS management, identifies its most challenging aspects, and offers evidence-based recommendations to improve management strategies and PAS outcomes. The first part of this two-part review highlighted the general anesthetic approach, surgical and interventional management strategies, specialized “centers of excellence,” and multidisciplinary PAS treatment teams. The high rates of PAS morbidity and mortality are often provoked by PAS-associated coagulopathies and peripartal hemorrhage (PPH). Anesthesiologists need to be prepared for massive blood loss, transfusion, and to manage potential coagulopathies. In this second part of this two-part review, we specifically reviewed the current literature pertaining to hemostatic changes, blood loss, transfusion management, and postpartum venous thromboembolism prophylaxis in PAS patients. Taken together, the two parts of this review provide a comprehensive survey of challenging aspects in PAS management for anesthesiologists.
In “Placenta Accreta Spectrum Part I: anesthesia considerations based on an extended review of the literature,” we discussed “Placenta Accreta Spectrum” (PAS) as being a rare but serious condition during pregnancy where part of the placenta abnormally attaches to the uterine wall and fails to spontaneously release after delivery .
The term PAS includes both adherent and invasive forms of accreta placentation and refers either to clinical symptoms, pathological findings or ultrasound imaging. The term itself has been redefined several times over the last decades—for example, “Abnormally Invasive Placenta” (AIP)—for which PAS prevalence estimation is found to be challenging . Nevertheless, rates are increasing and are now between 0.8 and 3.1 per 1,000 births after C-section . Depending on the extent of invasive growth, PAS can be subclassified—namely, placenta accreta, increta, and percreta. Irrespective of the surgical approach or the degree of invasive placental penetration, PAS is often accompanied with severe peripartum hemorrhage (PPH)—in comparison to placenta previa without accreta, placenta accreta shows an odds ratio (OR) of 89.5% for an estimated blood loss (EBL)>2 L, an OR of 29.6% for transfusion and an OR of 8.5% for a hospital stay > 4 days . Therefore, PAS is a serious medical condition associated with high maternal morbidity and mortality and presents anesthesiologists with several challenging management aspects. In the first part of this two-part literature survey, we addressed the general anesthetic and therapeutic approaches, as well as organizational and structural demands in PAS treatment.
Moreover, PAS is frequently accompanied by hemostatic changes, coagulopathies, and high blood loss. The knowledge of these possible conditions, diagnostic options, and sufficient management strategies is essential for anesthesiologists treating women with PAS and is presented here in the second part of this review series.
Literature findings – Placenta Accreta Spectrum Part I & II: anesthesia and hemostatic considerations based on an extended review of the literature
A detailed description of the literature review and screening process is presented in part one of this review series. Briefly, to identify relevant PAS literature, we performed a computerized Medline database search and screened 7,723 publication between 1973 and February 28 2021. Of those, we identified and included 55 anesthesiology relevant trials (n=3459 PAS patients) providing the basis of this review , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . Another 37 trials were included in an interventional radiology analysis (n=4507 PAS patients), which was only included in part one of this review.
From the 55 trials we extracted data regarding blood loss, transfusion, hemostatic diagnostic and therapy hysterectomy rates, intensive care unit (ICU) admission rates, operative and anesthetic approaches used, PAS type, and postoperative care. The trials included in this review are shown in Supplementary Table 1.
This part of the review summarizes the current literature in regard to the special hemostatic conditions in women with PAS, preoperative and intraoperative hemostatic diagnostics and treatment, preoperative anemia, blood loss, transfusion management, cell salvage, and postpartum venous thromboembolism (VTE) prophylaxis.
Coagulopathy in PAS
It is currently unknown exactly how coagulation is affected by PAS, but more than 30% of women with PAS undergoing hysterectomy developed coagulopathy—associated for example with changes in platelet count, international normalized ratio, and fibrinogen levels—and had an increased estimated blood loss .
We do know, however, that both (1) systemic coagulation changes during normal pregnancy and (2) the endothelium-like functions of placental-trophoblasts in the third stage of labor lead to increased coagulation and decreased fibrinolytic activity before birth , , . On the one hand, coagulation activation increases in PAS due to abnormal trophoblast invasion and maternal endothelium dysfunction in the placenta or the surrounding organs infiltrated by the placenta [1, 62, 63]. On the other hand, especially in extensive PAS (FIGO grade 3), prolonged prothrombin time and increased d-dimer and fibrin degradation products were detectable .
Prolonged prothrombin time might be indicate hypocoagulopathy : In normal gestation, trophoblasts provide laminar maternal blood flow and prevent bleeding at the maternal-fetal interface [59, 60, 65]. Placental trophoblasts express tissue factor (TF) and initialize coagulation via activation of blood-coagulation factor VII (FVII) and thrombin (blood-coagulation factor II; FII). In abnormal gestation, the invasive growth, the increased angiogenesis and proliferation—which might be induced by hypoxia inducible factor-1α (HIF-1α), one of the regulators of the signaling pathway in trophoblasts invasion—leads to increased TF and coagulation with consecutive consumption of coagulation factors during endothelial expression .
Increased d-dimer and fibrin degradation products in extended PAS are a result of increased fibrinolysis: Angiogenesis and lacunar deletions cause in in increased blood velocity and shear forces with excessive fibrinoid deposition at the uteroplacental interface and consumption of fibrinogen and increased fibrinolysis via reduced Plasminogen Activator Inhibitor (PAI I) level .
Thus, the abnormal trophoblast invasion and enhanced trophoblast activity, raises the suspicion that both local and systemic coagulation activities can switch from an increased coagulation state in the third stage of labor to a decreased state in extensive PAS. This may result in disseminated intravascular coagulation (DIC) with subsequent uncontrolled systemic coagulation activation and consumption, consecutive bleeding, and microvascular thrombosis as a dreaded complication in PPH in PAS patients [59, 60, 65]. When massive bleeding in PAS occurs, an inflammation-induced release of proinflammatory cytokines, like tumor necrosis factor-α (TNF) and interleukins (IL-1, IL-6), lead to massive expression of TF activating coagulation at the endothelium-like trophoblastic surface and normal endothelium [59, 60, 65]. On the one hand, decreased fibrinolysis, enhanced expression of PAI 1 + 2 and TAFI, and reduced coagulation inhibitors antithrombin (AT III) and protein C + S [12, 31, 59, 60, 65] may intensify coagulation in PPH related DIC. On the other hand, the changes in extensive PAS can cause consumption of utero-placental and systemic coagulation factors with enhanced bleeding during local resection or hysterectomy.
In conservative/expectant PAS management, leaving the placenta untouched minimizes the initial blood loss and the odds of a possible transition to a DIC-like hemostatic state. However, if the placenta is not removed, trophoblast-induced local coagulation activity can lead to massive consumption over a three month period, marked by decreased fibrinogen, increased D-dimers as a marker of local fibrinolysis, and increased risk of secondary PPH [11, 20, 68, 69].
International guidelines currently recommend both the (1) preoperative diagnosis and treatment of anemia and (2) patient blood management (PBM) concepts to maintain adequate hemoglobin levels and thereby reduce the need for allogenic blood transfusion intraoperatively , , , , . Prepartum anemia is associated with impaired peripartum outcome (e.g. morbidity), transfusion, and has been shown to be associated with postpartum depression, fatigue, and altered maternal-infant bonding . Nevertheless, we only identified one case report where a PAS patient (who was a Jehovah`s Witness with a Hb 12.5 g/dL) was administered a single dose of erythropoietin and intravenous iron before undergoing a caesarean section and delayed hysterectomy .
Because of the high risk of PPH in PAS, women should be preoperative screened for anemia and, if diagnosed, treated before childbirth [73, 74]. Hemodilution effects by increased red blood cells and plasma volume leads to a kind of physiological anemia in pregnancy . According to the UK National Institute for Health Care and Excellence (NICE), anemia is defined in hemoglobin-(Hb-)levels below 11 g/dL in the first trimester of pregnancy and below 10.5 g/dL from the second trimester until birth . Apart from PAS, the main cause of anemia in pregnancy is iron deficiency anemia, which should be diagnosed in the early pregnancy stage and at 28 weeks gestation in every woman [70, 77], , . Most guidelines recommend oral iron therapy when ferritin levels are below 30 μg/L . In PAS, anemia treatment might be indicated as early as possible to maintain Hb-levels above 11 g/dL during pregnancy. Particularly in advanced pregnancy, late PAS diagnoses, severe iron-deficiency, and oral iron intolerance, intravenous iron should be considered as a quick and effective method to increase preoperative Hb-levels [75, 78]. The Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines recently recommended the optimization of preoperative hemoglobin levels with intravenous iron .
