Jennifer Gilner, MD, PhD, Maternal-Fetal Medicine specialist, has led Duke’s Placenta Accreta Care Program since 2016. Today, it’s the most comprehensive program of its kind in North Carolina. The multidisciplinary team’s evidence-based screening and treatment protocols have fostered a destination program with superior patient outcomes. 

“Our program expanded with two additional faculty members and a nurse navigator, who helps our patients with the complex care process of this diagnosis,” says Gilner. More team members increase the capacity to manage more placenta accreta spectrum (PAS) cases, as well as implement standardized protocols for screening, diagnostics, and patient management. 

“Getting an accurate PAS diagnosis as early as possible allows us to risk-stratify the patient and create a customized care plan that reduces serious risks to mother and baby at the time of delivery,” says Gilner.

Nationally, between 40% and 50% of accreta spectrum cases are not suspected, which leads to more bleeding and other complications at delivery. “The greatest opportunity for impact is recognizing patients’ risk factors and referring for screening with specialized imaging by 26 weeks. Patients have significantly better outcomes if we monitor them and plan ahead,” says Gilner.

Major risk factors for developing an abnormal relationship between the uterine lining and the placenta include: 

• Having placenta growth near a prior uterine scar, most commonly from a prior cesarean
• Any placenta growth in an abnormal location (e.g., previa) or near an area of prior uterine procedure (e.g., cesarean, hysteroscopy, or D&C)

“If patients’ first or second trimester routine ultrasounds reveals a placenta low in the uterus, or near or covering the cervix, and they’ve had prior uterine surgeries, we strongly recommend referring to us for a consultative ultrasound,” says Gilner. 

Gilner helped develop an evidence-based protocol for diagnostic ultrasounds at Duke. The ultrasound takes more time, capturing images and specialized views that aren't part of a standard anatomy ultrasound. 

Current data suggests that the incidence of severe maternal morbidity of patients with PAS is higher than other serious conditions in pregnancy, such as pulmonary hypertension. “We can lower morbidity rates if we identify risk factors and plan for a safe delivery,” says Gilner.

“It’s widely published that delivery at a prepared center with an experienced team improves outcomes,” says Gilner. “We routinely get referrals from Georgia, Virginia, all over North Carolina, and states even farther away.”

Duke’s Placenta Accreta Care Program achieves lower severe maternal morbidity rates compared to national averages, including blood loss and likelihood of transfusion. The national rate for hemorrhage that requires transfusion is 46.9%, while Duke’s published rate of transfusion for scheduled delivery cases is 14.8%.

Duke's protocols to support exceptional outcomes include:

• Partnerning with interventional radiology colleagues to incorporate prophylactic multivessel embolization in severe accreta cases, reducing blood flow to surgical fields after delivery
• Implementing a comprehensive hemorrhage management protocol 
• Having a dedicated obstetric anesthesia group
• Having a well-established transfusion team and stocked blood bank 

Considering that 30 to 40% of patients with accreta require urgent or unscheduled delivery prior to their intended delivery date, it’s important for care teams to have standardized systems and mobilize quickly. “Our specialists are available 24/7,” says Gilner.

After a consultative ultrasound, Gilner’s team stratifies patients by level of risk to provide the most clinically appropriate recommendations. “Traveling to our center for delivery may be hard for some patients, so we only make that recommendation if the risk of needing a specialized surgical team is high. Patients with lower risks can often deliver with their local obstetrician. We can collaborate with them to develop a safe delivery plan,” says Gilner. 

The program also maintains as much normalcy as possible during the birth process for patients by including partners in the delivery room and having mothers awake during delivery.