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ob.placenta-previa.v1

Placenta Previa & Placenta Accreta Spectrum

obstetricsacuteadultpregnancy
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Acute obstetric emergency — abnormal placentation antepartum hemorrhage syndromes. Partition by previa type (low-lying < 2 cm not covering vs complete previa covering the internal os) × PAS depth (none / accreta / increta / percreta ± bladder/parametrial invasion) × clinical state (asymptomatic / sentinel bleed / massive hemorrhage) × prior-CS count (the dominant PAS pretest gradient) × gestational age. Distinguishes from placental abruption (PAINFUL bleed + uterine tenderness/hypertonus), vasa previa (fetal-vessel bleed at ROM), uterine rupture, and lower-genital-tract bleeding.

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Previa type + PAS-depth suspicion + clinical state + prior-CS count + GA cohort tagged

Patient inputs (21)

Tachypnea > 24 is a shock-index / qSOFA component; pregnant baseline ~ 16-22

Hypoxemia raises suspicion for amniotic fluid embolism (mimics sudden collapse + DIC at delivery) or pulmonary edema with overlap

Category I/II/III FHR interpretation drives delivery urgency — Category III with viable GA demands emergent cesarean

Prior cesarean count with co-existing previa is the dominant PAS pretest-probability axis (Silver 2006 PMID 16738145): with previa 1 CS ~ 3%, 2 ~ 11%, 3 ~ 40%, 4 ~ 61%, ≥ 5 ~ 67% accreta

Quantify visible vaginal blood loss + character (painless bright-red is classic previa); sentinel bleeds frequently precede a larger hemorrhage

Known previa / low-lying placenta + any prior US/MRI PAS markers (lacunae, loss of clear zone, bridging vessels) anchor the workup and accreta-center referral decision

Extreme preterm < 28 / preterm 28-33 / late preterm 34-36 / term ≥ 37 wk drives scheduled-delivery timing (previa 36-37+6 wk vs PAS 34-35+6 wk) + steroid + NICU planning

Baseline hemoglobin + serial trend (falling Hgb with active bleed); platelet count for DIC surveillance during massive hemorrhage

Type & screen on arrival; crossmatch ≥ 2-4 units PRBC if active bleeding, known PAS, or unstable; massive transfusion protocol activation if EBL > 1500 mL (Pacheco LD AJOG 2016 PMID 26348379)

DIC surveillance — fibrinogen < 200 mg/dL in pregnancy is critical (pregnancy baseline 350-650); PT/INR + aPTT prolonged → cryoprecipitate + FFP

Renal function (baseline for surgical planning + sepsis-AKI cross-reference) + liver function (HELLP overlap if pre-eclampsia)

TVUS is the safe gold standard for localising the placental edge relative to the internal os; serial at 32 wk (persistence) + 36 wk (delivery planning); ~ 90% of low-lying placentas migrate by term (RCOG GTG 27a 2018/2024)

Hypotension is a hemorrhagic-shock flag; MAP < 65 demands rapid resuscitation + potential emergent delivery; previa/PAS hemorrhage can be catastrophic and abrupt

Maternal tachycardia > 110 disproportionate to visible bleed is an early shock clue; obstetric hypovolemia presents with tachycardia before hypotension

Rh-negative mother with antepartum bleed requires RhoGAM ± dose-adjustment per Kleihauer-Betke quantification (ACOG PB 181 2017)

Targeted obstetric US for PAS markers (lacunae, loss of clear zone, myometrial thinning, bridging vessels, bladder-wall interruption); MRI adjunct if equivocal or to assess parametrial/posterior extension (FIGO 2024; ACOG/SMFM OCC 7 2018/2024)

Prior myomectomy, D&C, endometrial ablation, prior PAS — additional PAS risk factors beyond cesarean count; informs pretest probability

Pre-eclampsia is an independent delivery-timing co-driver; methylergonovine is contraindicated in HTN if uterotonics are needed at cesarean (ACOG PB 222 2020)

IVF/ART, advanced maternal age, multiparity, smoking are previa risk factors; inform pretest probability + counseling

