In this episode, Drs. Mark Hoffman and Amy Park invite Dr. Brett Einerson to speak about the diagnosis and management of placenta accreta spectrum (PAS) disorders.

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SHOW NOTES

Dr. Einerson is an assistant professor of OB/GYN in the division of Maternal Fetal Medicine (MFM) and Director of the Utah Placenta Accreta Program at the University of Utah, one of the busiest referral programs for PAS in the United States.

The doctors first discuss Dr. Einerson’s career path toward specialization in PAS. During his MFM fellowship in Utah, he encountered many difficult cases of PAS. He has had patients who have delivered 6-10 babies, and in Utah, family size is almost twice as large as the national average. PAS studies from overseas show that the median number of C-sections is 0 to 1 while Dr. Einerson's average accreta patient has had 2-3 prior C-sections. Given that there was not alot of research informing treatment for patients with PAS, Dr. Einerson was motivated to fill the void and embraced the diagnostic and surgical challenges associated with PAS.

The physicians go on to review the grading and classification of PAS. Although the traditional nomenclature uses accreta, increta, and percreta, pathologists and clinicians are noting that these descriptions of placenta accreta may not fully capture what the disease looks like in the hands of a surgeon. Now, there is increasing use of FIGO clinical grades 1, 2, and 3, which describes how PAS looks at the time of delivery. FIGO stage 1 involves attachment with no other changes, 2 describes vascular changes appearing on the outside of the uterus but no placental extension into the serosa, and stage 3 involves placenta that extends to the serosa with significant vascular changes.

Dr. Einerson goes on to discuss the difficulties of diagnosing PAS. Early PAS diagnosis starts with vigilant screening. Ultrasound is an important tool for screening, however even more critical is identifying patient risk factors such as prior C-sections and low-lying placenta. Caesarean scar pregnancy (CSP) and early placenta accreta spectrum are overlapping pathologies that have almost identical risk factors and very similar appearances. Dr. Einerson believes that most CSPs are early accretas. He advocates for high suspicion in patients with risk factors and a low threshold for referral to a specialty center for a second opinion.

Next, Dr. Einerson discusses what happens after PAS is diagnosed. His recommendation for black-and-white CSP deep within the scar at less than 10 weeks is pregnancy termination. The outcomes of early CSP treatment are much better than waiting for an ultrasound at 11 weeks, at which point the patient already has accreta and hysterectomy is almost unavoidable. Counseling patients with borderline PAS is much more difficult, according to Dr. Einerson. For these patients, overpreparation is key. This is likely to involve monthly ultrasounds as well as introducing the patients early on to the anesthesiology team, pelvic surgeons, and labor and delivery triage in case of a bleeding event. Unfortunately, patients may have to spend most of their pregnancy in the hospital.

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RESOURCES

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