top of page

BackTable / OBGYN / Article

The Greater Impact of Placenta Accreta Spectrum (PAS) on Quality of Life

Author Melissa Malena covers The Greater Impact of Placenta Accreta Spectrum (PAS) on Quality of Life on BackTable OBGYN

Melissa Malena • Jul 20, 2023 • 35 hits

Placenta accreta spectrum (PAS) is an uncommon and complex diagnosis that requires the collaboration of specialities to best care for patients. Regionalization of care allows for a team of specialized experts to treat PAS cases regularly, as opposed to a general practitioner treating one case a year. This experience mitigates stress for both the team and the patients. According to OBGYN Dr. Brett Einerson, the stress and trauma of PAS on patients is often overlooked, with many patients experiencing PTSD-like symptoms after delivery. To best manage PAS, Dr. Einerson calls for a multidisciplinary team, the regionalization of expertise, a continuation of care postpartum, and a focus on accessibility of care. This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable OBGYN Brief

• An interdisciplinary team with experience and familiarity with the imaging, surgery, and pathology of PAS cases are crucial for successful management.

• Regionalization of care may improve outcomes due to the accumulated experience and expertise at high-volume centers.

• Formalized communication methods, dedicated specialists and constantly having a back up team prepared are required to build an effective program for PAS treatment.

• Placenta accreta spectrum patients undergoing hysterectomy have two to five times the risk of experiencing pelvic pain, anxiety, depression, and postpartum grief, resulting in decreased quality of life. The current practice for caring for PAS patients is growing to include not just the physical, but also the psychological and emotional well-being of the patient.

The Greater Impact of Placenta Accreta Spectrum (PAS) on Quality of Life

Table of Contents

(1) Multidisciplinary Approach to Placenta Accreta Spectrum (PAS) Treatment

(2) Regionalization of Care in Placenta Accreta Spectrum

(3) Beyond the Physical: The Psychological Impact of Placenta Accreta Spectrum (PAS)

Multidisciplinary Approach to Placenta Accreta Spectrum (PAS) Treatment

With the increase in C-section scar pregnancies and the associated complexities of managing these cases, a pivotal question is raised about which specialty should take the lead in handling them. Dr. Einerson believes that it should be a shared responsibility, advocating for an interdisciplinary approach involving OB-GYNs, radiologists, anesthesiologists, pathologists, and various subspecialists. He highlights the importance of having a local champion in institutions treating PAS cases. His personal journey that led into specializing in PAS was greatly influenced by participating and observing numerous PAS cases during his fellowship and credits his team for their support in managing these complex cases. Dr. Mark Hoffman emphasizes the importance of learning by watching in such complex cases to attain a better functional understanding of the procedure and its complications.

[Dr. Amy Park]
Yes, I was just going to comment on that because way back when we were lucky to get a dating ultrasound. But ultrasound has become so much more accessible, better in terms of the clarity, et cetera, and it seems like there's just so many more C-sections scar pregnancies that are getting diagnosed. I think at least the Cleveland clinics have gotten a reputation for treating these.

That just brings up another question about what you just alluded to, like who should be owning this? What specialty? Because you're MFM and Justin Lapin is MFM and you guys do complex surgery. This is badass surgery, like much respect. You could tell that the residents when you came were like, "This guy knows," because you had all the pictures. It is like really tough surgery but some places it's MIGS, a lot of places it's ORC. You have a big collaboration with radiology.

I just had this conversation with my friend who's the upcoming president of SGO, Amanda Fader, and we were just talking about should ORC be owning PAS? I think they're like “Not us,” but I think some of them are like “We should be doing it.” I don't know. I'm not sure. I'm not part of that debate stream.

[Dr. Brett Einerson]
It's close to the bladder Amy. I think UroGyn probably should be the ones to own that.

[Dr. Amy Park]
No, I'm one of those not-it people but anyway, it's interesting. It seems very local. It seems like MFM definitely is involved on some level, but you take a lot of ownership. You have a program. You're the director of this thing and you get a lot of referrals through this network that you have. Just curious about your thoughts.
[Dr. Brett Einerson]
I think the answer to who owns this is all of us. The difficult thing is that this is a pathology and a disease that exists between subspecialties and even exists between specialties. You can be the best surgeon in the world. If you don't have a good OB anesthesiologist and blood bank, you can't take good care of patients with placenta accreta spectrum.