Quantifies fetomaternal hemorrhage; required for Rh-negative mother RhoGAM dose-adjustment (300 mcg per 30 mL fetal whole blood; ACOG PB 181 2017)

Lactate > 2 with shock features is a hemorrhagic-shock marker; drives massive transfusion + emergent delivery decision

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningprevia_pas_with_massive_hemorrhage_maternal_instability
    Placenta previa / PAS + massive antepartum or intrapartum hemorrhage with maternal hemorrhagic-shock features (SBP < 90 OR MAP < 65 OR HR > 120 OR lactate > 2 OR rapid Hgb decline) — life-threatening; emergent cesarean (± hysterectomy) regardless of GA + massive transfusion protocol (1:1:1 PRBC:FFP:platelets) + TXA + cryoprecipitate + ICU; do NOT delay for further imaging; do NOT perform digital cervical exam
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningprevia_pas_with_fetal_distress
    Placenta previa / PAS + Category III FHR (late decelerations, prolonged decelerations, bradycardia, sinusoidal, minimal variability) + viable GA + alive fetus — life-threatening fetal compromise; emergent cesarean with surgical team + neonatology stand-by + simultaneous maternal resuscitation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningplacenta_percreta_with_bladder_or_parametrial_invasion
    Placenta percreta with bladder and/or parametrial invasion (FIGO clinical grade 3 / percreta) — life-threatening surgical complexity; accreta center of excellence + full multidisciplinary team (MFM, gyn-onc/pelvic surgeon, urology, IR, anesthesia, critical care, blood bank, NICU); cesarean hysterectomy with placenta left in situ; consider staged/delayed surgery; do NOT attempt placental removal
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresuspected_PAS_high_risk_prior_cs_anterior_previa
    Suspected PAS — prior cesarean delivery (especially ≥ 2) + anterior placenta previa overlying the hysterotomy scar + sonographic markers (lacunae, loss of clear zone, myometrial thinning, bridging vessels, bladder-wall interruption) — severe; refer accreta center of excellence; targeted US ± MRI; planned cesarean hysterectomy 34+0-35+6 wk; preoperative ureteral stents; IR balloon; pretest probability gradient per Silver 2006 (with previa: 2 CS ~ 11%, 3 ~ 40%, 4 ~ 61%, ≥ 5 ~ 67%)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecomplete_previa_recurrent_or_heavy_antepartum_bleed
    Complete placenta previa with recurrent or heavy antepartum bleeding — severe; inpatient management; type & screen + crossmatch; antenatal corticosteroids if 24-34 wk; deliver if recurrent/heavy bleeding compromises mother or fetus rather than waiting for the scheduled 36-37+6 wk window
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresentinel_bleed_stable_preterm_previa
    Self-limited painless sentinel (herald) bleed with stable maternal-fetal status + preterm previa — severe (sentinel bleeds frequently precede a larger hemorrhage); inpatient observation; type & screen; antenatal corticosteroids if 24-34 wk; limited tocolysis only to gain a 48 h steroid window in the absence of ongoing bleeding/fetal compromise
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverescheduled_late_preterm_delivery_previa_vs_pas
    Scheduled late-preterm delivery timing decision — stable complete previa (no PAS) → scheduled cesarean 36+0-37+6 wk; suspected/confirmed PAS → scheduled cesarean hysterectomy 34+0-35+6 wk at an accreta center after a betamethasone course, before labor/bleeding — severe (timing balances prematurity vs catastrophic unscheduled hemorrhage)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererh_negative_with_previa_pas_bleed
    Rh-negative mother with placenta previa / PAS and an antepartum bleed — severe; Kleihauer-Betke to quantify fetomaternal hemorrhage; RhoGAM 300 mcg IM within 72 h, dose-adjusted per KB (300 mcg per 30 mL fetal whole blood); MCA-PSV doppler + MFM if large FMH
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereconservative_placenta_in_situ_PAS_surveillance
    Conservative (placenta-left-in-situ, uterine-preserving) PAS management in a highly selected fertility-desiring patient — severe; intensive surveillance for delayed secondary hemorrhage, infection/endometritis/sepsis, and need for interval or emergency hysterectomy; not routine; informed consent required; routes to id.sepsis.core.v1 if infection features emerge
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildlow_lying_placenta_second_trimester_surveillance
    Low-lying placenta (edge < 2 cm from os, not covering) on the 18-20 wk anatomy scan, asymptomatic — mild; repeat TVUS at 32 wk (~ 90% migrate/resolve by term); if persistent, repeat at 36 wk for delivery planning and convert to the previa pathway; pelvic-rest counseling and return precautions for any bleeding
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Placenta previa & PAS — hemorrhage resuscitation + expectant-vs-delivery + PAS surgical planning + limited tocolysis + RhoGAM (ACOG/SMFM OCC 7 2018/2024 + RCOG GTG 27a 2018/2024 + FIGO 2024 + Pacheco LD AJOG 2016)
axis: placenta_previa_pas_managementstep hemorrhage_resuscitation - Massive antepartum/intrapartum hemorrhage resuscitation — MTP 1:1:1 + TXA + cryoprecipitate (Pacheco LD AJOG 2016 PMID 26348379 + WOMAN 2017 PMID 28456509)
Selected step "Massive antepartum/intrapartum hemorrhage resuscitation — MTP 1:1:1 + TXA + cryoprecipitate (Pacheco LD AJOG 2016 PMID 26348379 + WOMAN 2017 PMID 28456509)" — Maternal hemorrhagic shock OR EBL > 1500 mL OR DIC features (fibrinogen < 200, platelets < 100, prolonged PT/aPTT) — previa/PAS catastrophic bleed
  • tranexamic acid
    first line
    antifibrinolytic
    1 g IV over 10 min within 3 h of birth • IV • single dose; may repeat 1 g IV × 1 after 30 min if continued bleeding
    triggers: postpartum_hemorrhage_or_high_risk_previa_pas_delivery
    WOMAN trial 2017 — TXA within 3 h reduces death due to bleeding (~ 19% relative reduction); PMID 28456509
    rxcui 10691
  • norepinephrine
    rescue
    alpha_beta_agonist
    0.05 mcg/kg/min, titrate to MAP ≥ 65 • IV (central preferred) • continuous
    triggers: refractory_hypotension_despite_volume_and_blood_products
    SSC 2026 first-line vasopressor for refractory shock; bridge to definitive surgical/transfusion control
    rxcui 7512
  • hydrocortisone
    rescue
    corticosteroid
    200 mg/day divided q6h OR continuous infusion • IV • q6h or continuous
    triggers: shock_on_pressors_gt_4h
    SSC 2026 conditional for refractory shock
    rxcui 5492

