Steps Description
Ultrasonography Routine ultrasonography, ideally performed before the third trimester (22-32 weeks)5, allows identification of the first signs of PAS disorders; after an obstetric-gynecological consultancy, a re-evaluation from two experienced sonographers is required
Magnetic resonance imaging Magnetic resonance imaging is indicated to confirm the diagnosis and better delineate the degree of trophoblastic invasion and its correlation with the anastomotic system of vessels in that area6
Involvement of a multidisciplinary team and planning After diagnosis confirmation, the delivery should be planned, with the involvement of a multidisciplinary team, including a gynecologist, anesthesiologist, neonatologist, urologist, and interventional radiologist, in addition to obstetricians and nurses7, that will follow the patients up to the end of post-surgery monitoring and manage pain control. Elective cesarean section is recommended at 36-37 weeks8 in asymptomatic women, in case of suspicion or diagnosis of PAS disorder, with respiratory distress syndrome prophylaxis. However, the exact timing is tailored for each pregnant woman by the gynecologist, who evaluates the risks for the mother and the gestational age of the fetus
Preoperative anesthetic examination and informed consent
During the preoperative anesthetic examination, the anesthesiologist first meets the patient and assesses general condition, airways, venous accesses, vertebral column status, and hemodynamic stability (Supporting Information 1); finally, the patient is given the score according to the American Society of Anesthesiologists (ASA) classification9. In this first visit, the anesthesiologist establishes a relationship based on trust, explains the phases of surgery in detail, and collects the informed consent, which includes all the possible interventions and complications (hysterectomy, lesions to the surrounding organs, need for blood product transfusions, admission in the Intensive Care Unit [ICU])
Multidisciplinary discussion A multidisciplinary discussion takes place to coordinate the health professionals involved in the management of the patient.
Transfusion service and ICU alerted About 3 days before surgery, the transfusion service should also be alerted: 4 units of packed red blood cells (PRBC) should be stocked in the blood bank of the operating room the day of surgery and further 4 units should be stocked on the hospital transfusion center. In addition, 6 g of fibrinogen and tranexamic acid should be available in the operating room. ICU is alerted to reserve a bed in case of need