Prepartum and intrapartum hematology laboratory tests, point-of-care (POC) diagnostics
Neither the recent SOGC guidelines  nor the studies included here offered any recommendations regarding preoperative coagulation tests. Other than Hb-levels, only 13 studies/case reports listed pre- and/or intraoperative blood tests including partial thromboplastin time (PTT) and/or prothrombin time (PT), platelets, D-dimers, and/or fibrinogen levels (Supplementary Table 1). We observed that the time of blood draw, coagulation studies/lab tests performed, and hemostatic therapies reported in the literature prior to transfusion varied considerably and were inconsistent. Five studies/case reports, for instance, measured D-dimer levels. Of those five, four studies reported a strong increase in D-dimers as a marker for the activation of the coagulation and fibrinolytic system during conservative management of PAS [10, 11, 20, 23]. We recommend assessing pre- and intrapartum coagulation, performing serial blood gas analyses and POC coagulation testing. Though prepartum fibrinogen levels and standard coagulation parameters in combination with viscoelastic tests (like rotational thrombelastometry-derived parameters; ROTEM®) are not able to “predict” PPH, if PPH occurs, reduced fibrinogen levels and viscoelastic tests have been shown to correlate with the severity of bleeding , , , , . The following blood tests should be performed mandatory prepartum: complete blood count (CBC) (specifically including platelets), fibrinogen levels, standard coagulation parameters, and D-dimers. Additionally, due to hemostatic changes in PAS, FVII, FVIII, von Willebrand factor (VWF), blood-coagulation factor XIII (FXIII), protein C + S, antithrombin, and/or viscoelastic tests may help determine the physiological pro-coagulant state before birth or to identify pre-, intra-, and postpartum changes during PAS treatment. A questionnaire may help identify patients at risk for potential secondary PPH due to personal and family history of bleeding (e.g. unusual bleeding after minor trauma, surgery or tooth extraction, known coagulation disorders, heavy or prolonged menstrual periods, and bleeding after delivery) .
Blood loss and transfusion
Measurement of blood loss
Blood loss was reported in 47 of the included case repots/studies. These included data from 2,982 women, reporting an average blood loss of approximately 1854 mL. 22 publications reported losses greater than 2 L (Figure 1, Supplementary Table 1).
In a recently published international multicenter study of 338 women with PAS, the median of visually estimated and/or measured and/or weighted blood loss was 2 L . Unplanned hysterectomy or delivery by surgeons without experience in PAS was associated with an increased risk of blood loss > 3.5 L compared to planned hysterectomy, focal resection, or conservative management when delayed hysterectomy was not required .
We recommend a multimodal approach to assessing intraoperative blood loss during PAS-surgery—namely, (1) using blood collection drapes, (2) weighing wringed surgical sponges, (3) assessing fluid levels in surgical suction canisters, and finally (4) verifying non-transfused cell salvage blood canister levels , , . Moreover, verification via calculation using the formula Volume of Blood Loss (mL) = Estimated Blood Volume (mL) x ln (hemoglobin [g/L]/0.33 before delivery/postpartum hemoglobin [g/L]/0.33) might be helpful to estimate blood loss .
Transfusion and fluid management
44 case reports/studies reported blood product transfusion data, including red blood cell concentrates (RBC), platelet concentrates (PLT), or fresh frozen plasma (FFP) (Supplementary Table 1). Up to two units of RBC were given in eight studies/case reports, two to four units in 12 studies/case reports, and greater than 4 units of RBCs were transfused in 20 studies/case reports. Four studies/case reports reported no RBC transfusion (Figure 2). The analysis contained data from 2,660 women with an average transfusion of 4.5 units of RBC per woman.
30 studies/case-reports reported having transfused 1 to 5 units of FFPs and 14 studies/case reports reported PLT transfusion (Supplementary Table 1). Taken together, this data indicates that though not every PAS patient undergoing C-section suffered from PPH, the patients with PAS who did have PPH were frequently transfused due to massive blood loss and accompanying coagulopathy.
Postpartum anemia due to bleeding may be associated with an increased risk of infection, enhanced cardiovascular stress, symptoms of anemia (including reduced capability for postpartum care of the baby, headache, fatigue, reduced lactation), postpartum depression, and prolonged hospital stay [91, 92]. That said, a prospective randomized non-inferiority trial in 521 women found that patients with severe postpartum anemia (Hb-level 4.8–7.9 g/dL, without severe anemic symptoms or comorbidities) who received RBC transfusion were significantly less likely to have physical fatigue three days respectively one week postpartum than patients who were not transfused . However, the observed effect was only little. Moreover, there was no difference in health-related quality of life six weeks postpartum between the transfusion and control groups. Therefore, restrictive transfusion management is justifiable . According to NATA guidelines (Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis), women should undergo crossmatching for blood type and red cell antibodies at 28 weeks gestation . In non-bleeding patients whose Hb-levels are < 6 g/dL, we consider transfusing a single RBC and then continue Hb-monitoring post-transfusion .
To generate balanced hemostasis and avoid dilutional coagulopathy (note: dilutional coagulopathy generally occurs when RBCs are exclusively transfused—i.e. without FFP or PLT) fixed RBC:FFP:PLT transfusion ratios in massive bleeding are currently being debated. In theory, a fixed-ratio transfusion approach is useful to mimic the replacement of whole blood specifically in emergency settings where diagnostic coagulation test results are not available. Currently, however, fixed transfusion ratios vary across PPH guidelines [94, 95]. For PAS patients with PPH in particular there are no fixed ratio transfusions recommended in current guidelines. This may be for several reasons. First, when bleeding occurs in PAS, massive blood loss is likely to be limited to specific timepoints, e.g. during local placental resection, in contrast to the unlimited continuous bleeding seen in uterine atony. In our opinion, because PAS patients have an increased risk of coagulopathy, transfusion treatment should focus on hemostatic requirements, meaning that peripartum permissive anemia can be tolerated if Hb-levels are > 6 g/dL. Secondly, massive blood loss in PAS can usually be anticipated, which allows for preoperative diagnostics (e.g. point-of-care testing, hemostatic state), hemostatic agent treatment, and the preparation and organization of transfusion-related systems prior to surgery, namely, setting up rapid transfusion systems (Level 1®), fast-thawing FFP microwaves, and cell salvage systems (Cell Saver®). Finally, because bleeding is generally anticipated in PAS patients, cell salvage systems are frequently used intraoperatively. Therefore, it is understandable that none of the studies that we identified in this review reported using fixed transfusion ratios. A multimodal approach combining classical institutional fluid, transfusion, and hemostatic/PPH protocols seems more useful than fixed transfusion ratios . Patient comorbidity, wishes, clinical anemia, and risk of intraoperative bleeding prior to surgery should be considered. If massive bleeding is encountered, rapid transfusion systems and ready-to-use blood products should already be in the operating room.
Colloid solutions enhance dilutional coagulopathy (and may impair long-term renal function) and should therefore be avoided or strictly limited to emergency use during PAS bleedings , , . Balanced gelatin polypeptide solutions also have been shown to integrate into clots and may alter fibrin-polymerization and clot-firmness . Therefore, to avoid coagulopathy and interstitial and tissue edema, extracellular fluids should be replaced in a protocol-based manner . During (emergency) massive bleeding in PAS, high volume resuscitation with balanced crystalloid and colloid solutions should specifically be used only to “bridge” the time until FFP transfusion and advanced hemodynamic monitoring is available.
