From the Guidelines
Management of a stuck placenta (placenta accreta) requires immediate recognition and a multidisciplinary approach, with the definitive management typically being cesarean hysterectomy without attempts to remove the placenta, as forced removal can trigger catastrophic hemorrhage 1. When placenta accreta is suspected or diagnosed, delivery should be planned at a tertiary care center with experienced personnel and access to blood products. The patient should be stabilized with large-bore IV access, cross-matched blood products (4-6 units of packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate), and fluid resuscitation. Uterotonics like oxytocin (40 units in 1L of normal saline), methylergonovine (0.2mg IM), or carboprost (250mcg IM) may be administered to control bleeding. In cases where fertility preservation is desired and the accreta is focal, conservative management with partial resection and uterine reconstruction may be considered, though this carries risks of delayed hemorrhage and infection. Adjunctive measures include uterine artery embolization, balloon tamponade, or B-Lynch sutures. Methotrexate is no longer recommended for conservative management due to limited efficacy and potential toxicity. Placenta accreta occurs when the placenta abnormally invades the uterine wall due to defective decidualization, often at sites of previous uterine scarring, and carries significant maternal morbidity and mortality risks primarily from hemorrhage 1.
Some key points to consider in the management of placenta accreta include:
- Accurate antenatal diagnosis is needed to plan for an appropriate delivery strategy at an experienced center in order to reduce maternal morbidity 1.
- The timing of the delivery is planned carefully on a case-by-case basis at around 34 to 38 weeks to achieve optimal fetal maturity and avoid the chance of spontaneous labor.
- A contingency plan for emergent delivery should be in place.
- Obtaining radiologic and clinical data when PASD is first suspected can play a significant role in formulating an appropriate delivery strategy and contingency plan.
- High-risk patients should be followed closely by experienced centers where emergent mobilization of a multidisciplinary team needed for a scheduled or unscheduled delivery is feasible.
Overall, the management of placenta accreta requires a multidisciplinary approach and careful planning to minimize the risks of maternal morbidity and mortality.
From the Research
Management of Placenta Accreta
The management of placenta accreta, also known as a stuck placenta, involves several approaches to prevent and control bleeding. Some of the key management strategies include:
- Conservative management, where the placenta is left in situ to resorb on its own 2, 3
- Surgical intervention, such as hysterectomy, to remove the placenta and control bleeding 3, 4
- Medical treatment with methotrexate to help reduce the size of the placenta and promote resorption 5
- Use of tranexamic acid to control bleeding and prevent hyperfibrinolysis 2, 6
- Resuscitative endovascular balloon occlusion of the aorta to control bleeding during cesarean hysterectomy 6
Conservative Management
Conservative management of placenta accreta involves leaving the placenta in situ and monitoring the patient for signs of bleeding or infection. This approach can be effective in some cases, but it requires careful patient selection and individualization 3. Complications of conservative management can include secondary hemorrhage, infection, and disseminated intravascular coagulation 2.
Surgical Intervention
Surgical intervention, such as hysterectomy, may be necessary to control bleeding and remove the placenta. This approach is often required in cases where the placenta is heavily adherent to the uterus or has invaded surrounding tissues 3, 4. Caesarean hysterectomy is a common procedure used to manage placenta accreta, and it can be performed under general or neuraxial anesthesia 4.
Medical Treatment
Medical treatment with methotrexate has been used to help reduce the size of the placenta and promote resorption. This approach can be effective in some cases, but it requires careful monitoring and management of the patient 5.
Use of Tranexamic Acid
Tranexamic acid has been used to control bleeding and prevent hyperfibrinolysis in patients with placenta accreta. This medication can be effective in reducing the risk of bleeding and improving outcomes for patients with this condition 2, 6. However, its use should be carefully considered, especially when used in combination with other treatments such as arterial balloon occlusion 6.