What is the management of placenta accreta?

Management of Placenta Accreta Spectrum

Women with suspected placenta accreta spectrum should be delivered at a level III or IV maternal care center with a multidisciplinary team experienced in managing this condition to minimize maternal morbidity and mortality. 1

Diagnosis and Risk Assessment

• Primary risk factors:

  • Previous cesarean delivery (risk increases with number of prior cesareans)
  • Placenta previa (especially with prior cesarean)
  • Prior uterine surgeries or curettage
  • Advanced maternal age
  • Multiparity
  • Asherman syndrome

• Risk stratification: For women with placenta previa and prior cesarean deliveries, risk increases dramatically:

  • 1 prior cesarean: 11% risk
  • 2 prior cesareans: 40% risk
  • 3 prior cesareans: 61% risk
  • 4+ prior cesareans: 67% risk 1

Preoperative Planning

• Timing of delivery: Schedule delivery at 34-36 weeks of gestation to avoid emergency delivery for hemorrhage, which occurs in approximately 50% of cases after 36 weeks 1

• Antenatal corticosteroids: Administer if delivery is planned before 37 weeks for fetal lung maturity 1

• Preoperative preparation:

  • Optimize hemoglobin levels (treat anemia if present)
  • Arrange multidisciplinary team consultation (maternal-fetal medicine, gynecologic oncology or pelvic surgeons, urology, interventional radiology, anesthesiology, critical care, neonatology)
  • Alert blood bank and establish massive transfusion protocol
  • Consider ureteric stent placement if bladder involvement is suspected 1, 2

Surgical Management

Primary Approach

• Cesarean hysterectomy with placenta left in situ is the standard treatment 1, 3
  • Make uterine incision away from placenta when possible
  • Deliver fetus without disturbing placenta
  • Do not attempt placental removal (associated with significant hemorrhage)
  • Close uterine incision rapidly if proceeding to hysterectomy
  • Perform total hysterectomy with placenta left in place 1, 2

Intraoperative Management

• Ensure adequate IV access (multiple large-bore IVs)
• Have blood products immediately available
• Consider cell salvage technology if available 2
• Administer tranexamic acid (1g IV) to reduce blood loss 2
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 2

Management of Unexpected Placenta Accreta

If placenta accreta is discovered unexpectedly during delivery:

1. Temporarily pause the case
2. Alert anesthesia team and consider general anesthesia
3. Obtain additional IV access
4. Order blood products
5. Alert critical care personnel
6. If expertise is unavailable, consider stabilization and transfer 1

Alternative Management Approaches

Conservative Management

• Definition: Removal of placenta or uteroplacental tissue without removing uterus
• Appropriate for: Carefully selected cases with focal placental adherence
• Considerations: Should be considered investigational with uncertain efficacy 1

Expectant Management

• Definition: Leaving placenta partially or totally in situ
• Risks: High risk of delayed hemorrhage, infection
• Recurrence risk: 28.6% risk of recurrent placenta accreta in subsequent pregnancies 1
• Recommendation: Consider only for carefully selected cases after detailed counseling 1

Postoperative Care

• Intensive hemodynamic monitoring in ICU setting
• Vigilance for ongoing bleeding with low threshold for reoperation
• Monitor for complications:
  • Renal failure
  • Liver failure
  • Infection
  • Unrecognized urologic injuries
  • Pulmonary edema
  • Disseminated intravascular coagulation
  • Sheehan syndrome 1, 2

Key Points for Improved Outcomes

• Early diagnosis through imaging (ultrasound, MRI for ambiguous cases) 3
• Delivery at a center with appropriate resources before onset of labor or bleeding 1
• Multidisciplinary team approach with experienced surgeons 1, 4
• Avoidance of placental disruption 1, 3
• Availability of massive transfusion capabilities 1, 2

Placenta accreta spectrum represents a significant obstetric challenge with substantial maternal morbidity and mortality risks. The increasing cesarean delivery rate has led to higher incidence of this condition, making proper management increasingly important in modern obstetric practice 1, 4.