Autologous blood transfusion: Cell salvage systems (e.g. Cell Saver®) collect and process maternal blood for re-/autotransfusion during surgery. This process has been shown to be well tolerated in obstetric patients with a high risk of bleeding [92, 101]. Thirteen of the studies included here reported the use of cell salvage in PAS management and re-transfused roughly 300–500 mL of blood (Supplementary Table 1). In a recent trial, 3,038 women at risk of PPH were randomly assigned to cell salvage vs. routine care . Allogenic donor blood transfusion was similar in both groups, but increased in the routine care group if emergency C-section was performed . During massive bleeds, cell salvage may reduce the need for additional allogenic transfusion without increasing the risk of amniotic fluid embolism due to high quality filtering techniques [92, 94, 101, 102]. In PAS, cell salvage systems can be prepared prior to surgery and should be used according to multimodal fluid, transfusion, and hemostatic/PPH protocols . Autologous blood transfusion seems especially useful in non-massive continuous bleeding. In this setting, transfusing roughly 300 mL of autologous blood may circumvent allogenic RBC transfusion altogether. Importantly, rhesus testing and appropriate treatment (anti-D isoimmunization) is necessary before transfusion of autologous blood to avoid maternal immunization by rhesus positive child [92, 94, 101, 102]. As a side note, cell salvage systems have white blood cell (WBC) filters that additionally remove remaining components of the amniotic fluid, WBCs, and squamous cells. These filters additionally reduce bacterial contamination of the autologous blood during re-transfusion , but can induce hypotension by inducing bradykinin release from platelets as they pass through the negatively charged filter membrane [104, 105].
Tranexamic acid (TXA) and hemostatic agent requirements
Both decreased and increased fibrinolysis can occur as part of PAS coagulopathy [1, 62, 63, 67]. Therefore, prophylactic antifibrinolytic agents like TXA should be handled with care and might be considered in PAS patients with high risk of bleeding, e.g. immediately before starting caesarean section (due to high risk on hyperfibrinolysis during massive bleeding in PAS) . All data on the prophylactic use of TXA are mainly based on all-cause PPH: A metanalysis of eight RCTs found reduced postpartum bleeding (mean difference −160 mL blood; −224 mL to −95 mL) after prophylactic administration of 1–2 g TXA prior to elective C-sections . A multicenter RCT of prophylactic TXA vs. placebo after planned cesarean delivery at ≥34 weeks gestation in 4,431 women showed that TXA significantly reduced the incidence of PPH (26.7 vs. 31.6%), though secondary outcomes (EBL and transfusion rate) did not differ across groups . For vaginal delivery, a multicenter double-blind randomized trial in 4,079 women found that patients who received 1 g of TXA prophylactically were significantly less likely to have clinically relevant PPH, though no difference in RBC transfusion was observed . None of the studies reported an increased risk of adverse events, but history of thromboembolic events and contraindications for the use of TXA as well as potentially decreased fibrinolysis should be considered if TXA is administered prophylactically in PAS patients.
The therapeutic use of TXA is targeting potential enhanced clot destruction and deficient clot strength during PPH. However, only six of the studies included in this review reported TXA treatment, the majority of which did not perform prophylactic administration before bleeding (Supplementary Table 1). Again, there is no evidence on differential approaches of TXA administration depending on the grade of PAS or the prepartum coagulation state in PAS and recommendations are mainly based on PPH data of all causes: The results of the international double-blind placebo-controlled multicenter World Maternal Antifibrinolytic (WOMAN) trial (20,060 patients with PPH) suggest that early administration of TXA (within 3 h of childbirth) reduces the risk of exsanguination without an increased risk for adverse events . However, several issues in trial performance should be considered. The trial was mainly performed in low-income countries (with 20-30-fold higher mortality rates than European countries) without using a nationwide-adjusted PPH algorithm. Initial primary outcome (prevention of hysterectomy) was modified after patient recruitment due to high hysterectomy rates and lack of alternatives in PPH treatment . No differences in transfusion or volume of blood lost were observed. Thromboembolic events (like deep vein thrombosis) were detected via patient reporting with a lower incidence than in obstetric patients without PPH in European countries . Therefore, it is unclear if these results are universally applicable. Nevertheless, the therapeutic use of TXA is highly recommended in PPH- and PAS guidelines [80, 92, 96, 107, 109], , .
Of the studies included in this review, 14 reported the administration of additional hemostatic agents during in PAS treatment. Fibrinogen was required in only two of the reported cases/studies. Cryoprecipitate (not universally licensed throughout Europe), a plasma-derived frozen blood product containing mainly fibrinogen, factor VIII, factor XIII and von Willebrand factor, was administrated in ten of the reported cases/studies (Supplementary Table 1). Activated recombinant factor VII and prothrombin complex concentrate (PPC/PPSB: factor II, VII, IX, X and protein C + S) was administered during massive bleeding in one case report (Supplementary Table 1).
International PPH guidelines currently recommended fibrinogen administration following TXA administration and cryoprecipitate/PPSB/FFP if persistent bleeding is observed and >1.5 L of blood has been lost [96, 109, 111, 112]. Additionally, both (1) FXIII (to improved clot stability) and (2) desmopressin (to increased endothelial VWF release and prevention of FVIII reduction) may be indicated as supportive coagulation treatments in persistent bleeding [96, 109, 111, 112]. To minimize dilutional coagulopathy and DIC in PAS, hemostatic agents might be administered in the early stages of PPH, especially if extensive invasive placenta percreta is observed or intraoperative bleeding risk is high.
Initial coagulopathy is likely less pronounced in patients undergoing conservative PAS management. However, local and secondary systemic hemostatic consumption may lead to time-delayed coagulopathy. Therefore, coagulation should be closely monitored and TXA, fibrinogen, and FXIII administration may be indicated . There is no data concerning the time frame or periodical of coagulation monitoring in conservative PAS management. The placental period may be drawn out for months . During this time a continuous consumptions factors may occur—indicating a close meshed monitoring of coagulation factors. With lack of evidence, an interval of 4 weeks appears to be appropriate, in absence of clinical symptoms.
Postpartum venous thromboembolism (VTE) prophylaxis
None of the trials/case reports included in this review reported increased postoperative VTE incidence in PAS. Moreover, specifics regarding postoperative anticoagulant VTE prophylaxis were generally not reported. However, pregnancy-associated VTE is a leading cause of maternal morbidity and mortality . In pregnancy the hypercoagulable state and the inferior vena cava compression by the gravid uterus increases the risk for VTE. The adjusted odds ratio (OR) for VTE after any cesarean section is 3.5. Therefore, all women undergoing cesarean sections should be considered for thromboprophylaxis with low-molecular-weight heparin (LMWH) for ten days after delivery apart from those having an elective cesarean section without any additional risk factors. Persistence of three or more risk factors should warrant extended VTE prophylaxis up to six weeks . Beside VTE history prior to pregnancy and/or the presence of thrombophilia (e.g. Factor-V-Leiden mutation) most of the VTE-risk factors such as age > 35 years, parity ≥ 3, preterm delivery < 37 weeks, PPH and surgery, transfusion are common in women with PAS [113, 117].
In addition to VTE prophylaxis with LMWH, intermittent pneumatic compression (IPC) may facilitate VTE prevention. There is no evidence regarding IPC in PAS in particular. However, several trials showed effectiveness and safety of IPC—for example in women undergoing gynecologic surgery , , , . Therefore, the use of IPC may be considered.
This review highlights numerous aspects to be considered in PAS management. A PAS-Algorithm optimizes interdisciplinary communication over the entire period of therapy and helps schedule (preoperative) diagnostics and therapy. Every aspect associated with PAS can and should be approached in a structured way. Part I of this review includes a PAS-Algorithm that also contains the hemostatic considerations discussed here in this second part of this review series.
Figure 3 shows a possible PAS-Algorithm, already presented in the first part of this review series.
As reported in part one of this two-part review series, PAS is a rare and heterogeneous condition. Definitions vary and few studies were designed to specifically assess coagulopathies and transfusion management in PAS patients. As such, the information garnered herein was frequently drawn from secondary outcome measures or baseline study characteristics. Study quality varied and methods, reporting, and statistics were heterogeneous. Currently, there are few meta-analyses, systematic reviews, or randomized-controlled trials available and the majority of PAS data are taken from retrospective studies, case reports, or case series. Besides, due to the different terms used to describe the condition of PAS, the research may be incomplete. Furthermore, there is no database recording every PAS case. Therefore, it seems reasonable, that omplicative PAS cases were published more frequently, potentially leading to an overestimation of the severity of this condition.
PAS is a rare condition with several peculiarities that lead to a high morbidity and mortality. This presents a challenge to everyone involved in PAS therapy, especially anesthesiologists. Apart from the specifics in anesthetic, surgical, and interventional approaches, as well as structural and organizational requirements—all of which were addressed in the first part of this series—PAS is frequently accompanied by coagulopathy and massive PPH. Coagulopathy often even presents as a “DIC-like” state. Anesthesiologists need to anticipate possible hemostatic changes and severe bleeding. Over the past few years, diagnostic and therapeutic options have evolved considerably. POC testing provides prompt diagnosis of hemostatic disturbances and specific hemostatic agents may, if used reasonably, help prevent or stop ongoing PPH. Therefore, the knowledge of a targeted medical diagnosis and therapy is essential. Structured preoperative interdisciplinary planning is vital to reduce morbidity and mortality. A PAS-Algorithm provides good feasibility to organize and optimize multidisciplinary care throughout entire treatment course. Though evidence is increasing, we have made the recommendations herein based on a relative paucity of literature. High-quality trials are needed to ensure the best possible treatment for PAS patients.
