Bonanni Giulia, Lopez-Giron Maria C, Allen Lisa, Fox Karin, Silver Robert M, Hobson Sebastian R, Nieto-Calvache Albaro J, Collins Sally, Wielgos Miroslaw, Jauniaux Eric, Bartels Helena C, Sentilhes Loïc, Kingdom John, Chantraine Frederic, Wax Joseph R, Cahill Alison, Abuhamad Alfred, de-Campos Diogo Ayres, Aagaard Kjersti, Shamshirsaz Amir A, Shainker Scott A, Shamshirsaz Alireza A
Fetal Care and Surgery Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
Department of Women, Children, and Public Health Sciences, IRCCS Agostino Gemelli University Polyclinic Foundation, Catholic University of the Sacred Heart, Rome, Italy.
JAMA Netw Open. 2025 Jul 1;8(7):e2521909. doi: 10.1001/jamanetworkopen.2025.21909.
Placenta accreta spectrum (PAS) is a complex, life-threatening condition that demands a multidisciplinary approach involving obstetrics, maternal-fetal medicine, and various surgical and medical specialties. Effective management relies on multispecialty collaboration and consensus, supported by standardized protocols, to optimize outcomes, guide informed clinical decisions, and mitigate the risks associated with PAS.
To examine clinical practice guidelines for PAS inclusive of high-income countries and low- to middle-income countries (LMICs) identifying areas of consensus and gaps in guidance.
A comprehensive search of PubMed, GIN Library, and ECRI Guidelines Trust identified all PAS-related clinical practice guidelines published from January 1, 2014, to January 31, 2024. Additional searches included professional societies' designated websites and cited references. Two independent reviewers screened the guidelines, resolving conflicts through cross-referencing. Initially, 2 independent reviewers provided structured review and feedback to refine, correct, or highlight areas of consensus, disagreement, or insufficient evidence. Any instances of nonagreement were adjudicated by majority panel agreement, arising from a panel of 15 to 18 experts, all authors of PAS guidelines. Agreement scores for each recommendation area (eg, epidemiology, diagnosis, and antenatal management) were categorized as high agreement (≥75%), poor consensus (<50% or ≥30% insufficient evidence), and high levels of insufficient evidence (≥50% of recommendations with insufficient evidence) based on a priori score criteria.
A total of 14 guidelines from 18 articles from national and international societies were included. High agreement was noted in areas such as specialized expertise (100%), antenatal management (88.9%), diagnosis (76.9%), and epidemiology (75.0%). Poor consensus characterized cesarean hysterectomy management (38.5% insufficient evidence and 23.0% disagreement), conservative techniques (33.3% insufficient evidence and 11.1% disagreement), and fertility counseling (30.0% insufficient evidence and 10.0% disagreement). Despite the high risk of anemia, consensus was lacking on iron supplementation strategies. Recommendations for thromboembolism prevention varied, with some guidelines favoring pharmacologic interventions and others advocating for nonpharmacologic measures. Hemorrhage management and postnatal management recommendations, including iron supplementation and thromboembolism prevention, were characterized by high levels of insufficient evidence (55.6% and 57.1%, respectively). Only 1 article (5.6%) specifically addressed LMICs, highlighting substantial underrepresentation.
This systematic review of PAS guidelines identified significant discrepancies and insufficient evidence in key aspects of care. The findings underscore the urgent need for further research and quality measures to enhance standardized approaches and improve patient outcomes. The limited availability of recommendations applicable to LMICs highlights the critical need for tailored guidance that accounts for resource constraints and clinical access challenges unique to these settings.
胎盘植入谱系疾病（PAS）是一种复杂的、危及生命的疾病，需要多学科方法，涉及产科、母胎医学以及各种外科和医学专科。有效的管理依赖于多专业协作和共识，并以标准化方案为支持，以优化治疗结果、指导明智的临床决策并降低与PAS相关的风险。
审查包括高收入国家和低收入及中等收入国家（LMICs）在内的PAS临床实践指南，确定共识领域和指导方面的差距。
全面检索PubMed、GIN图书馆和ECRI指南信托库，以确定2014年1月1日至2024年1月31日期间发布的所有与PAS相关的临床实践指南。其他检索包括专业协会指定的网站和引用的参考文献。两名独立评审员筛选指南，通过交叉引用解决冲突。最初，两名独立评审员提供结构化审查和反馈，以完善、纠正或突出共识、分歧或证据不足的领域。任何不一致的情况均由15至18名专家组成的小组以多数意见裁定，这些专家均为PAS指南的作者。根据预先设定的评分标准，每个推荐领域（如流行病学、诊断和产前管理）的一致性得分分为高一致性（≥75%）、低共识（<50%或≥30%证据不足）和高证据不足水平（≥50%的推荐证据不足）。
纳入了来自国家和国际协会的18篇文章中的14项指南。在专业知识（100%）、产前管理（88.9%）、诊断（76.9%）和流行病学（75.0%）等领域发现了高度一致性。剖宫产子宫切除术管理（38.5%证据不足和23.0%分歧）、保守技术（33.3%证据不足和11.1%分歧）和生育咨询（30.0%证据不足和10.0%分歧）的共识较低。尽管贫血风险很高，但在铁补充策略上缺乏共识。血栓栓塞预防的建议各不相同，一些指南倾向于药物干预，另一些则主张非药物措施。出血管理和产后管理建议，包括铁补充和血栓栓塞预防，证据不足的水平较高（分别为55.