outpatient playbook — drug actions (4)

  1. 1. iron repletion if postpartum anemia
    rxcui 24947
    Ferrous sulfate 325 mg PO TID; IV iron if severe anemia (Hgb < 8) or non-tolerant • PO/IV • TID PO or per infusion protocol
    trigger: Postpartum Hgb < 11 g/dL (previa/PAS hemorrhage often → significant anemia)
    Restore iron stores; reduce fatigue + improve recovery (ACOG general postpartum guidance)
  2. 2. betamethasone (antepartum, if scheduled preterm delivery)
    rxcui 1514
    12 mg IM × 2 doses 24 h apart • IM • q24h × 2
    trigger: Scheduled late-preterm delivery window approaching (previa 36-37+6 wk / PAS 34-35+6 wk) or delivery anticipated 24-34 wk
    ACOG CO 713 2017 / ALPS NEJM 2016 — fetal lung maturation
  3. 3. contraception
    Per ACOG MEC + patient preference (LARC, COC, POP, DMPA, etc.; permanent if hysterectomy performed) • PO/IM/implant/IUD • per agent
    trigger: Patient request + medical eligibility
    Counsel ≥ 18 mo interpregnancy interval; cesarean-scar PAS risk rises with each repeat CS; ACOG MEC
  4. 4. influenza + COVID + Tdap vaccines per ACIP
    Per ACIP • IM • per schedule
    trigger: Postpartum
    Standard ACIP recommendations