Research funding: None declared.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: All authors state no conflict of interest in relation to this study. R.E. states no conflict of interest. P.C. states no conflict of interest. PY.D. received honoraria for lecture and consulting for CAF-DCF an LFB company. T.B. received research funds in relation to DFG-project BR2925/11-1. C.O.L. states no conflict of interest. P.N. states no conflict of interest. C.S. reports grants from Deutsche Forschungsgemeinschaft/German Research Society, grants from Deutsches Zentrum für Luft- und Raumfahrt e.V. (DLR)/German Aerospace Center, grants from Einstein Stiftung Berlin/Einstein Foundation Berlin, grants from Gemeinsamer Bundesausschuss/Federal Joint Committee (G-BA), grants from Inneruniversitäre Forsch-ungsförderung/Inner University Grants, grants from Projektträger im DLR/Porject Management Agency, grants from Stifterverband/Non-Profit Society Promoting Science and Education, grants from European Society of Anaesthesiology and Intensive Care, grants from Baxter Deutschland GmbH, grants from Fresenius Medical Care, grants from Grünenthal GmbH, grants from Masimo Europe Ltd., grants from Pfizer Pharma PFE GmbH, personal fees from Georg Thieme Verlang, grants from Dr. F. Köhler Chemie GmbH, grants from Sintetica GmbH, grants from Stifterverband für die deutsche Wissenschaft e.V./Philips, grants from Stiftung Charité, grants from AGUETTANT Deutschland GmbH, grants from AbbVie Deutschland GmbH & Co. KG, grants from Amomed Pharma GmbH, grants from InTouch Health, grants from Copra System GmbH, grants from Correvio GmbH, grants from Gemeinsamer Bundesausschuss/Federal Joint Committee (G-BA) -Innovationsfond, grants from Max-Planck-Gesellschaft zur Förderung der Wissenschaft e.V., grants from Deutsche Gesellschaft für Anesthesiologie & Intensivmedizin (DGAI), grants from Stifterverband für die deutsche Wissenschaft e.V./Medtronic, grants from Philips Electronics Nederland BV, grants from BMBF/RKI, grants from BMBF, grants from Deutsche Forschungsgemeinschaft/German Research Societ, grants from Drägerwerk AG & Co. KGaA outside the submitted work. In addition C.S. has the patents 10 2014 215 211.9, 10 2018 114 364.8, 10 2018 110 275.5, 50 2015 010 534.8, 50 2015 010 347.7, 10 2014 215 212.7 licensed. W.H. states no conflict of interest. L.K. reports honoraria for lecture from Novo Nordisk, CSL Behring and HICC Deutschland GbR.
Informed consent: Not applicable.
Ethical approval: Not applicable.
1. Collins, SL, Alemdar, B, van Beekhuizen, HJ, Bertholdt, C, Braun, T, Calda, P, et al.. Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta. Am J Obstet Gynecol 2019;220:511–26. https://doi.org/10.1016/j.ajog.2019.02.054.Search in Google Scholar PubMed
2. Jauniaux, E, Chantraine, F, Silver, RM, Langhoff-Roos, J. For the FIGO placenta accreta diagnosis and management expert consensus panel. FIGO consensus guidelines on placenta accreta spectrum disorders: epidemiology. Int J Gynecol Obstet 2018;140:265–73. https://doi.org/10.1002/ijgo.12407.Search in Google Scholar PubMed
3. Esakoff, TF, Sparks, TN, Kaimal, AJ, Kim, LH, Feldstein, VA, Goldstein, RB, et al.. Diagnosis and morbidity of placenta accreta: diagnosis and morbidity of placenta accreta. Ultrasound Obstet Gynecol 2011;37:324–7. https://doi.org/10.1002/uog.8827.Search in Google Scholar PubMed
4. Quist-Nelson, J, Crank, A, Oliver, EA, Kim, CH, Richard, S, George, B, et al.. The compliance with a patient-safety bundle for management of placenta accreta spectrum. J Matern Fetal Neonatal Med 2019;34:1–7. https://doi.org/10.1080/14767058.2019.1671349.Search in Google Scholar PubMed
5. Nieto, AJ, Echavarría, MP, Carvajal, JA, Messa, A, Burgos, JM, Ordoñez, C, et al.. Placenta accreta: importance of a multidisciplinary approach in the Colombian hospital setting. J Matern Fetal Neonatal Med 2020;33:1321–9. https://doi.org/10.1080/14767058.2018.1517328.Search in Google Scholar PubMed
6. Khokhar, RS, Baaj, J, Khan, MU, Dammas, FA, Rashid, N. Placenta accreta and anesthesia: a multidisciplinary approach. Saudi J Anaesth 2016;10:332–4. https://doi.org/10.4103/1658-354x.174913.Search in Google Scholar PubMed PubMed Central
7. Sivasankar, C. Perioperative management of undiagnosed placenta percreta: case report and management strategies. Int J Womens Health 2012;4:451–4. https://doi.org/10.2147/ijwh.s35104.Search in Google Scholar PubMed PubMed Central
8. Fratto, VM, Conturie, CL, Ballas, J, Pettit, KE, Stephenson, ML, Truong, YN, et al.. Assessing the multidisciplinary team approaches to placenta accreta spectrum across five institutions within the University of California fetal Consortium (UCfC). J Matern Fetal Neonatal Med 2021;34:2971–6. https://doi.org/10.1080/14767058.2019.1676411.Search in Google Scholar PubMed
9. Nieto-Calvache, AJ, López-Girón, MC, Quintero-Santacruz, M, Bryon, AM, Burgos-Luna, JM, Echavarría-David, MP, et al.. A systematic multidisciplinary initiative may reduce the need for blood products in patients with abnormally invasive placenta. J Matern Fetal Neonatal Med 2022;35:738–44. https://doi.org/10.1080/14767058.2020.1731460.Search in Google Scholar PubMed
10. Biele, C, Kaufner, L, Schwickert, A, Nonnenmacher, A, von Weizsäcker, K, Muallem, MZ, et al.. Conservative management of abnormally invasive placenta complicated by local hyperfibrinolysis and beginning disseminated intravascular coagulation. Arch Gynecol Obstet 2021;303:61–8. https://doi.org/10.1007/s00404-020-05721-0.Search in Google Scholar PubMed PubMed Central
11. Matsuzaki, S, Yoshino, K, Endo, M, Tomimatsu, T, Takiuchi, T, Mimura, K, et al.. Successful anticoagulant therapy for disseminated intravascular coagulation during conservative management of placenta percreta: a case report and literature review. BMC Pregnancy Childbirth 2017;17:443. https://doi.org/10.1186/s12884-017-1634-8.Search in Google Scholar PubMed PubMed Central
12. Salim, R, Chulski, A, Romano, S, Garmi, G, Rudin, M, Shalev, E. Precesarean prophylactic balloon catheters for suspected placenta accreta: a randomized controlled trial. Obstet Gynecol 2015;126:1022–8. https://doi.org/10.1097/aog.0000000000001113.Search in Google Scholar PubMed
13. Zhu, H, Wang, S, Shi, J, Yao, L, Wang, L, Chen, H, et al.. Prophylactic endovascular balloon occlusion of the aorta in cases of placenta accreta spectrum during caesarean section: points from the anaesthesiologist’s perspective. BMC Pregnancy Childbirth 2020;20:446. https://doi.org/10.1186/s12884-020-03136-y.Search in Google Scholar PubMed PubMed Central
14. Dai, M, Jin, G, Lin, J, Zhang, Y, Chen, Y, Zhou, Q, et al.. Control of postpartum hemorrhage in women with placenta accreta spectrum using prophylactic balloon occlusion combined with Pituitrin intra-arterial infusion. Eur Radiol 2020;30:4524–33. https://doi.org/10.1007/s00330-020-06813-w.Search in Google Scholar PubMed
15. Cali, G, Forlani, F, Giambanco, L, Amico, ML, Vallone, M, Puccio, G, et al.. Prophylactic use of intravascular balloon catheters in women with placenta accreta, increta and percreta. Eur J Obstet Gynecol Reprod Biol 2014;179:36–41. https://doi.org/10.1016/j.ejogrb.2014.05.007.Search in Google Scholar PubMed