This is, I like to say, interdisciplinary. The thing that's leached in the literature is multidisciplinary but it's really interdisciplinary care for these patients. I think that there isn't one specialty optimally situated to be the future caretaker for these patients. It's imperative on OB-GYNs to, I think, be the central rallying force around getting radiology, NICU, OB anesthesiology, pathology, and the various subspecialists together to do as good a job of taking care of these patients locally and regionally.

To some degree, MFM makes a little bit of sense because it's the one where most MFMs have at least some familiarity with their imaging and interest and investment in getting the diagnosis right. The problem of course for MFMs is that for many of us, 75% of our specialty is consultative. Many MFMs don't cover labor, delivery, much less want to perform a planned cesarean hysterectomy. In those cases for the average or meeting MFM, it's imperative to rally a team.

I think about interdisciplinary care as there needs to be a champion locally if you're going to be a center that takes care of placenta accreta spectrum. I know colleagues from general OB-GYN who do that really well. I have colleagues from GYNORC who are that team at their local institution. There's MFMs who do it clearly, there are MIS people who do that really well. I think whatever subspecialty it is, I think that there has to be active investment in understanding the imaging and the surgery, and the pathology. That in itself is an impossible task for one type of subspecialist and really requires an interdisciplinary approach.

I think gynecologists are incredible in the work that they do, but a lot of them do not come out of fellowship having seen a ton of cases. If you talk with our gynecologists, although they are the best situated to handle difficult pelvic surgery, a lot of them just haven't seen enough cases to be familiar with the pitfalls and avoid the worst outcomes during a PAS case. A lot of their training is on the fly. Once they get out of fellowship, they get called in for these difficult cases. To me, locally and regionally, it's about finding a team to put together who's going to really concentrate on getting better at this really difficult surgery. That's going to probably involve multiple subspecialists.

[Dr. Amy Park]
Can you just talk a little bit about your journey? It's just hard, like you're saying, to get the volume even if you're an MFM, you're a referral center so you're getting it but how did you get trained up? How did you assemble your team? How do you take calls? These are all very crucial elements.

[Dr. Brett Einerson]
Sure. Yes, I took interest in placenta accreta spectrum from a research perspective first and then figured out that clinically and surgically. It was a challenge that I wanted to take on. Midway through my fellowship, I started going to as many accreta cases as I could possibly go to. Even if I wasn't the fellow assigned to the cases, as one of the surgical assistants, I was there to see the surgical team operate.

It's remarkable how much I learned from just watching cases even when I wasn't there operating. You see the pitfalls, you see the approaches that work and the approaches that don't. I was able to see 25 to 30 cases during my fellowship and by the time I graduated, I had been one of the surgeons assisting on most of the cases that I had seen. I showed up to learn about the surgery, learn about the way that other people in the department were handling it. At the time it was mostly MFM delivering the baby, the gynecologist did the hysterectomy.

There were gynecologists who taught me a lot. At the end of my fellowship when I said, "I want to build this PAS program and I want to make this as good as possible for patients," I had gynecologists who already knew me, who were willing to invest in me, who were willing to walk me through cases, who were willing to be my surgical assist for the first couple of cases that I had as attending and they really helped me to do that. At the end of about 18 months, they and I agreed, "All right these are cases that Brett and a small team of non-gynecologist can handle and when things get difficult or if the disease is really bad, we'll have the gynecologist there on backup."

[Dr. Mark Hoffman]
That's such a great point for learners, for trainees. I think Elliot Richard said the same thing. Most of it's just showing up. A lot of it is in getting into the OR and watching other people operate, watching how they get set up, watching the team, how they interact with the other people in the room, watching how they physically do the techniques. To become an expert in something, just sometimes watching as opposed to when you're actually in there doing it and you're really focused on a small narrow window of a procedure, watching something can let you see a bit more of the whole thing. It's a great, great lesson there, a great story in how you went from becoming just someone who wanted to watch a bunch to becoming honestly the expert in this. That's a great story.

Listen to the Full Podcast

Placenta Accreta Spectrum (PAS) with Dr. Brett Einerson on the BackTable OBGYN Podcast)
Ep 25 Placenta Accreta Spectrum (PAS) with Dr. Brett Einerson
00:00 / 01:04

Earn CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs. Follow the button below to claim your credits on CMEfy.