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Painless bright-red vaginal bleeding in pregnancy ≥ 20 wk — gateway feature of placenta previa; distinguishes from the painful, tender, hypertonic uterus of placental abruption (Oyelese Smulian 2006; cross-anchor Oyelese Ananth 2006 PMID 17012465); Self-limited painless herald (sentinel) bleed in a pregnancy ≥ 20 wk — frequently precedes a larger hemorrhage (RCOG GTG 27a 2018/2024); Placenta overlying or within 2 cm of the internal cervical os on TVUS at ≥ 20 wk (complete previa) OR placental edge < 2 cm from os not covering (low-lying placenta) (RCOG GTG 27a 2018/2024).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Placenta Previa & Placenta Accreta Spectrum** (ob.placenta-previa.v1).
Phenotype framing: Placental abruption (PAINFUL bleed + uterine tenderness/hypertonus; named painless-vs-painful pivot — routes to ob.placental-abruption.v1), vasa previa (fetal-vessel bleed at ROM; APT/Kleihauer for fetal Hgb; RCOG GTG 27b), uterine rupture (prior cesarean; loss of station; severe pain), bloody show with labor (small amount + mucus + cervical change), lower-genital-tract bleed (cervicitis, polyp, cervical CA), PAS subtype (accreta vs increta vs percreta ± bladder invasion).
Scope: Acute obstetric emergency — abnormal placentation antepartum hemorrhage syndromes. Partition by previa type (low-lying < 2 cm not covering vs complete previa covering the internal os) × PAS depth (none / accreta / increta / percreta ± bladder/parametrial invasion) × clinical state (asymptomatic / sentinel bleed / massive hemorrhage) × prior-CS count (the dominant PAS pretest gradient) × gestational age. Distinguishes from placental abruption (PAINFUL bleed + uterine tenderness/hypertonus), vasa previa (fetal-vessel bleed at ROM), uterine rupture, and lower-genital-tract bleeding.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Placenta previa & PAS — hemorrhage resuscitation + expectant-vs-delivery + PAS surgical planning + limited tocolysis + RhoGAM (ACOG/SMFM OCC 7 2018/2024 + RCOG GTG 27a 2018/2024 + FIGO 2024 + Pacheco LD AJOG 2016)** — step "Massive antepartum/intrapartum hemorrhage resuscitation — MTP 1:1:1 + TXA + cryoprecipitate (Pacheco LD AJOG 2016 PMID 26348379 + WOMAN 2017 PMID 28456509)".
1. tranexamic acid 1 g IV over 10 min within 3 h of birth IV single dose; may repeat 1 g IV × 1 after 30 min if continued bleeding (antifibrinolytic, first line) — WOMAN trial 2017 — TXA within 3 h reduces death due to bleeding (~ 19% relative reduction); PMID 28456509
2. norepinephrine 0.05 mcg/kg/min, titrate to MAP ≥ 65 IV (central preferred) continuous (alpha_beta_agonist, rescue) — SSC 2026 first-line vasopressor for refractory shock; bridge to definitive surgical/transfusion control
3. hydrocortisone 200 mg/day divided q6h OR continuous infusion IV q6h or continuous (corticosteroid, rescue) — SSC 2026 conditional for refractory shock

Setting playbook (outpatient) — Asymptomatic-previa antepartum surveillance (pelvic rest + serial TVUS, never-bled patients only) AND routine postpartum 6-wk visit + previa/PAS-specific anticipatory guidance (previa recurrence ~ 4-8%; PAS history → accreta-center planning for future pregnancy + interpregnancy-interval counseling; iron repletion; contraception; mental-health screen given peripartum hysterectomy/massive hemorrhage; immunization; newborn high-risk peds 24-48 h post-discharge)
4. iron repletion if postpartum anemia Ferrous sulfate 325 mg PO TID; IV iron if severe anemia (Hgb < 8) or non-tolerant PO/IV TID PO or per infusion protocol — Postpartum Hgb < 11 g/dL (previa/PAS hemorrhage often → significant anemia) (Restore iron stores; reduce fatigue + improve recovery (ACOG general postpartum guidance))
5. betamethasone (antepartum, if scheduled preterm delivery) 12 mg IM × 2 doses 24 h apart IM q24h × 2 — Scheduled late-preterm delivery window approaching (previa 36-37+6 wk / PAS 34-35+6 wk) or delivery anticipated 24-34 wk (ACOG CO 713 2017 / ALPS NEJM 2016 — fetal lung maturation)
6. contraception Per ACOG MEC + patient preference (LARC, COC, POP, DMPA, etc.; permanent if hysterectomy performed) PO/IM/implant/IUD per agent — Patient request + medical eligibility (Counsel ≥ 18 mo interpregnancy interval; cesarean-scar PAS risk rises with each repeat CS; ACOG MEC)
7. influenza + COVID + Tdap vaccines per ACIP Per ACIP IM per schedule — Postpartum (Standard ACIP recommendations)

