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 |