BackTable CMEfy button

Stay Up To Date



Sign Up:

Regionalization of Care in Placenta Accreta Spectrum

Dr. Brett Einerson explains the challenges of regionalization of care in the management of Placenta Accreta Spectrum (PAS) patients, particularly for those living in remote or rural areas. Dr. Einerson shares the data from his practice in Salt Lake, mentioning that 65% of patients come from more than 45 minutes away, which creates risks and logistical burdens for these patients. He suggests that high volume centers can lead to better outcomes and calls for strategies to make these centers more accessible. Dr. Einerson also emphasizes the importance of a centralized, multidisciplinary team approach for dealing with PAS cases, providing insights on assembling such teams, operationalizing communication, and learning from each other's expertise. He recommends that this team not only discusses upcoming cases but also reviews past cases regularly to identify areas of improvement.

[Dr. Amy Park]
Well, I wanted to ask about the regionalization of care because that's always been a hot topic of high-volume centers and high-volume surgeons taking care of these conditions. I think that's definitely been a theme throughout UroGyn, now for MIGS and we're talking about plus PAS, but it's a burden for the patients. Chatting about this rural west situation and what's the average travel time and how do you provide for the patients who are coming in and have six other kids at home and when do you require for them to come? It's a heavy lift for these families to come in.

[Dr. Brett Einerson]
We looked at our data on proximity to care here in Salt Lake and the population centers are highly concentrated along the Wasatch, which is a mountain range that runs from southern Idaho basically down to almost Arizona. The vast majority of people in Utah live within a couple of miles east or west of that range, but we looked at where our patients were coming from and 65% were coming from more than 45 minutes away.

One of the reasons I was interested in that is because 45 minutes is my distance at which my sphincter tone increases and I'm worried about that person being at home. If they start bleeding at 28 weeks, I don't want them to be more than 45 minutes from the hospital and even, honestly, you want them to be closer if they're going to start to bleed, but a full third of our patients come from more than three hours away. It is a unique challenge of location. The same is true of my colleagues who work in Arkansas. The same is true of my colleagues who even work in parts of the Midwest and even parts of the Southeast.

I think that wherever you are in the country, you're going to have patients that are coming from long distances. The reality is that volume and experience almost certainly matter if PAS care mimics basically every other surgical subspecialty, and there's no reason to think that it won't. If you don't see something, except for every couple of years, you're not going to be as familiar with avoiding the problems of PAS surgery as if you see a couple of months. It's really our job, I think, to figure out how to do this thoughtfully to say, "The best outcome is probably--" Well, first of all, we should show that the best outcomes are going to come at higher volume centers.

Second of all, we should figure out ways to make it accessible to people who don't live near one of those places. A lot of my patients, in fact, disproportionately, come from places that don't have access to tertiary care medicine. Because they don't have access to VBAC in parts of Idaho and parts of Montana and parts of Wyoming. It's a huge financial burden and logistical burden for them to come at 30 or 32 weeks and live in Salt Lake City for a couple weeks and then deliver and spend a few more weeks in Salt Lake City while their baby is growing and feeding in the NICU. That's an incredible burden that we're only beginning to understand.

I don't have a magic wand to hear the problem of how do we make our hospitals fit to do this in more areas of the country, but I do think that for the time being, regionalization of care is going to lead to better outcomes because of volume.

[Dr. Amy Park]

How did you assemble your team? Do you have an interdisciplinary team and how do you organize it? Do you have weekly conferences? What are the logistics to establish best practices and review the cases, et cetera?

[Dr. Brett Einerson]
We're only beginning to understand best practice. It's hard to make recommendations for other centers that may only see six or seven cases a year and compare their processes to a really, really busy center that's seeing multiple consults every week for placenta accreta spectrum, but I think that there are a couple things that everybody should be doing. I can talk a little bit about how we have operationalized this.

To me, it's important to have formalized communication in some way. I'm sort of an email hater, so you'll have to forgive me, but email is not the greatest for interdisciplinary discussions. It's fine and if it's what you've got, then try to optimize it, but I think that there is benefit in people getting together, looking at images, reviewing images of the surgery, and talking with a pathologist face-to-face.

What we did when starting to formalize the program in 2018 here was get together every month and have basically a tumor board for placenta accreta spectrum. I know not every center's going to be able to do that, but we have learned so much from each other that I talked about how this is a problem that exists between specialties. It's amazing how much a surgeon can learn from a radiologist, how much a radiologist can learn from a pathologist, and how surprised some pathologists will be upon looking at the images of what a placenta accreta spectrum looks like in the body.