16. Sentilhes, L, Ambroselli, C, Kayem, G, Provansal, M, Fernandez, H, Perrotin, F, et al.. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol 2010;115:526–34. https://doi.org/10.1097/aog.0b013e3181d066d4.Search in Google Scholar PubMed
17. Schwickert, A, van Beekhuizen, HJ, Bertholdt, C, Fox, KA, Kayem, G, Morel, O, et al.. Association of peripartum management and high maternal blood loss at cesarean delivery for placenta accreta spectrum (PAS): a multinational database study. Acta Obstet Gynecol Scand 2021;100(1 Suppl):29–40. https://doi.org/10.1111/aogs.14103.Search in Google Scholar PubMed
18. Frank Wolf, M, Maymon, S, Shnaider, O, Singer-Jordan, J, Maymon, R, Bornstein, J, et al.. Two approaches for placenta accreta spectrum: B-lynch suture versus pelvic artery endovascular balloon. J Matern Fetal Neonatal Med 2020;33:2711–7. https://doi.org/10.1080/14767058.2018.1558199.Search in Google Scholar PubMed
19. Fishel Bartal, M, Papanna, R, Zacharias, NM, Soriano-Calderon, N, Limas, M, Blackwell, SC, et al.. Planned versus unplanned delivery for placenta accreta spectrum. Am J Perinatol 2020;39:252–8. https://doi.org/10.1055/s-0040-1714676.Search in Google Scholar PubMed
20. Schröder, L, Pötzsch, B, Rühl, H, Gembruch, U, Merz, WM. Tranexamic acid for hyperfibrinolytic hemorrhage during conservative management of placenta percreta. Obstet Gynecol 2015;126:1012–5.10.1097/AOG.0000000000000915Search in Google Scholar PubMed
21. Weiniger, CF, Elram, T, Ginosar, Y, Mankuta, D, Weissman, C, Ezra, Y. Anaesthetic management of placenta accreta: use of a pre-operative high and low suspicion classification. Anaesthesia 2005;60:1079–84. https://doi.org/10.1111/j.1365-2044.2005.04369.x.Search in Google Scholar PubMed
22. Taylor, NJ, Russell, R. Anaesthesia for abnormally invasive placenta: a single-institution case series. Int J Obstet Anesth 2017;30:10–5. https://doi.org/10.1016/j.ijoa.2017.01.008.Search in Google Scholar PubMed
23. Bourrellier, L, Bensalem, R, Bersot, Y, Bertrand, A, Duminil, L, Malinovsky, JM, et al.. Disseminated intravascular coagulation syndrome two months after conservative management of placenta accreta. About two patients. Eur J Obstet Gynecol Reprod Biol 2017;215:266–7. https://doi.org/10.1016/j.ejogrb.2017.06.031.Search in Google Scholar PubMed
24. Shamshirsaz, AA, Fox, KA, Erfani, H, Clark, SL, Hui, SK, Shamshirsaz, AA, et al.. Coagulopathy in surgical management of placenta accreta spectrum. Eur J Obstet Gynecol Reprod Biol 2019;237:126–30. https://doi.org/10.1016/j.ejogrb.2019.04.026.Search in Google Scholar PubMed
25. Papillon-Smith, J, Hobson, S, Allen, L, Kingdom, J, Windrim, R, Murji, A. Prophylactic internal iliac artery ligation versus balloon occlusion for placenta accreta spectrum disorders: a retrospective cohort study. Int J Gynaecol Obstet 2020;151:91–6. https://doi.org/10.1002/ijgo.13256.Search in Google Scholar PubMed
26. Saito, K, Mariya, T, Fujibe, Y, Saito, M, Hirokawa, N, Ishioka, S, et al.. Common iliac artery dissection as a complication of common iliac artery balloon occlusion for placenta percreta: a case report. J Obstet Gynaecol Res 2021;47:1172–7. https://doi.org/10.1111/jog.14601.Search in Google Scholar PubMed
27. Zhou, X, Sun, X, Wang, M, Huang, L, Xiong, W. The effectiveness of prophylactic internal iliac artery balloon occlusion in the treatment of patients with pernicious placenta previa coexisting with placenta accreta. J Matern Fetal Neonatal Med 2021;34:93–8. https://doi.org/10.1080/14767058.2019.1599350.Search in Google Scholar PubMed
28. Yamada, T, Hirahata, E, Ihara, N, Nishimura, D, Inoue, K, Kato, J, et al.. Cesarean hysterectomy in a hybrid operating room for placenta percreta: a report of three cases. JA Clin Rep 2019;5:9. https://doi.org/10.1186/s40981-019-0230-5.Search in Google Scholar PubMed PubMed Central
29. Mei, Y, Luo, D, Wei, S, Wang, L, Liao, X, Jing, H, et al.. Comparison of emergency cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters in patients with placenta accreta spectrum. J Matern Fetal Neonatal Med 2020;35:3190–5. https://doi.org/10.1080/14767058.2020.1815187.Search in Google Scholar PubMed
30. Pinas-Carrillo, A, Bhide, A, Moore, J, Hartopp, R, Belli, AM, Arulkumaran, S, et al.. Outcomes of the first 50 patients with abnormally invasive placenta managed using the “Triple P Procedure” conservative surgical approach. Int J Gynaecol Obstet 2020;148:65–71. https://doi.org/10.1002/ijgo.12990.Search in Google Scholar PubMed
31. Li, P, Liu, X, Li, X, Wei, X, Liao, J. Clinical outcomes and anesthetic management of pregnancies with placenta previa and suspicion for placenta accreta undergoing intraoperative abdominal aortic balloon occlusion during cesarean section. BMC Anesthesiol 2020;20:133. https://doi.org/10.1186/s12871-020-01040-8.Search in Google Scholar PubMed PubMed Central
32. Peng, W, Shen, L, Wang, S, Wang, H. Retrospective analysis of 586 cases of placenta previa and accreta. J Obstet Gynaecol 2020;40:609–13. https://doi.org/10.1080/01443615.2019.1634019.Search in Google Scholar PubMed
33. Liu, J, Xu, J, Jiao, D, Duan, X, Han, X. Comparison of the efficacy of prophylactic balloon occlusion of the abdominal aorta at or below the level of the renal artery in women with placenta accreta undergoing cesarean section. J Matern Fetal Neonatal Med 2021;34:2427–34. https://doi.org/10.1080/14767058.2019.1667325.Search in Google Scholar PubMed
34. Whittington, JR, Pagan, ME, Nevil, BD, Kalkwarf, KJ, Sharawi, NE, Hughes, DS, et al.. Risk of vascular complications in prophylactic compared to emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) in the management of placenta accreta spectrum. J Matern Fetal Neonatal Med 2022;35:3049–52. https://doi.org/10.1080/14767058.2020.1802717.Search in Google Scholar PubMed
35. Stubbs, MK, Wellbeloved, MA, Vally, JC. The management of patients with placenta percreta: a case series comparing the use of resuscitative endovascular balloon occlusion of the aorta with aortic cross clamp. Indian J Anaesth 2020;64:520–3. https://doi.org/10.4103/ija.ija_121_20.Search in Google Scholar PubMed PubMed Central
36. Tokue, H, Tokue, A, Tsushima, Y, Kameda, T. Safety and efficacy of aortic vs. internal iliac balloon occlusion for cesarean delivery in coexisting placenta accreta and placenta previa. Cardiovasc Intervent Radiol 2020;43:1277–84. https://doi.org/10.1007/s00270-020-02548-9.Search in Google Scholar PubMed
37. Cho, SB, Hong, SJ, Lee, S, Won, JH, Choi, HC, Ha, JY, et al.. Preoperative prophylactic balloon-assisted occlusion of the internal iliac arteries in the management of placenta increta/percreta. Medicina 2020;56:368. https://doi.org/10.3390/medicina56080368.Search in Google Scholar PubMed PubMed Central
38. Yuan, Q, Jin, Y, Chen, L, Ling, L, Bai, XM. Prophylactic uterine artery embolization during cesarean delivery for placenta previa complicated by placenta accreta. Int J Gynaecol Obstet 2020;149:43–7. https://doi.org/10.1002/ijgo.13072.Search in Google Scholar PubMed
39. Titapant, V, Tongdee, T, Pooliam, J, Wataganara, T. Retrospective analysis of 113 consecutive cases of placenta accreta spectrum from a single tertiary care center. J Matern Fetal Neonatal Med 2020;33:3324–31. https://doi.org/10.1080/14767058.2018.1530757.Search in Google Scholar PubMed