Non-pharmacologic actions:
- Pelvic rest + activity counseling for stable asymptomatic outpatient previa (never-bled, reliable access only)
- Mental health counseling / therapy if EPDS ≥ 10 or PCL-5 elevated (peripartum hysterectomy / massive hemorrhage is a known PTSD trigger)
- Lactation continued support if breastfeeding
- Postpartum exercise progression per ACOG; cesarean/hysterectomy recovery timeline
- Future-pregnancy preconception counseling — encourage ≥ 18 mo interpregnancy interval, accreta-center planning if PAS history, early placental-localisation US in any subsequent pregnancy
- Pediatric follow-up coordination for high-risk newborn if preterm

AVOID / contraindication checks:
- No digital cervical exam if previa suspected until excluded or OR double setup (RCOG GTG 27a 2018/2024)
- Do not attempt placental removal in PAS leave placenta in situ (ACOG/SMFM OCC 7 2018/2024 + FIGO 2024)
- PAS delivery at accreta center of excellence multidisciplinary team (ACOG/SMFM OCC 7 2018/2024)
- Tocolysis contraindicated with significant or ongoing antepartum hemorrhage (RCOG GTG 27a 2018/2024)
- NSAIDs avoid antepartum PDA constriction and bleeding (ACOG general guidance)
- Methylergonovine contraindicated in hypertension or preeclampsia (ACOG PB 222 2020 / ACOG PB 183 2017)
- Do not delay emergent delivery for imaging in unstable antepartum hemorrhage (ACOG/SMFM OCC 7 2018/2024)
- Kleihauer betke required for Rh negative mother RhoGAM dose adjustment (ACOG PB 181 2017)
- Massive transfusion 1to1to1 PRBC FFP platelets with cryo for fibrinogen lt 200 (Pacheco LD AJOG 2016 PMID 26348379)
- Tranexamic acid within 3 hours of birth only (WOMAN 2017 PMID 28456509)

Monitoring

Regimen monitoring:
- Antepartum: serial TVUS at 32 wk (persistence) + 36 wk (delivery planning); ~ 90% low-lying placentas migrate by term
- Maternal vitals q15 min while bleeding; q1 h once stable; q4 h ≥ 24 h post-delivery
- Continuous EFM during active bleeding + intrapartum (Category I/II/III interpretation)
- Serial Hgb + coag panel q1-2 h while active bleeding; q4-6 h while stabilising
- Fibrinogen target ≥ 200 mg/dL — cryoprecipitate replacement if below
- Platelet target > 50K intrapartum; > 100K if active hemorrhage
- Type & screen up; crossmatch ≥ 2-4 units PRBC (more for known PAS); MTP ready if unstable
- Urine output ≥ 0.5 mL/kg/h; ureteral-stent patency post-PAS surgery
- Kleihauer-Betke for Rh-negative mother — RhoGAM dose-adjustment per result
- Fundal tone + lochia q15-60 min postpartum (atony surveillance — previa/PAS is a top PPH risk)
- Conservative placenta-in-situ PAS: serial β-hCG/US + temperature + bleeding surveillance for delayed hemorrhage / infection / need for interval hysterectomy
- Newborn handoff: previa/PAS + GA + delivery mode → peds / neonatology

