Global Guidelines on Placenta Accreta Spectrum Disorders: A Commentary From the Chinese Perspective
Year: 2025
Type: article
Abstract: To editor: Placenta Accreta Spectrum (PAS) is a complex and life-threatening obstetric condition for both mother and fetus.1 Its effective management depends heavily on Multidisciplinary Team (MDT) collaboration, consensus-driven clinical decision-making, and standardized treatment pathways to optimize outcomes and reduce associated risks.2,3 To promote standardized management of PAS, various national and regional professional organizations have issued clinical practice guidelines that cover the screening, diagnosis, and treatment of PAS. However, significant inconsistencies remain across these guidelines in key areas, necessitating a systematic assessment of the degree of consensus and divergence among them. In July 2025, Harvard Medical School published a systematic review in JAMA Network Open evaluating the consensus and discrepancies among multiple PAS clinical practice guidelines from countries of varying income levels.4 The study systematically searched PubMed, the GIN Library, and the ECRI Guidelines Trust for PAS-related clinical practice guidelines published between January 1, 2014, and January 31, 2024. Additional documents were identified by screening professional society websites and reviewing reference lists. Ultimately, 14 national or international guidelines referenced in 18 publications were included. After preliminary appraisal, the researchers structurally categorized the guideline recommendations and assessed levels of consensus, divergence, or insufficient evidence. Where discrepancies existed, a panel of 15–18 PAS guideline authors adjudicated final interpretations by majority vote. The degree of consensus was classified as follows: strong agreement (≥ 75% concordance across recommendations), poor consensus (< 50% agreement or ≥ 30% deemed “insufficient evidence”), and evidence severely lacking (≥ 50% of recommendations labelled as “insufficient evidence”). The study identified high levels of consensus in the following aspects of PAS clinical management: Multidisciplinary team composition (100% agreement): All guidelines emphasize the necessity of an MDT consisting of obstetricians, anesthesiologists, urologists, neonatologists, and others to enhance surgical safety and emergency preparedness. Antenatal management (88.9% agreement): Most guidelines recommend managing PAS in tertiary hospitals or high-level perinatal care centers, emphasize timely referral, and advocate for planned cesarean delivery—typically between 34 and 35 weeks of gestation. Diagnosis (76.9% agreement): Transvaginal and color Doppler ultrasound remain the first-line screening tools, while MRI is recommended for further evaluation in suspicious cases, especially for posterior placenta or placental invasion near a uterine scar. Epidemiology (75.0% agreement): Global consensus recognizes prior cesarean delivery as the leading risk factor for PAS, with a rising incidence worldwide. Other associated risk factors include prior myomectomy, other uterine surgeries, and placenta previa. However, the study revealed substantial divergence and insufficient evidence in the following areas of PAS management: Cesarean hysterectomy (38.5% insufficient evidence; 23.0% disagreement): Disagreement persists regarding whether a planned hysterectomy should be routinely performed. Some guidelines emphasize that preserving the uterus may increase complications, while others advocate for intraoperative individualized decision-making. Conservative management techniques (33.3% insufficient evidence; 11.1% disagreement): There is no consensus on the use of conservative approaches such as retained placenta management, uterine-sparing surgery, or postoperative methotrexate therapy. Evidence remains limited concerning patient selection, complication prevention, and long-term follow-up. Fertility counseling (30.0% insufficient evidence; 10.0% disagreement): Guidelines vary in recommendations regarding future fertility counseling for PAS patients. While some advocate for comprehensive preoperative risk discussions, others do not provide explicit guidance. Anemia and hemorrhage management (including iron supplementation and thromboprophylaxis): Although anemia is common in PAS, consensus is lacking on iron supplementation strategies (55.6% insufficient evidence). Blood transfusion protocols, prophylactic hemostatic interventions (e.g., balloon occlusion, gauze packing), and postoperative anticoagulation vary widely. Thrombosis prevention approaches also differ substantially across guidelines (57.1% insufficient evidence), with some recommending pharmacological interventions and others supporting non-pharmacologic options. This review systematically evaluated and compared PAS management guidelines from various countries and international organizations. It identified both high-consensus and high-variability areas, offering practical insights for clinical practice and policy-making. Areas with significant divergence—such as conservative treatment, fertility preservation, and postpartum management—highlight potential directions for