Care Pathways and Services

PAS Centres provide specialised treatment as part of a regional network arrangement with local maternity services in accordance with predefined referral guidelines and protocols.   

 

Elective pathway  

Women with a confirmed diagnosis of PAS as outlined in Annex 1 must be referred to the PAS Centre. Women reviewed in the PAS Centre and assessed as being at high risk or confirmed with PAS must be delivered by the MDT in the PAS Centre. The PAS Centre must ensure that women and birthing people who require treatment are fully informed of the risks, the treatment and the post-operative care and are fully consented.

(Insert Annex 1)   

 

Non-elective pathway   

If at the time of an elective repeat caesarean section, where both mother and baby are stable, it is immediately apparent that abnormally invasive placenta is present on opening the abdomen, delivery should be delayed until the appropriate staff and resources have been assembled and adequate blood products are available. This may involve the closure of the maternal abdomen and urgent transfer to the AIP Centre. These cases will be managed according to a predefined protocol. If emergency delivery is required, the baby may be delivered via a uterine incision which avoids the placenta. If the mother remains stable, the hysterotomy may be closed leaving the placenta in situ and the patient transferred urgently to the designated AIP Centre. If the mother is unstable, definitive treatment must occur without transfer to the AIP Centre. If the AIP is diagnosed after vaginal delivery the cases will be dealt with on an individual basis following discussion with the AIP centre in accordance with predefined guidance and protocols.  

 

Clinical classification of PAS at delivery – International Federation of Gynaecology and Obstetrics (FIGO)    

The following FIGO grades are used to classify the clinical diagnosis of PAS at delivery: -   

Grade 1: Abnormally adherent placenta (placenta adherent or accreta)   

Grade 2: Abnormally invasive placentation (placenta increta)   

Grade 3a, b and c: Abnormally invasive placentation (placenta percreta)   

A full description of the FIGO classification is outlined in Annex 2 (insert)  

 

Diagnostic service   

An expert-led diagnostic service (usually ultrasound-based but may include magnetic resonance imaging: MRI) to diagnose PAS and assess the level of risk posed by the PAS. Experienced surgical team working to predefined intra-operative criteria for clinical confirmation of PAS. Pathological expertise working to predefined criteria for histological confirmation of the diagnosis.  

 

Multidisciplinary Team   

• Named expert PAS diagnostic specialists (usually foetal medicine doctors or radiologists)  

• Named obstetricians with experience in high-risk intrapartum care including massive obstetric haemorrhage (MOH)  

• Named specialist surgeons with experience in complex pelvic surgery (usually gynae oncologists)   

• Named consultant urologists experienced in bladder and ureteric reconstruction   

• Named obstetric anaesthetists with experience in high-risk intrapartum care  

• Named consultant neonatologist  

 

Interdependent Services    

• Haematology team (consultant and technician)   

• Perinatal pathology   

• On-site level 3 neonatal critical care  

• On-site fetal medicine services  

• On-site adult intensive care unit  

• Midwifery staff trained in postnatal care of the seriously ill woman