DOI: 10.1002/ijgo.

12406

FIGO GUIDELINES

FIGO consensus guidelines on placenta accreta spectrum

Eric Jauniaux1,* | Diogo Ayres-de-Campos2 | for the FIGO Placenta Accreta Diagnosis
and Management Expert Consensus Panela

1
EGA Institute for Women’s Health, Faculty of Population Health Sciences, University College London, London, UK
2
Medical School, Santa Maria Hospital, University of Lisbon, Lisbon, Portugal

*Correspondence
Eric Jauniaux, EGA Institute for Women’s Health, Faculty of Population Health Sciences, University College London, London, UK.
Email: [Link]@[Link]

Developed by the FIGO Safe Motherhood and Newborn Health Committee; coordinated by Eric Jauniaux, lead developer and corresponding author.
★
The views expressed in this document reflect the opinion of the individuals and not necessarily those of the institutions that they represent.
a
FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel members are listed at the end of the paper.

Placenta accreta is a histopathologic term for a condition first described has been reported in most medium-­ and high-­income countries.5 It
in 1937 by obstetrician Frederick C. Irving and pathologist Arthur T. should be noted that changes in the incidence of PAS disorders sec-
1
Hertig at the Boston Lying-­In Hospital. Their study described 18 new ondary to increased cesarean delivery rates may be delayed by up to
cases of placenta accreta presenting with “the abnormal adherence 10 years, depending on birth rates and interpregnancy intervals, which
of the afterbirth in whole or in parts to the underlying uterine wall.” vary in different parts of world. For the USA alone, it was estimated in
Attempts to remove the placenta led to major postpartum hemor- 2011 that, if the cesarean delivery rate continues to increase as it has
rhage that required emergency or secondary hysterectomy to control done before, by 2020 the cesarean delivery rate will be over 50% and
the bleeding in 14 cases. The histologic criterion used for their diag- there will be an additional 4504 annual cases of PAS disorders and 130
nosis of accreta placentation was the complete or partial absence of maternal deaths due to its complications.6 Thus, it is not surprising
the decidua basalis—a sign that is still used today in many clinical and that 80 years later, more than 90% of women presenting with a pla-
2
histopathological studies. There were case reports published in the centa accreta have had at least one prior cesarean delivery.5–9
decade before Irving and Hertig published their series but the detailed PAS disorders were first defined by Luke et al.3 to include both
description of the cases included in their study makes it the first piv- abnormally adherent and invasive placentas. Three categories are now
otal publication on placenta accreta. considered: (1) adherent placenta accreta, also described by pathol-
Irving and Hertig described all their cases as “vera” or “adherent,” ogists as “placenta creta, vera or adherenta” when the villi simply
where the villi were attached to the surface of the myometrium without adhere to the myometrium; (2) placenta increta, when the villi invade
invading it. They discussed the possibility of deeper penetration of the the myometrium; and (3) placenta percreta, when villi invade the full
villi into the myometrium, but none of their cases or those described in thickness of the myometrium including the uterine serosa and some-
their literature review presented with histologic features of myometrial times adjacent pelvic organs.3–5 Variations in the lateral extension of
invasion by placental tissue. Only one of their cases and another from myometrial invasion also divide PAS disorders into the focal, partial,
their literature review had undergone a prior cesarean delivery. More or total categories, depending on the number of placental cotyledons
than 95% of the cases reported in their paper had a history of man- involved. Finally, the degree of villous adhesion or invasion is rarely
ual removal, curettage, and/or endometritis. Thirty years later, similar uniform throughout the placenta, limiting the accuracy of microscopic
reviews of the literature reported a history of one or more cesarean diagnosis when the whole uteroplacental interface is not available
deliveries in more than a quarter of women presenting with placenta for analysis.3 This terminology describes accurately the spectrum of
accreta, as well as the occurrence of the more invasive forms.3,4 Over accreta placentation; however, an increasing number of clinicians have
the last 40 years, cesarean delivery rates around the world have risen started using an archaic “Victorian” etymology, i.e. “morbidly adherent
from less than 10% to over 30%, and almost simultaneously a 10-­fold placenta” (MAP), to describe the different grades of accreta placen-
increase in the incidence of placenta accreta spectrum (PAS) disorders tation. This is confusing and misleading, as technically it excludes the

