top of page

BackTable / OBGYN / Podcast / Episode #25

Placenta Accreta Spectrum (PAS)

with Dr. Brett Einerson

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.

Be part of the conversation. Put your sponsored messaging on this episode. Learn how.

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

BackTable, LLC (Producer). (2023, June 15). Ep. 25 – Placenta Accreta Spectrum (PAS) [Audio podcast]. Retrieved from https://www.backtable.com

Free 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

Follow:

Subscribe:

Sign Up:

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.

Synopsis

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.

Dr. Einerson goes on to give a definition for PAS, which is a rare obstetric complication where the placenta attaches abnormally into the uterus and doesn’t let go at the time of delivery. Consequently, there is an increased risk for significant hemorrhage. As its name suggests, PAS exists on a spectrum. There are milder cases where the placenta is just abnormally attached and may not even look different either sonographically or physically at the time of delivery. Then there are severe cases in which the placenta attaches into the prior scar, completely remodels the uterus, and distorts the normal pelvic anatomy by turning the pelvic vasculature into a kind of “superhighway of blood flow.”

Dr. Einerson then discusses the etiology and pathophysiology of PAS. An embryo or early placenta attaches into a very small area of C-section scar or other scar from prior surgery. In the most severe forms of PAS, the placenta is growing within a C-section scar, stretching, distorting, and ultimately remodeling that part of the uterus and possibly other surrounding anatomical structures. PAS is an attachment and remodeling problem.

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.

Next, Dr. Einerson describes the logistics of setting up and operating an interdisciplinary PAS team. He suggests assembling a small, central team of people from the specialities involved who are interested in taking care of PAS cases and who can also form the core call team. A local champion is needed, and this person can be from general OB/GYN, gynecologic oncology, MIGS or MFM. At the Utah Placenta Accreta Program, the interdisciplinary team consists of a surgically inclined general OB/GYN, two MFMs who have received additional training in surgical care or PAS, and several interested gynecologic oncologists. Dr. Einerson recommends conducting a monthly interdisciplinary meeting, similar to tumor board, to discuss PAS cases. Other specialities to include in the meeting include anesthesia, radiology, pathology, NICU, gynecologic surgery, and others who may be involved such as urology, general surgery, trauma surgery, or interventional radiology.

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.

Finally, the doctors end by discussing social determinants of health, access to care, as well as the psychological toll of a PAS diagnosis.

Resources

Einerson BD, Gilner JB, Zuckerwise LC. Placenta Accreta Spectrum [published online ahead of print, 2023 Jun 8]. Obstet Gynecol. 2023;10.1097/AOG.0000000000005229. doi:10.1097/AOG.0000000000005229
https://pubmed.ncbi.nlm.nih.gov/37290094/

Bartels, H.C., Horsch, A., Cooney, N. et al. Living beyond placenta accreta spectrum: parent’s experience of the postnatal journey and recommendations for an integrated care pathway. BMC Pregnancy Childbirth 22, 397 (2022). https://doi.org/10.1186/s12884-022-04726-8
https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-022-04726-8

Bartels, H.C., Terlizzi, K., Cooney, N., Kranidi, A., Cronin, M., Lalor, J.G. and Brennan, D.J. (2021), Quality of life and sexual function after a pregnancy complicated by placenta accreta spectrum. Aust N Z J Obstet Gynaecol, 61: 708-714. https://doi.org/10.1111/ajo.13338
https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/ajo.13338

Transcript Preview

[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.

Disclaimer: The Materials available on BackTable.com 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.

backtable-earn-free-cme.jpg
backtable-plus-vi-cta.jpg
Become a BackTable Sponsor

Up Next

Tackling the Big Uterus with Dr. Uchenna Acholonu on the BackTable OBGYN Podcast)
Understanding Rising Endometrial Cancer Rates with Dr. Amanda Fader and Dr. Matthew Powell on the BackTable OBGYN Podcast)
AI Scribes: Enhancing Patient & Physician Interaction with Elie Toubiana on the BackTable OBGYN Podcast)
AI Advancements in Gynecologic Surgery with Dr. Vadim Morozov on the BackTable OBGYN Podcast)
Insights on OBGYN Coding & Reimbursements with Dr. Barbara Levy on the BackTable OBGYN Podcast)
In-Depth: Endometrial Ablation with Dr. Barbara Levy on the BackTable OBGYN Podcast)

Articles

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

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

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

Placenta Accreta Spectrum Overview

Topics

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