40. Kim, MJ, Kim, IJ, Kim, S, Park, IY. Postpartum hemorrhage with uterine artery embolization: the risk of complications of uterine artery embolization. Minim Invasive Ther Allied Technol 2022;31:276–83. https://doi.org/10.1080/13645706.2020.1789662.Search in Google Scholar PubMed
41. Frasca, D. A Cesarean hysterectomy for invading placenta percreta: anesthetic safety considerations--a case report. AANA J 2012;80:373–8.Search in Google Scholar
42. Kamani, AA, Gambling, DR, Christilaw, J, Flanagan, ML. Anaesthetic management of patients with placenta accreta. Can J Anaesth 1987;34:613–7. https://doi.org/10.1007/bf03010522.Search in Google Scholar
43. Desbriere, R, Pascal, A, Katsogiannou, M, Mace, P, Laplane, C, Amar-Millet, A, et al.. Delayed disseminated intravascular coagulation revealed by spontaneous hematomas after conservative treatment of placenta percreta. Eur J Obstet Gynecol Reprod Biol 2018;226:77–8. https://doi.org/10.1016/j.ejogrb.2018.05.020.Search in Google Scholar PubMed
44. Kume, K, Tsutsumi, MY, Soga, T, Sakai, Y, Kambe, N, Kawanishi, R, et al.. A case of placenta percreta with massive hemorrhage during cesarean section. J Med Invest 2014;61:208–12. https://doi.org/10.2152/jmi.61.208.Search in Google Scholar PubMed
45. Binici, O, Büyükfırat, E. Anesthesia for cesarean section in parturients with abnormal placentation: a retrospective study. Cureus 2019;11:e5033. https://doi.org/10.7759/cureus.5033.Search in Google Scholar PubMed PubMed Central
46. Karacaer, F, Biricik, E, Ilgınel, M, Tunay, D, Sucu, M, Ünlügenç, H. Retrospective analysis of eighty-nine caesarean section cases with abnormal placental invasion. Turk J Anaesthesiol Reanim 2019;47:112–9. https://doi.org/10.5152/tjar.2018.31799.Search in Google Scholar PubMed PubMed Central
47. Atallah, D, Abou Zeid, H, Moubarak, M, Moussa, M, Nassif, N, Jebara, V. “You only live twice”: multidisciplinary management of catastrophic case in placenta Accreta Spectrum-a case report. BMC Pregnancy Childbirth 2020;20:135. https://doi.org/10.1186/s12884-020-2817-2.Search in Google Scholar PubMed PubMed Central
48. Ma, Y, You, Y, Jiang, X, Lin, X. Use of nitroglycerin for parallel transverse uterine cesarean section in patients with pernicious placenta previa and placenta accrete and predicted difficult airway: a case report and review of literature. Med 2020;99:e18943. https://doi.org/10.1097/md.0000000000018943.Search in Google Scholar PubMed PubMed Central
49. Ito, M, Oshita, K, Tanaka, K, Hara, M, Hiraki, T. Massive obstetric hemorrhage during cesarean section in a patient after conception by frozen-thawed embryo transfer: a case report. JA Clin Rep 2020;6:2. https://doi.org/10.1186/s40981-019-0308-0.Search in Google Scholar PubMed PubMed Central
50. Cojocaru, L, Lankford, A, Galey, J, Bharadwaj, S, Kodali, BS, Kennedy, K, et al.. Surgical advances in the management of placenta accreta spectrum: establishing new expectations for operative blood loss. J Matern Fetal Neonatal Med 2020;3:1–10. https://doi.org/10.1080/14767058.2020.1852213.Search in Google Scholar PubMed
51. Urfalıoglu, A, Öksüz, G, Bilal, B, Teksen, S, Calışır, F, Boran, ÖF, et al.. Retrospective evaluation of anesthetic management in cesarean sections of pregnant women with placental anomaly. Anesthesiol Res Pract 2020;2020:1358258. https://doi.org/10.1155/2020/1358258.Search in Google Scholar PubMed PubMed Central
52. Bartels, HC, Mulligan, KM, Craven, S, Rogers, AC, Higgins, S, O’Brien, DJ, et al.. Maternal morbidity in placenta accreta spectrum following introduction of a multi-disciplinary service compared to standard care: an Irish perspective. Ir J Med Sci 2021;190:1451–7. https://doi.org/10.1007/s11845-020-02473-3.Search in Google Scholar
53. Khoiwal, K, Gaurav, A, Kapur, D, Kumari, O, Sharma, P, Bhandari, R, et al.. Placenta percreta - a management dilemma: an institutional experience and review of the literature. J Turk Ger Gynecol Assoc 2020;21:228–35. https://doi.org/10.4274/jtgga.galenos.2020.2020.0106.Search in Google Scholar
54. Imtiaz, R, Masood, Z, Husain, S, Husain, S, Izhar, R, Hussain, S. A comparison of antenatally and intraoperatively diagnosed cases of placenta accreta spectrum. J Turk Ger Gynecol Assoc 2020;21:84–9. https://doi.org/10.4274/jtgga.galenos.2019.2019.0063.Search in Google Scholar
55. Herbert, K, Buchbinder, L, Seshachellam, V, Lee, L. Resuscitative endovascular balloon occlusion of the aorta and concomitant tranexamic acid for cesarean hysterectomy complicated by common femoral artery thrombosis: a case report. Cureus 2020;12:e11197. https://doi.org/10.7759/cureus.11197.Search in Google Scholar
56. Bluth, A, Schindelhauer, A, Nitzsche, K, Wimberger, P, Birdir, C. Placenta accreta spectrum disorders-experience of management in a German tertiary perinatal centre. Arch Gynecol Obstet 2021;303:1451–60. https://doi.org/10.1007/s00404-020-05875-x.Search in Google Scholar
57. Chen, M, Liu, X, You, Y, Wang, X, Li, T, Luo, H, et al.. Internal iliac artery balloon occlusion for placenta previa and suspected placenta accreta: a randomized controlled trial. Obstet Gynecol 2020;135:1112–9. https://doi.org/10.1097/aog.0000000000003792.Search in Google Scholar
58. Bergakker, SA. Case report: management of elective cesarean delivery in the presence of placenta previa and placenta accreta. AANA J 2010;78:380–4.Search in Google Scholar
59. Erez, O. Disseminated intravascular coagulation in pregnancy - clinical phenotypes and diagnostic scores. Thromb Res 2017;151(1 Suppl):56–60. https://doi.org/10.1016/S0049-3848(17)30069-5.Search in Google Scholar
60. Erez, O, Mastrolia, SA, Thachil, J. Disseminated intravascular coagulation in pregnancy: insights in pathophysiology, diagnosis and management. Am J Obstet Gynecol 2015;213:452–63. https://doi.org/10.1016/j.ajog.2015.03.054.Search in Google Scholar PubMed
61. Schwickert, A, Chantraine, F, Ehrlich, L, Henrich, W, Muallem, MZ, Nonnenmacher, A, et al.. Maternal serum VEGF predicts abnormally invasive placenta better than NT-proBNP: a multicenter case-control study. Reprod Sci 2021;28:361–70. https://doi.org/10.1007/s43032-020-00319-y.Search in Google Scholar PubMed PubMed Central
62. Snir, A, Brenner, B, Paz, B, Ohel, G, Lanir, N. The role of fibrin matrices and tissue factor in early-term trophoblast proliferation and spreading. Thromb Res 2013;132:477–83. https://doi.org/10.1016/j.thromres.2013.08.023.Search in Google Scholar PubMed
63. Solomon, C, Collis, RE, Collins, PW. Haemostatic monitoring during postpartum haemorrhage and implications for management. Br J Anaesth 2012;109:851–63. https://doi.org/10.1093/bja/aes361.Search in Google Scholar PubMed PubMed Central
64. Guo, Z, Han, X, Zhang, H, Zheng, W, Yang, H, Ma, J. Association between pre-delivery coagulation indicators and invasive placenta accreta spectrum. Clin Appl Thromb Hemost 2022;28:107602962110705. https://doi.org/10.1177/10760296211070580.Search in Google Scholar PubMed PubMed Central
65. Cunningham, FG, Nelson, DB. Disseminated intravascular coagulation syndromes in obstetrics. Obstet Gynecol 2015;126:999–1011. https://doi.org/10.1097/aog.0000000000001110.Search in Google Scholar PubMed