Int J Gynecol Obstet 2018; 140: 261–264 [Link]/journal/ijgo

invasive forms of PAS disorders. Other terms used include “placental There is also wide variation globally on the management of PAS
adhesive disorders,” “abnormally adherent placenta,” “abnormal pla- disorders, with some centers opting for a radical approach, whereas
cental adherence,” and “advanced invasive placentation”, all of which others have proposed a range of conservative approaches.20,21 Over
are exclusive rather then inclusive and ignore both clinical and patho- the last decade, there has been an increasing number of case reports,
logical diagnostic standards. cohort studies, modeling work, and systematic reviews on the diag-
It is essential to evaluate epidemiological data and outcome nosis and management of PAS disorders. The American College of
based on clear diagnostic criteria and this is only possible if the Obstetricians and Gynecologists (ACOG) and the Royal College of
same starting points are used. It would be considered inadequate Obstetricians and Gynaecologists (RCOG) have published guidelines
if an invasive tumor of the uterine cervix or any other organs, such with evidence-­based approaches for optimized clinical management
as the liver, was encumbered with a similar plethora of inaccurate of PAS disorders.22,23 However, these guidelines are designed for the
terminology. Therefore, when evaluating accreta placentation to specific needs of local healthcare environments. Again the success
obtain accurate epidemiologic data there is a need for a standardized rate and outcome of each procedure is directly linked to the degree
approach. The term PAS disorders proposed by Luke et al.3 provides of placental invasiveness in depth and laterally. Thus the evaluation
standardized terminology, which covers the depth of villous inva- of the efficacy and safety of a management method depends on the
siveness, lateral extension of accreta placentation, and the possible accuracy of the clinical diagnosis and confirmation of the depth of
combination of different depths of invasiveness in the same placenta placental invasiveness should be confirmed by adequate pathological
accreta. Thus, for the purposes of simplicity and clarity, the present examination. Limited data exist from low-­income countries, but with
guidelines use PAS disorders to describe the different pathological cesarean deliveries increasing globally, the prevalence and incidence
forms of accreta placentation. of PAS disorders are rapidly becoming a global issue and an interna-
There is increasing evidence that the management of women tional approach to this complex obstetric condition is needed.
with PAS disorders by multidisciplinary teams in centers of excel- The present guidelines were developed by the FIGO Safe
lence decreases maternal morbidity and mortality when compared Motherhood and Newborn Health Committee. In September 2016, all
with standard obstetric care.10–13 Adequate multidisciplinary team national member societies of FIGO were contacted by email and asked
management of PAS disorders can only be arranged when the diag- to appoint one expert with wide knowledge of the scientific literature
nosis is made prenatally and the involvement of pelvic organs and on PAS disorders, good written and spoken English, and availability to
tissues around the uterus has been accurately defined. New imaging provide prompt written feedback by email. A total of 34 experts were
techniques have played an increasing role in the prenatal diagno- nominated for the consensus panel. Geographical representation of
sis of this condition, facilitating prenatal management and allowing the members of the consensus panel is given in Figure 1.
programmed delivery tailored for the individual need of the patient The process of guideline development and consensus recommen-
14
in the adequate environment. Ultrasound imaging is the most dations started in January 2017 and included three rounds for each
commonly used technique to diagnose PAS disorders prenatally. chapter. Each round started with a draft version of each chapter, which
However, the terminology employed to describe the different cat- was sent by email to the panel members. Feedback from the panel was
egories of ultrasound signs was also heterogeneous and complex. received within a timeframe of 3 weeks. The authors considered all
Together with the lack of detailed histopathologic correlations in comments and a revised manuscript was produced for the next round.
most studies, this may explain why no single ultrasound sign or set After the three-­round process was complete, the members of the
combination of ultrasound signs has been found to be specific for panel were asked to read the final version and provide written consent
the depth of abnormal placentation, and accurate for the differen- for their name to be included in the panel list for that chapter. The
15–17
tial diagnosis between adherent and invasive placentation. The consensus process for the four chapters was concluded in July 2017.
European Working Group on Abnormally Invasive Placenta (EW-­ The aim of these consensus guidelines is to improve the diagnosis
AIP) and the AIP international expert group have recently proposed and management of PAS disorders throughout the world, thus reduc-
a standardized description of ultrasound signs used in the diagnosis ing the burden of maternal mortality and long-­term sequelae that arise
18,19
of PAS disorders. from this disease.
Ultrasound signs of adherent and invasive placentation vary with
gestational age and depend on the thickness and composition of the
CO NS ENS U S PANEL
placental bed, number of prior uterine scars, presence of scar defects
between pregnancies, depth of invasion, and the lateral extension of Greg Duncombe (Australia and New Zealand), Philipp Klaritsch
the villous tissue.17 Prospective studies providing correlation between (Germany), Frédéric Chantraine (Belgium), John Kingdom (Canada),
prenatal imaging findings, clinical data at delivery, and histopathology Lene Grønbeck (Denmark), Kristiina Rull (Estonia), Balkachew Nigatu
are essential to improve the screening, diagnosis, and management of (Ethiopia), Minna Tikkanen (Finland), Loïc Sentilhes (France), Tengiz
PAS disorders. Research protocols should be standardized and used Asatiani (Georgia), Wing-­Cheong Leung (Hong Kong), Taghreed
by both clinicians and pathologists to better define the ultrasound AIhaidari (Iraq), Donal Brennan (Ireland), Eiji Kondoh (Japan), Jeong-­In
signs that may be useful in the screening of women at high risk for Yang (South Korea), Muhieddine Seoud (Lebanon), Ravindran
PAS disorders. Jegasothy (Malaysia), Salvador Espino y Sosa (Mexico), Benoit Jacod
Jauniaux ET AL. | 263