Setting (outpatient) monitoring:
- Antepartum: serial TVUS 32/36 wk; bleeding-episode review at each visit
- 6-wk postpartum visit; additional visit at 1-2 wk if cesarean/hysterectomy wound concern
- Newborn outpatient peds at 24-48 h then 1 wk then 1 mo if preterm
- Maternal mental health re-screen at 6 wk + 3 mo + 6 mo
- Future-pregnancy preconception visit when contemplated (accreta-center planning if PAS history)

Follow-up plan: 6-wk postpartum visit + previa/PAS-specific anticipatory guidance: previa recurrence ~ 4-8% in a subsequent pregnancy; PAS history → high recurrence risk + accreta-center planning for any future pregnancy; iron repletion for postpartum/hemorrhage anemia; contraception counseling + ≥ 18 mo interpregnancy interval discussion (cesarean-scar PAS risk rises with each repeat CS); mental-health screen (EPDS for PPD; PCL-5 for peripartum PTSD given peripartum hysterectomy / massive hemorrhage); pelvic-floor and surgical-recovery follow-up; immunization audit (Tdap, influenza, COVID per ACIP); newborn outpatient 24-48 h post-discharge peds visit + developmental tracking for the first year if preterm. Counsel that hysterectomy ends fertility where performed; fertility-sparing conservative PAS management carries delayed-hemorrhage/infection surveillance.
- Close-out criterion: Postpartum visit complete; future-pregnancy / accreta-center counseling delivered; iron + mental-health + contraception addressed; newborn followup arranged

Monitoring phase: Antepartum expectant: serial TVUS (32/36 wk), pelvic rest adherence, bleeding-episode log, Hgb trend, fetal growth/wellbeing; inpatient maternal vitals + intermittent EFM if has bled. Perioperative/intrapartum: continuous EFM, maternal vitals q15 min, serial Hgb + coag q1-2 h while active, fluid balance, urine output ≥ 0.5 mL/kg/h, ureteral-stent patency post-PAS surgery. Postpartum: vitals q15 min × 2 h then q1 h × 4 h then q4 h × 24 h, fundal tone + lochia (atony surveillance — previa/PAS is a top PPH risk), repeat CBC + coag q4-6 h until stable; ICU continuous arterial line + central venous catheter + lactate q2-4 h until normalised + daily SOFA if critical.

Disposition

Current setting: outpatient — Asymptomatic-previa antepartum surveillance (pelvic rest + serial TVUS, never-bled patients only) AND routine postpartum 6-wk visit + previa/PAS-specific anticipatory guidance (previa recurrence ~ 4-8%; PAS history → accreta-center planning for future pregnancy + interpregnancy-interval counseling; iron repletion; contraception; mental-health screen given peripartum hysterectomy/massive hemorrhage; immunization; newborn high-risk peds 24-48 h post-discharge)

Disposition criteria:
- Resolution: 6-wk postpartum visit complete, mental health stable, contraception in place, immunizations up to date, future-pregnancy / accreta-center counseling delivered, newborn developmental tracking ongoing → discharge from previa/PAS-specific surveillance back to routine primary care + preconception planning with MFM referral for any future pregnancy

Escalation triggers (move to higher acuity):
- Any antepartum bleeding in an outpatient previa patient → immediate ED / L&D (no digital exam)
- Postpartum bleeding / persistent uterine tenderness / foul lochia → endometritis or retained-products workup (ED visit)
- New mental health crisis (PHQ-9 ≥ 15 or suicidal ideation) → urgent mental health referral
- Newborn high-risk features → urgent peds visit

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Placenta previa / PAS + massive antepartum or intrapartum hemorrhage with maternal hemorrhagic-shock features (SBP < 90 OR MAP < 65 OR HR > 120 OR lactate > 2 OR rapid Hgb decline) — life-threatening; emergent cesarean (± hysterectomy) regardless of GA + massive transfusion protocol (1:1:1 PRBC:FFP:platelets) + TXA + cryoprecipitate + ICU; do NOT delay for further imaging; do NOT perform digital cervical exam
- [LIFE_THREATENING] Placenta previa / PAS + Category III FHR (late decelerations, prolonged decelerations, bradycardia, sinusoidal, minimal variability) + viable GA + alive fetus — life-threatening fetal compromise; emergent cesarean with surgical team + neonatology stand-by + simultaneous maternal resuscitation
- [LIFE_THREATENING] Placenta percreta with bladder and/or parametrial invasion (FIGO clinical grade 3 / percreta) — life-threatening surgical complexity; accreta center of excellence + full multidisciplinary team (MFM, gyn-onc/pelvic surgeon, urology, IR, anesthesia, critical care, blood bank, NICU); cesarean hysterectomy with placenta left in situ; consider staged/delayed surgery; do NOT attempt placental removal