future PAS research. Finally, the study noted that most current guidelines are derived from high-income countries, with limited coverage of low-resource settings, underscoring the need for more inclusive and globally applicable PAS protocols. Although this review excluded China’s national PAS guidelines due to language-based inclusion criteria, a comparative analysis (Supplementary Table 1, https://links.lww.com/MFM/A108) indicates that the Guidelines and Expert Consensus for the Diagnosis and Management of Placenta Accreta Spectrum Disorders (2023)5,6 are broadly aligned with international standards, while being more specifically adapted to the epidemiological and clinical realities of PAS in China. In particular: (1) The persistently high cesarean section rate, together with the large number of abortions, myomectomies, and other intrauterine procedures, has resulted in a substantial burden of PAS cases associated with uterine scarring, often presenting with greater clinical complexity7–9; (2) The uneven distribution of medical resources means that some primary hospitals lack standardized expertise in PAS identification and management, underscoring the need for a regionally coordinated care network and efficient referral pathways.10 Consequently, the Chinese guidelines place stronger emphasis on tertiary hospitals as leaders in regional collaborative systems and advocate for individualized, and where feasible, conservative treatment strategies. Both Chinese and international guidelines remain insufficient in providing comprehensive and actionable recommendations on fertility preservation and counseling. This omission reflects not only the paucity of high-quality evidence but also a broader neglect of long-term quality-of-life considerations for women with PAS. Given that many affected patients are young and may desire future fertility, there is an urgent need for standardized and culturally sensitive strategies to be incorporated into future guideline development. Prioritizing this issue would strengthen the humanistic dimension of perinatal care and represent a pivotal advance in safeguarding patient autonomy and reproductive rights worldwide.11 Looking ahead, there is an urgent need to address the paucity of high-quality evidence in PAS management, particularly concerning controversial topics such as accurate prediction, the safety and efficacy of conservative strategies, and adjunctive approaches.12 Several of China’s contributions could be structured to align with the highest standards of international scientific rigor, thereby ensuring that its clinical experience and research evidence serve as a valuable reference for international organizations and guideline developers. First, establishing national multicenter registries and prospective cohorts would leverage China’s uniquely large and heterogeneous PAS population, generating real-world evidence with standardized outcome measures directly comparable to international datasets. Second, conducting multicenter randomized controlled trials (RCTs), especially on unresolved questions such as conservative surgery, fertility preservation, and postpartum management—would fill critical evidence gaps that currently limit guideline recommendations. Moreover, by actively engaging in, and potentially leading, global collaborations under FIGO, ISUOG, or with organizations such as the NICHD, China can ensure that its extensive clinical experience contributes to more inclusive and evidence-based international standards. Taken together, such efforts would not only strengthen the evidence base for PAS care worldwide but also allow China to play a formative role in shaping global consensus and guidelines. Both international and Chinese guidelines on PAS demonstrate strong consensus regarding MDT management, diagnostic modalities, and risk assessment, providing a solid foundation for the global standardization of care. Nonetheless, as Bonanni et al. have noted, current global guidelines remain more focused on the priorities and capacities of high-resource settings4. Future initiatives should strengthen evidence-based collaboration across countries and integrate data and experiences from developing regions, thereby fostering the development of more inclusive and globally applicable frameworks for PAS management. Funding This study was supported by the National Key Research and Development Program of China under grant number 2022YFC2704501. Author Contributions Yongdan Ma: Conceptualization, Writing and Revising the original draft; Jingmei Ma: Review the original draft, Funding acquisition. Conflicts of Interest None. Data Availability Data sharing not applicable to this article as no datasets were generated or analyzed during the current study. Editor Note Jingmei Ma serves as an editorial board member of Maternal-Fetal Medicine. The article was handled according to the journal’s standard editorial procedures, with peer review conducted independently of this editor and their research group.
Source: Maternal-Fetal Medicine
Authors: Yongdan Ma, Jingmei Ma
Institutions: Peking University, Peking University First Hospital
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4415684738