FIGURE 1 Geographical representation of the members of the Consensus Panel.

(Netherlands), Francesco D’Antonio (Norway), Nusrat Shah (Pakistan), eds. Textbook of Caesarean Section. Oxford: Oxford University Press;
Dorota Bomba-­Opon (Poland), Diogo Ayres-­de-­Campos (Portugal), 2016:1–8.
9. Jauniaux E, Bhide A, Wright JD. Placenta accreta. In: Gabbe SG, Niebyl
Katarina Jeremic (Serbia), Tan Lay Kok (Singapore), Priya Soma-­Pillay
JR, Simpson JL, Landon M, Galan H, Jauniaux E, Driscoll DA, Berghella
(South Africa), Nataša Tul Mandić (Slovenia), Pelle Lindqvist (Sweden), V, Grobman WA, eds. Obstetrics: Normal and Problem Pregnancies, 7th
Thora Berglind Arnadottir (Sweden), Irene Hoesli (Switzerland), Unnop edn. Philadelphia: Elsevier; 2016:456–466.
Jaisamrarn (Thailand), Amal Al Mulla (United Arab Emirates), Stephen 10. Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases
of placenta accreta managed by a multidisciplinary care team compared
Robson (UK), Rafael Cortez (Venezuela).
with standard obstetric care. Obstet Gynecol. 2011;117:331–337.
11. Chantraine F, Braun T, Gonser M, Henrich W, Tutschek B. Prenatal
diagnosis of abnormally invasive placenta reduces maternal peri-
CO NFLI CTS OF I NTE RE S T
partum hemorrhage and morbidity. Acta Obstet Gynecol Scand.
The authors have no conflicts of interest to declare. 2013;92:439–444.
12. Silver RM, Fox KA, Barton JR, et al. Center of excellence for placenta
accreta. Am J Obstet Gynecol. 2015;212:561–568.
13. Shamshirsaz AA, Fox KA, Salmanian B, et al. Maternal morbidity in
REFERENCES
patients with morbidly adherent placenta treated with and with-
1. Irving FC, Hertig AT. A study of placenta accreta. Surg Gynec Obstet. out a standardized multidisciplinary approach. Am J Obstet Gynecol.
1937;64:178–200. 2015;212(218):e1–e9.
2. Benirschke K, Burton GJ, Baergen RN. Pathology of the Human 14. Jauniaux E, Bhide A, Kennedy A, Woodward P, Hubinont C; for the
Placenta, 6th edn. Berlin: Springer-Verlag; 2012. FIGO Placenta Accreta Diagnosis and Management Expert Consensus
3. Luke RK, Sharpe JW, Greene RR. Placenta accreta: The adherent or Panel. FIGO consensus guidelines on placenta accreta spectrum dis-
invasive placenta. Am J Obstet Gynecol. 1966;95:660–668. orders: Prenatal diagnosis and screening. Int J Gynecol Obstet. 2018;
4. Fox H. Placenta accreta: 1945-­1969. Obstet Gynecol Survey. 140:274–280.
1972;27:475–490. 15. Jauniaux E, Collins SL, Jurkovic D, Burton GJ. Accreta placentation:
5. Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. A systematic review of prenatal ultrasound imaging and grading of
