The impact of a stratified placenta accreta risk protocol at a single institution

Multidisciplinary care at a Placenta Accreta Center improves patient outcomes but may incur morbidity and significant deviation in birth process. We evaluated a stratified protocol of accreta risk and intervention. In March 2020, we initiated a stratified accreta protocol based on clinical risk factors and sonographic assessment. Women with anticipated increta/percreta had a multidisciplinary cesarean hysterectomy. Women with anticipated accreta/focal accreta stratified into a Medium Risk protocol, delivering on the Labor and Delivery unit with enhanced precautions for hemorrhage. Deliveries coded for placenta accreta spectrum from 1/1/2018 to 6/30/2022, and deliveries that stratified into the protocol were compared for delivery interventions and morbidities. 371 system charts coded for accreta and 42 patients referred to the accreta protocol were reviewed. Of these, 58 patients were identified at our institution that had management informed by suspicion for accreta. After program initiation, women having a repeat cesarean at risk for accreta/focal accreta increased from 4 to 22 women, with sonographic suspicion increasing from 0 to 41%. Although the gestational age at birth was 2 weeks earlier (38 vs. 36wks, p=0.054 by t-test), unplanned hysterectomy (75% vs. 10%, p=0.01 by Fischers exact test), estimated blood loss (2575 vs 1555mL, p=0.113 by t-test), red blood cell transfusion (3.5 vs. 0 units, unable calculate p-value), use of cell salvage (0 vs 36%, unable to calculate p-value) and ICU stay (50% vs 5%, p=0.052 by Fischer exact test) all differed after program initiation (Table 1), though significance was limited by small numbers. There were 3/19 (16%) unplanned hysterectomies prior to program initiation, and 5/39 (13%) after (difference NS by Fischer exact test), including three women who underwent vaginal delivery at their preference despite antenatal concern for possible focal accreta. A stratified risk algorithm may offer women with suspected accreta choices to minimize interventions and morbidity at birth.