66. Chen, Y, Wang, L, Bao, J, Sha, X, Cui, L, Huang, Q, et al.. Persistent hypoxia induced autophagy leading to invasiveness of trophoblasts in placenta accreta. J Matern Fetal Neonatal Med 2021;34:1297–303. https://doi.org/10.1080/14767058.2019.1635582.Search in Google Scholar PubMed
67. Jauniaux, E, Hussein, AM, Elbarmelgy, RM, Elbarmelgy, RA, Burton, GJ. Failure of placental detachment in accreta placentation is associated with excessive fibrinoid deposition at the utero-placental interface. Am J Obstet Gynecol 2022;226:243.e1–10. https://doi.org/10.1016/j.ajog.2021.08.026.Search in Google Scholar PubMed
68. Judy, AE, Lyell, DJ, Druzin, ML, Dorigo, O. Disseminated intravascular coagulation complicating the conservative management of placenta percreta. Obstet Gynecol 2015;126:1016–8. https://doi.org/10.1097/aog.0000000000000960.Search in Google Scholar PubMed
69. Al-Khan, A, Bulmer, JN, Chantraine, F, Chen, CP, Chen, Q, Collins, S, et al.. IFPA Meeting 2012 Workshop Report III: trophoblast deportation, gestational trophoblastic disease, placental insufficiency and fetal growth restriction, trophoblast over-invasion and accreta-related pathologies, placental thrombosis and fibrinolysis. Placenta 2013;34:S11–6. https://doi.org/10.1016/j.placenta.2012.11.018.Search in Google Scholar PubMed
70. Muñoz, M, Acheson, AG, Auerbach, M, Besser, M, Habler, O, Kehlet, H, et al.. International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia 2017;72:233–47. https://doi.org/10.1111/anae.13773.Search in Google Scholar PubMed
71. Mueller, MM, Van Remoortel, H, Meybohm, P, Aranko, K, Aubron, C, Burger, R, et al.. Patient blood management: recommendations from the 2018 frankfurt consensus conference. JAMA 2019;321:983–97. https://doi.org/10.1001/jama.2019.0554.Search in Google Scholar PubMed
72. Kaufner, L, von Heymann, C. AWMF Leitlinie 001-024l_S3_Praeoperative-Anaemie; 2018. [Online]. Available from: https://www.awmf.org/uploads/tx_szleitlinien/001-024l_S3_Praeoperative-Anaemie_2018-04-verlaengert.pdf.Search in Google Scholar
74. Surbek, D, Vial, Y, Girard, T, Breymann, C, Bencaiova, GA, Baud, D, et al.. Patient blood management (PBM) in pregnancy and childbirth: literature review and expert opinion. Arch Gynecol Obstet 2020;301:627–41. https://doi.org/10.1007/s00404-019-05374-8.Search in Google Scholar PubMed PubMed Central
76. Mauritz, AA, Dominguez, JE, Guinn, NR, Gilner, J, Habib, AS. Blood-conservation strategies in a blood-refusal parturient with placenta previa and placenta percreta. A A Case Rep 2016;6:111–3. https://doi.org/10.1213/xaa.0000000000000258.Search in Google Scholar
77. Harding, K, Holmes, A, Phillips, C, Lightfood, D, Osman, I, Black, M, et al.. Antenatal care for uncomplicated pregnancies, NICE Guidance, 2021 [Online]. Available from: https://www.nice.org.uk/guidance/ng201.Search in Google Scholar
78. Breymann, C, Honegger, C, Hösli, I, Surbek, D. Diagnosis and treatment of iron-deficiency anaemia in pregnancy and postpartum. Arch Gynecol Obstet 2017;296:1229–34. https://doi.org/10.1007/s00404-017-4526-2.Search in Google Scholar PubMed
79. Pavord, S, Myers, B, Robinson, S, Allard, S, Strong, J, Oppenheimer, C, et al.. UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol 2012;156:588–600. https://doi.org/10.1111/j.1365-2141.2011.09012.x.Search in Google Scholar PubMed
80. Hobson, SR, Kingdom, JC, Murji, A, Windrim, RC, Carvalho, JCA, Singh, SS, et al.. No. 383-Screening, diagnosis, and management of placenta accreta spectrum disorders. J Obstet Gynaecol Can 2019;41:1035–49. https://doi.org/10.1016/j.jogc.2018.12.004.Search in Google Scholar PubMed
81. Kaufner, L, Henkelmann, A, von Heymann, C, Feldheiser, A, Mickley, L, Niepraschk-von Dollen, K, et al.. Can prepartum thromboelastometry-derived parameters and fibrinogen levels really predict postpartum hemorrhage? J Perinat Med 2017;45:427–35. https://doi.org/10.1515/jpm-2016-0009.Search in Google Scholar PubMed
82. Karlsson, O, Jeppsson, A, Thornemo, M, Lafrenz, H, Rådström, M, Hellgren, M. Fibrinogen plasma concentration before delivery is not associated with postpartum haemorrhage: a prospective observational study. Br J Anaesth 2015;115:99–104. https://doi.org/10.1093/bja/aev039.Search in Google Scholar PubMed
83. Collins, PW, Lilley, G, Bruynseels, D, Laurent, DBS, Cannings-John, R, Precious, E, et al.. Fibrin-based clot formation as an early and rapid biomarker for progression of postpartum hemorrhage: a prospective study. Blood 2014;124:1727–36. https://doi.org/10.1182/blood-2014-04-567891.Search in Google Scholar PubMed
84. de Lange, NM, van Rheenen-Flach, LE, Lancé, MD, Mooyman, L, Woiski, M, van Pampus, EC, et al.. Peri-partum reference ranges for ROTEM(R) thromboelastometry. Br J Anaesth 2014;112:852–9. https://doi.org/10.1093/bja/aet480.Search in Google Scholar PubMed
85. Charbit, B, Mandelbrot, L, Samain, E, Baron, G, Haddaoui, B, Keita, H, et al.. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemostasis 2007;5:266–73. https://doi.org/10.1111/j.1538-7836.2007.02297.x.Search in Google Scholar PubMed
86. Bonhomme, F, Boehlen, F, Clergue, F, de Moerloose, P. Preoperative hemostatic assessment: a new and simple bleeding questionnaire. Can J Anesth/J Can Anesth 2016;63:1007–15. https://doi.org/10.1007/s12630-016-0688-9.Search in Google Scholar PubMed
87. Kahr, MK, Brun, R, Zimmermann, R, Franke, D, Haslinger, C. Validation of a quantitative system for real-time measurement of postpartum blood loss. Arch Gynecol Obstet 2018;298:1071–7. https://doi.org/10.1007/s00404-018-4896-0.Search in Google Scholar PubMed
88. Diaz, V, Abalos, E, Carroli, G. Methods for blood loss estimation after vaginal birth. Cochrane Database Syst Rev 2018;9:CD010980. https://doi.org/10.1002/14651858.CD010980.pub2.Search in Google Scholar PubMed PubMed Central
89. Bamberg, C, Niepraschk-von Dollen, K, Mickley, L, Henkelmann, A, Hinkson, L, Kaufner, L, et al.. Evaluation of measured postpartum blood loss after vaginal delivery using a collector bag in relation to postpartum hemorrhage management strategies: a prospective observational study. J Perinat Med 2015;44:433–9. https://doi.org/10.1515/jpm-2015-0200.Search in Google Scholar PubMed
90. Brecher, M, Monk, T, Goodnough, L. A standardized method for calculating blood loss. Transfusion 1997;37:1070–4. https://doi.org/10.1046/j.1537-2995.1997.371098016448.x.Search in Google Scholar PubMed
91. Eckerdal, P, Kollia, N, Löfblad, J, Hellgren, C, Karlsson, L, Högberg, U, et al.. Delineating the association between heavy postpartum haemorrhage and postpartum depression. Plos One 2016;11:e0144274. https://doi.org/10.1371/journal.pone.0144274.Search in Google Scholar PubMed PubMed Central
92. Muñoz, M, Stensballe, J, Ducloy-Bouthors, AS, Bonnet, MP, De Robertis, E, Fornet, I, et al.. Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. In: A NATA consensus statement. Milan, Italy: Blood Transfusion; 2019, vol. 17:112–36 pp.Search in Google Scholar
93. Prick, B, Jansen, A, Steegers, E, Hop, W, Essink-Bot, M, Uyl-de Groot, C, et al.. Transfusion policy after severe postpartum haemorrhage: a randomised non-inferiority trial. BJOG An Int J Obstet Gynaecol 2014;121:1005–14. https://doi.org/10.1111/1471-0528.12531.Search in Google Scholar PubMed