The effect of cesarean delivery rates on the future incidence of pla- villous invasiveness. Am J Obstet Gynecol. 2016;215:712–721.
centa previa, placenta accreta, and maternal mortality. J Matern Fetal 16. Jauniaux E, Bhide A. Prenatal ultrasound diagnosis and outcome of
Neonatal Med. 2011;24:1341–1346. placenta previa accreta after caesarean delivery: A systematic review
6. Jauniaux E, Chantraine F, Silver RM, Langhoff-Roos J; for the FIGO and meta-­analysis. Am J Obstet Gynecol. 2017;217:27–36.
Placenta Accreta Diagnosis and Management Expert Consensus 17. Jauniaux E, Collins SL, Burton GJ. Placenta accreta spectrum:
Panel. FIGO consensus guidelines on placenta accreta spectrum dis- Pathophysiology and evidence-­based anatomy for prenatal ultrasound
orders: Epidemiology. Int J Gynecol Obstet. 2018;140:265–273. imaging. Am J Obstet Gynecol. 2018. pii: S0002-9378(17)30731-7.
7. Jauniaux E, Jurkovic D. Placenta accreta: Pathogenesis of a 20th cen- [Link] [Epub ahead of print].
tury iatrogenic uterine disease. Placenta. 2012;33:244–251. 18. Collins SL, Ashcroft A, Braun T, et al. Proposal for standardized ultra-
8. Jauniaux E, Grobmann W. Caesarean section: Introduction to the sound descriptions of abnormally invasive placenta (AIP). Ultrasound
“World’s No. 1” Surgical Procedure. In: Jauniaux E, Grobman W, Obstet Gynecol. 2016;47:271–275.
264 | Jauniaux ET AL.

19. Alfirevic Z, Tang A-W, Collins SL, Robson SC, Palacios-Jaraquemada 21. Sentilhes L, Kayem G, Chandraharan E, Palacios-Jaraquemada J,
J; Ad-hoc International AIP Expert Group. Pro forma for ultra- Jauniaux E; for the FIGO Placenta Accreta Diagnosis and Management
sound reporting in suspected abnormally invasive placenta (AIP): Expert Consensus Panel. FIGO consensus guidelines on placenta
An international consensus. Ultrasound Obstet Gynecol. 2016;47: accreta spectrum disorders: Conservative management. Int J Gynecol
276–278. Obstet. 2018;140:291–298.
20. Allen L, Jauniaux E, Hobson S, Paillon-Smith J, Belfort MA; for the 22. Committee on Obstetric Practice. Committee opinion no. 529:
FIGO Placenta Accreta Diagnosis and Management Expert Consensus Placenta accreta. Obstet Gynecol. 2012;120:207–211.
Panel. FIGO consensus guidelines on placenta accreta spectrum dis- 23. Royal College of Obstetricians and Gynaecologists. Placenta praevia,
orders: Nonconservative surgical management. Int J Gynecol Obstet. placenta praevia accreta and vasa praevia: diagnosis and manage-
2018;140:281–290. ment. Green–top guideline No. 27. London: RCOG; 2011.