I don't think those same realizations, the same eureka moments would've happened in an email chain. I think they happened because we got together and started talking about what we were seeing. When we had the diagnosis wrong, why did we have it wrong? When we encountered difficulties during surgery, this is the reason that we had them. What can we do next time to avoid this?

I think there is a reason that tumor board has become so entrenched in cancer care ethics, because it's effective to get together face-to-face or Zoom face to Zoom face and talk through difficult cases. That's really what placenta accreta care is, difficult cases. They span multiple disciplines. That's my first suggestion to people. Find a champion, whatever subspecialty it is, and get organized enough to have periodic meetings.

At a less busy center, it might not be every month like we do it. It might just be ad hoc. When you have a case coming up, we're going to meet three weeks before the delivery date and talk through it. Anesthesia, NICU, radiology, obstetrics, gynecologic surgery, and anybody else that's going to be involved like urology or general surgery or trauma surgery for interventional radiology. I think that's the best way to really unlock a ton of great iterative team learning at your institution.

I think it also helps to centralize the number of people who are taking care of these cases. If you've got an oncology division of 12 people, it doesn't matter how busy you are. Each individual, one of those 12 people, is not going to see that many cases from year to year. My suggestion, based on what we've learned, is to try to get a smaller number of people really interested in taking care of these cases from the specialties that are involved.

For us, that looks like one surgically inclined general OB-GYN, two MFMs who have gotten additional training in surgical care of PAS, and then preferentially, we try to target a couple of the gynecologists who are most interested. The downfall of that is that if you have emergency cases and you don't have a good call system for that central team, then people who haven't seen this problem in a bunch of years try to scramble and take care of those people all of the time. If you're going to centralize care and only have a few people do the surgeries, I also think that those people should serve as a call team for accreta.

One mistake I made early on of being attending was to try to be that one person on call 365 days a year. Don't do that. Find a group of obstetricians who can help do that and find a group of backup pelvic surgeons who have a little bit more interest in this problem. I think that's the foundation of your call team as well as your surgical team for most of these cases.

[Dr. Amy Park]
Thank you so much for answering my questions. I find it fascinating and I don't know how many centers there are, but I think that here at the clinic, we're building an advanced complex pelvic surgery program within MFM. People who've had ileal conduits, for example, and are pregnant or I think that these things are all operational best practices. It's good to learn from people who've set it up and you learn the hard way like we all do.

Beyond the Physical: The Psychological Impact of Placenta Accreta Spectrum (PAS)

Dr. Brett Einerson reveals that patients with PAS, who underwent hysterectomy, experienced two to five times the risk of pelvic pain, anxiety, depression, postpartum grief, and loss. He emphasizes that the problem persists far beyond the immediate physical recovery, with many patients experiencing PTSD-like symptoms. This problem is not confined to any particular region, with patients from around the world expressing similar experiences. Dr. Einerson urges healthcare providers to acknowledge this reality and to connect with their patients, inquiring about their wellbeing even a year after the procedure. He highlights how his practice has transformed by integrating psychological care into their approach to patients.

[Dr. Brett Einerson]
I gave a talk a couple of years ago and said, this is the most pressing current issue that's not being addressed in placenta accreta care. We've been so laser-focused and rightfully so, on keeping moms from dying, keeping cases from getting to the point of massive blood loss that we have not done as good of a job as a field, in my opinion, of addressing the anticipation of anxiety associated with PAS and then post-delivery care for the psychological fallout and long-term outcomes that are really pretty bad associated with this.

I actually did a study at the end of my fellowship with a medical student named Brian Grover that just asked patients how they were doing at 6 months, 12 months, 24 months, 36 months, out all the way, some to 5 years. We asked them how they were doing from a psychological and health standpoint. Compared to people who were having a third or fourth C-section but didn't have accreta, patients with placenta accreta spectrum who underwent hysterectomy had two to five times the risk of pelvic pain, difficulty with sex, anxiety, and depression, postpartum grief and loss, decreased quality of life on quality of life surveys.

It's incredibly important for us to acknowledge that the morbidity does not end if we avoid the ICU or discharge that person home from the hospital. The morbidity continues on well beyond that. There are other studies out there by Toll that suggest that PTSD-like symptoms are incredibly common in patients that fits with my experience. There are logistical postpartum problems with coordinating, with sending a person back to Montana where their gynecologist doesn't really know what's happened and having them get postpartum care. It's an incredible challenge and an incredibly underappreciated challenge, I think, taking care of these patients long term.