94. American College of Obstetricians and Gynecologists. ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 76, October 2006: postpartum hemorrhage. Obstet Gynecol 2006;108:1039–47. https://doi.org/10.1097/00006250-200610000-00046.Search in Google Scholar PubMed
95. Patil, V, Ratnayake, G, Fastovets, G, Wijayatilake, DS. Clinical pearls part 3: anaesthetic management of abnormally invasive placentation. Curr Opin Anaesthesiol 2018;31:280–9. https://doi.org/10.1097/aco.0000000000000601.Search in Google Scholar PubMed
97. Gattas, DJ, Dan, A, Myburgh, J, Billot, L, Lo, S, Finfer, S, et al.. CHEST Management Committee. Fluid resuscitation with 6% hydroxyethyl starch (130/0.4 and 130/0.42) in acutely ill patients: systematic review of effects on mortality and treatment with renal replacement therapy. Intensive Care Med 2013;39:558–68. https://doi.org/10.1007/s00134-013-2840-0.Search in Google Scholar PubMed
98. Hunsicker, O, Francis, RC. Assessment of hemodynamic efficacy and safety of 6% hydroxyethyl starch 130/0.4 vs. 0.9% NaCl fluid replacement in patients with severe sepsis: how to guide fluid therapy? Crit Care 2012;16:464. https://doi.org/10.1186/cc11836.Search in Google Scholar PubMed PubMed Central
99. Eur. Med. Agency. Hydroxyethyl-starch solutions (HES) should no longer be used in patients with sepsis or burn injuries critically ill – CMDh endorses PRAC recommendations; 2013 [Online]. Available from: https://www.ema.europa.eu/en/news/hydroxyethyl-starch-solutions-hes-should-no-longer-be-used-patients-sepsis-burn-injuries-critically.Search in Google Scholar
100. Mardel, SN, Saunders, FM, Allen, H, Menezes, G, Edwards, CM, Ollerenshaw, L, et al.. Reduced quality of clot formation with gelatin-based plasma substitutes. Br J Anaesth 1998;80:204–7. https://doi.org/10.1093/bja/80.2.204.Search in Google Scholar PubMed
101. Kozek-Langenecker, SA, Ahmed, AB, Afshari, A, Albaladejo, P, Aldecoa, C, Barauskas, G, et al.. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology First update 2016. Eur J Anaesthesiol 2017;34:332–95. https://doi.org/10.1097/eja.0000000000000630.Search in Google Scholar
102. Khan, KS, Moore, P, Wilson, M, Hooper, R, Allard, S, Wrench, I, et al.. A randomised controlled trial and economic evaluation of intraoperative cell salvage during caesarean section in women at risk of haemorrhage: the SALVO (cell SALVage in Obstetrics) trial. Health Technol Assess 2018;22:1–88. https://doi.org/10.3310/hta22020.Search in Google Scholar PubMed PubMed Central
104. Rogers, WK, Wernimont, SA, Kumar, GC, Bennett, E, Chestnut, DH. Acute hypotension associated with intraoperative cell salvage using a leukocyte depletion filter during management of obstetric hemorrhage due to amniotic fluid embolism. Anesth Analg 2013;117:449–52. https://doi.org/10.1213/ane.0b013e3182938079.Search in Google Scholar PubMed
106. Simonazzi, G, Bisulli, M, Saccone, G, Moro, E, Marshall, A, Berghella, V. Tranexamic acid for preventing postpartum blood loss after cesarean delivery: a systematic review and meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand 2016;95:28–37. https://doi.org/10.1111/aogs.12798.Search in Google Scholar PubMed
107. Sentilhes, L, Sénat, MV, Le Lous, M, Winer, N, Rozenberg, P, Kayem, G, et al.. Tranexamic acid for the prevention of blood loss after cesarean delivery. N Engl J Med 2021;384:1623–34. https://doi.org/10.1056/nejmoa2028788.Search in Google Scholar
108. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017;389:2105–16. https://doi.org/10.1016/S0140-6736(17)30638-4.Search in Google Scholar
109. Schlembach, D, Helmer, H, Henrich, W, von Heymann, C, Kainer, F, Korte, W, et al.. Peripartum haemorrhage, diagnosis and therapy. Guideline of the DGGG, OEGGG and SGGG (S2k level, AWMF registry No. 015/063, march 2016). Geburtshilfe Frauenheilkd 2018;78:382–99. https://doi.org/10.1055/a-0582-0122.Search in Google Scholar PubMed PubMed Central
110. World Health Organization. WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage; 2017. [Online]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK493081/.Search in Google Scholar
111. Mavrides, E, Allard, S, Chandraharan, E, Collins, P, Green, L, Hunt, BJ, et al.. Prevention and management of postpartum haemorrhage: green-top guideline no. 52. BJOG 2017;124:e106–49. https://doi.org/10.1111/1471-0528.14178.Search in Google Scholar PubMed
113. Bates, SM, Rajasekhar, A, Middeldorp, S, McLintock, C, Rodger, MA, James, AH, et al.. American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy. Blood Adv 2018;2:3317–59. https://doi.org/10.1182/bloodadvances.2018024802.Search in Google Scholar PubMed PubMed Central
114. Samama, CM, Albaladejo, P, Laversin, S, Marret, E. Prévention de la maladie thromboembolique veineuse périopératoire et obstétricale. Ann Fr Anesth Reanim 2005;24:853–61. https://doi.org/10.1016/j.annfar.2005.06.011.Search in Google Scholar PubMed
115. Bates, SM, Greer, IA, Middeldorp, S, Veenstra, DL, Prabulos, AM, Vandvik, PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy. Chest 2012;141:e691S–736S. https://doi.org/10.1378/chest.11-2300.Search in Google Scholar PubMed PubMed Central
116. Nelson-Piercy, C, MacCallum, P, Mackillop, L. Reducing the risk of venous thromboembolism during pregnancy and the puerperium green-top guideline no. 37a April 2015. London, UK: Royal College of Obstetricians & Gynaecologists; 2015.Search in Google Scholar
117. Encke, A, Haas, S, Kopp, I, Abholz, HH, Bode, C, Bootz, F, et al.. S3-Leitlinie prophylaxe der venösen Thromboembolie (VTE), 2. Komplett überarbeitete Auflage 2015;238:95–9.Search in Google Scholar
118. Sang, CQ, Zhao, N, Zhang, J, Wang, SZ, Guo, SL, Li, SH, et al.. Different combination strategies for prophylaxis of venous thromboembolism in patients: a prospective multicenter randomized controlled study. Sci Rep 2018;8:8277. https://doi.org/10.1038/s41598-018-25274-2.Search in Google Scholar PubMed PubMed Central
119. Feng, JP, Xiong, YT, Fan, ZQ, Yan, LJ, Wang, JY, Gu, ZJ. Efficacy of intermittent pneumatic compression for venous thromboembolism prophylaxis in patients undergoing gynecologic surgery: a systematic review and meta-analysis. Oncotarget 2017;8:20371–9. https://doi.org/10.18632/oncotarget.13620.Search in Google Scholar PubMed PubMed Central
120. Kakkos, SK, Caprini, JA, Geroulakos, G, Nicolaides, AN, Stansby, G, Reddy, DJ. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. In: Cochrane database of systematic reviews. Chichester, UK: John Wiley & Sons; 2008. [Online].10.1002/14651858.CD005258.pub2Search in Google Scholar PubMed
121. Sabri, S, Roberts, VC, Cotton, LT. Prevention of early postoperative deep vein thrombosis by intermittent compression of the leg during surgery. BMJ 1971;4:394–6. https://doi.org/10.1136/bmj.4.5784.394.Search in Google Scholar PubMed PubMed Central
The online version of this article offers supplementary material (https://doi.org/10.1515/jpm-2022-0233).
© 2022 the author(s), published by De Gruyter, Berlin/Boston
This work is licensed under the Creative Commons Attribution 4.0 International License.