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Am J Obstet Gynecol. 2019 Mar 5. pii: S0002-9378(19)30433-8. doi: 10.1016/j.ajog.2019.02.054. [Epub ahead of print]

Evidence-based guidelines for the management of abnormally-invasive placenta (AIP): recommendations from the International Society for AIP.

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The Nuffield Dept. of Women's and Reproductive Health, University of Oxford, Oxford, UK; The Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK. Electronic address:
Department of Obstetrics and Gynecology, South General Hospital, Stockholm , Sweden.
Erasmus MC, Dept of Gynaecological Oncology, Rotterdam, The Netherlands.
Centre Hospitalier Régional Universitaire de Nancy, Université de Lorraine, France.
Departments of Obstetrics and Division of 'Experimental Obstetrics̔;, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany.
Department of Obstetrics and Gynecology, General Faculty Hospital, Charles University, Prague, Czech Republic.
Port-Royal Maternity Unit, Cochin Hospital, Paris-Descartes University, DHU Risk and Pregnancy, Assistance Publique-Hôpitaux de Paris, Paris, France.
Department of Obstetrics and Gynecology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.
Department of Obstetrics, Rigshospitalet, University of Copenhagen, Denmark.
Department of Obstetrics and Gynecology , Hôpital Trousseau, Assistance Publique des Hôpitaux de Paris, University Pierre and Marie Curie , Paris , France.
Department of Gynecology Obstetrics II and Reproductive Medicine, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, APHP; Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine, Paris, France.
Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Italy.
Department of Obstetrics, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Italy; Department of Women, Children and of General and Specialized Surgery, University "Luigi Vanvitelli", Naples, Italy.
Medical University of Vienna, Department of Obstetrics and Gynecology, Division of Obstetrics and feto-maternal Medicine, Waehringer Guertel 18-20, 1090 Vienna, Austria.
Department of Obstetrics and Gynecology, CHR Citadelle, University of Liege, Liege, Belgium.
Vrouw & Baby, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.
Department of Perinatology and Gynecology, University of Medical Sciences, Poznan, Poland.
Vivantes Network for Health, Clinicum Neukoelln, Clinic for Obstetric Medicine, Berlin, Germany.
Department of Obstetrics and Gynecology , Hôpital Pellegrin, CHU de Bordeaux , Bordeaux , France.
Fetomaternal Medical Center, Dept of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Finland.
Prenatal Zurich, Zürich, Switzerland, and Heinrich Heine University. Düsseldorf, Germany.
Norwegian National Advisory Unit on Women's Health, Division of Obstetrics and Gynaecology, Oslo University Hospital, Rikshospitalet and Institute of Clinical Medicine, University of Oslo, Norway.


The worldwide incidence of abnormally invasive placenta is rapidly rising following the trend of increasing caesarean delivery. It is a heterogeneous condition and has a high maternal morbidity and mortality rate, presenting specific intra-partum challenges. Its rarity makes developing individual expertise difficult for the majority of clinicians. The International Society for Abnormally Invasive Placenta aims to improve clinicians understanding and skills in managing this difficult condition. By pooling knowledge, experience and expertise gained within a variety of different healthcare systems the society seeks to improve the outcomes for women with abnormally invasive placenta globally. The recommendations presented herewith were reached using a modified Delphi technique and are based on the best available evidence. The evidence base for each is presented using a formal grading system. The topics chosen address the most pertinent questions regarding intra-partum management of abnormally invasive placenta with respect to clinically relevant outcomes including: Definition of a center of excellence; requirement for antenatal hospitalization; antenatal optimization of hemoglobin; gestational age for delivery; antenatal corticosteroid administration; use of pre-operative cystoscopy, ureteric stents and prophylactic pelvic arterial balloon catheters; maternal position for surgery; type of skin incision; position of the uterine incision; use of inter-operative ultrasound; prophylactic administration of oxytocin; optimal method for intra-operative diagnosis; use of expectant management; adjuvant therapies for expectant management; use of local surgical resection; type of hysterectomy; use of delayed hysterectomy; intra-operative measures to treat life-threatening hemorrhage; fertility after conservative management.


abnormally invasive placenta; accreta; guideline; increta; morbidly adherent placenta; percreta; placenta; placenta accreta spectrum


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