[Dr. Amy Park]
I agree. The PTSD in UroGyn about fourth-degree tears, anal sphincteroplasty, all that stuff. There's like a lasting sequelae. Interestingly, there used to be this person who was quite active. It used to be called Mothers with Fourth-Degree Tears, but now it's called something differently to be more inclusive. She just struck a chord with how many people out there were suffering from PTSD after this traumatic delivery event.

Losing your uterus and having a preterm delivery and living somewhere away from your family for a couple of months, it's a lot of stuff going on. That is incredible. I can see that as being a huge need to study because it's not really well understood. At least you're making the inroads into it. I wonder if it's also a little cultural, like are there international studies looking at this too?

[Dr. Brett Einerson]
Honestly, the best studies on patient experience related to placenta accreta spectrum are from Ireland. A person who I've gotten to know pretty well, Helena Bartels, has done a ton of work on this in Northern Ireland to try to assess the patient experience and long-term outcomes associated with placenta accreta spectrum. The things that their patients say in their quality of studies are the same things that our patients are saying in Utah. If we had a larger sample, I feel confident that patients in rural Kentucky and patients in Cleveland, and patients in suburban Los Angeles would be saying a lot of the same things.

My challenge to people who are taking care of placenta accreta spectrum is that if you don't think this is a problem, then ask your patients, check in with them 12 months from now. I guarantee that even if you've been the best doctor that you can possibly meet, even if you've reduced morbidity to the maximum extent, your patients were still terrified by this problem.

I had a patient who talked about writing letters to her kids because she was worried that she wouldn't make it through surgery. I had no idea that she was going through that. I was confident that we were doing the best possible care that we could do for her. I was totally blind to the fact that she was so psychologically distraught that she was worried about just coming out the other side. We've completely changed the way we address the psychological needs of our patients because we were so moved by our patients and what they told us, they were appreciative of their care and they also felt like they needed so much more help psychologically and emotionally.

[Dr. Mark Hoffman]
It's a testament to you as not just a physician, but also as a person to look at your patients as people because you clearly have a great deal of talent and brains and logistical and administrative abilities to put a program like this together, but you can forget. There's so many things you just-- well if it just goes well, then everything else is someone else's problem, but taking the extra steps and to think about it in those terms is something we all don't do as well.

I won't speak for others, but I know that there's times when I've been very grateful to have had some patients who were willing to share their experience with me, that you went the step further and asked the questions to others so we could have some data so we could have a conversation so we could understand how to change practice and which sounds like you've done in Utah.

Kudos to you and your patients are extremely lucky to have you and we're all lucky to have now the opportunity to hear from you and understand more about not just the diagnosis and management, but the whole, you say spectrum. I think I've just now expanded my definition of the accreta spectrum. It's all the way through the postpartum and to the social and emotional side of it too. Great work.

Podcast Contributors

Dr. Brett Einerson discusses Placenta Accreta Spectrum (PAS) on the BackTable 25 Podcast

Dr. Brett Einerson

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.

Dr. Amy Park discusses Placenta Accreta Spectrum (PAS) on the BackTable 25 Podcast

Dr. Amy Park

Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.

Dr. Mark Hoffman discusses Placenta Accreta Spectrum (PAS) on the BackTable 25 Podcast

Dr. Mark Hoffman

Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.

Cite This Podcast

BackTable, LLC (Producer). (2023, June 15). Ep. 25 – Placenta Accreta Spectrum (PAS) [Audio podcast]. Retrieved from

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.



Placenta Accreta Spectrum (PAS) with Dr. Brett Einerson on the BackTable OBGYN Podcast)
IR/OB Collaboration in Treating Postpartum Hemorrhage with Dr. Roxane Rampersad and Dr. Anthony Shanks on the BackTable OBGYN Podcast)


Placenta Accreta Spectrum Best Practices in Diagnosis, Treatment & Risk Management

Placenta Accreta Spectrum Overview


Hysterectomy Procedure Prep
Placenta Accreta Condition Overview
Placenta Accreta Spectrum Condition Overview

Get in touch!

We want to hear from you. Let us know if you’re interested in partnering with BackTable as a Podcast guest, a sponsor, or as a member of the BackTable Team.

Select which show(s) you would like to subscribe to:

Thanks! Message sent.

bottom of page