Citations

- ACOG/SMFM Obstetric Care Consensus 7 — Placenta Accreta Spectrum (Obstet Gynecol 2018; 132(6): e259-e275; reaffirmed 2024) + RCOG Green-top Guideline 27a — Placenta Praevia and Placenta Praevia Accreta (2018, reaffirmed 2024) + RCOG Green-top 27b — Vasa Praevia (2018, reaffirmed 2024) + FIGO consensus guidelines on placenta accreta spectrum disorders (2024 update) + Silver RM et al — Maternal morbidity associated with multiple repeat cesarean deliveries (NICHD MFMU; Obstet Gynecol 2006; 107(6): 1226-1232; PMID 16738145) + Oyelese Y, Smulian JC — Placenta previa, placenta accreta, and vasa previa (Obstet Gynecol 2006; 107(4): 927-941) + Pacheco LD et al — An update on the use of massive transfusion protocols in obstetrics (Am J Obstet Gynecol 2016; PMID 26348379) + WOMAN trial Shakur 2017 (Lancet; PMID 28456509) + ACOG PB 181 2017 Anti-D Immunoprophylaxis + ACOG CO 713 2017 / ALPS NEJM 2016 antenatal corticosteroids + ACOG PB 222 2020 Gestational HTN and Pre-eclampsia [PMID:16738145](https://pubmed.ncbi.nlm.nih.gov/16738145/)
- Cited evidence (PMID 26348379) [PMID:26348379](https://pubmed.ncbi.nlm.nih.gov/26348379/)
- Cited evidence (PMID 28456509) [PMID:28456509](https://pubmed.ncbi.nlm.nih.gov/28456509/)
- Cited evidence (PMID 17012465) [PMID:17012465](https://pubmed.ncbi.nlm.nih.gov/17012465/)
- Cited evidence (PMID 21241259) [PMID:21241259](https://pubmed.ncbi.nlm.nih.gov/21241259/)

Last reconciled with current guidelines: 2026-05-15.
References
  • ACOG/SMFM Obstetric Care Consensus 7 — Placenta Accreta Spectrum (Obstet Gynecol 2018; 132(6): e259-e275; reaffirmed 2024) + RCOG Green-top Guideline 27a — Placenta Praevia and Placenta Praevia Accreta (2018, reaffirmed 2024) + RCOG Green-top 27b — Vasa Praevia (2018, reaffirmed 2024) + FIGO consensus guidelines on placenta accreta spectrum disorders (2024 update) + Silver RM et al — Maternal morbidity associated with multiple repeat cesarean deliveries (NICHD MFMU; Obstet Gynecol 2006; 107(6): 1226-1232; PMID 16738145) + Oyelese Y, Smulian JC — Placenta previa, placenta accreta, and vasa previa (Obstet Gynecol 2006; 107(4): 927-941) + Pacheco LD et al — An update on the use of massive transfusion protocols in obstetrics (Am J Obstet Gynecol 2016; PMID 26348379) + WOMAN trial Shakur 2017 (Lancet; PMID 28456509) + ACOG PB 181 2017 Anti-D Immunoprophylaxis + ACOG CO 713 2017 / ALPS NEJM 2016 antenatal corticosteroids + ACOG PB 222 2020 Gestational HTN and Pre-eclampsia — PMID:16738145
  • Cited evidence (PMID 26348379) — PMID:26348379
  • Cited evidence (PMID 28456509) — PMID:28456509
  • Cited evidence (PMID 17012465) — PMID:17012465
  • Cited evidence (PMID 21241259) — PMID:21241259