What is the management of sepsis due to placenta accreta?

Management of Sepsis Due to Placenta Accreta

In cases of sepsis due to placenta accreta, immediate hysterectomy is the standard treatment to prevent life-threatening complications, as placenta accreta spectrum is potentially life-threatening and sepsis represents a severe complication requiring definitive intervention. 1, 2

Initial Management of Sepsis in Placenta Accreta

• Immediate resuscitation measures:

  • Initiate broad-spectrum antibiotics immediately
  • Establish adequate IV access (multiple large-bore lines)
  • Implement massive transfusion protocol with fixed ratio of packed red blood cells, fresh frozen plasma, and platelets 2
  • Fluid resuscitation to maintain hemodynamic stability
  • Transfer to ICU setting for intensive hemodynamic monitoring

• Surgical intervention:

  • Mobilize multidisciplinary team including:
    • Experienced obstetric surgeons
    • Anesthesia team
    • Critical care personnel
    • Interventional radiology (if available)
  • Proceed to hysterectomy as the definitive treatment 1, 2
  • Leave placenta in situ during the procedure to minimize blood loss

Rationale for Hysterectomy in Septic Placenta Accreta

Hysterectomy is indicated because:

1. The infected placental tissue serves as a persistent source of infection
2. Conservative management in the setting of sepsis carries high risk of septic shock 3
3. Attempting placental removal in septic cases can precipitate catastrophic hemorrhage and worsen septic shock 3

Risks of Conservative Management in Septic Cases

Conservative management (leaving placenta in situ) carries significant risks when sepsis is present:

• Persistent infection despite antibiotic therapy 3
• Progression to septic shock (particularly during attempts at placental removal) 3
• Delayed hemorrhage requiring emergency intervention
• Increased maternal mortality risk

A case report demonstrated that evacuation of retained placenta in a conservatively managed patient with persistent fever resulted in immediate septic shock, highlighting the danger of this approach 3.

Special Considerations

• If the patient is hemodynamically unstable:

  • Stabilize with fluids, vasopressors, and blood products before surgery
  • Consider temporary measures like abdominal packing and tranexamic acid infusion if immediate hysterectomy isn't possible 1

• If at a facility without appropriate resources:

  • Initiate antibiotics and resuscitation
  • Stabilize for transfer to a higher level facility with multidisciplinary expertise 1, 2
  • Avoid attempts at placental removal before transfer

Postoperative Care

• Continue broad-spectrum antibiotics
• Maintain vigilance for ongoing bleeding and infection
• Monitor for complications including:
  • Renal failure
  • Liver failure
  • Pulmonary edema
  • Disseminated intravascular coagulation 1, 2

Pitfalls to Avoid

• Attempting conservative management in the setting of sepsis
• Delayed surgical intervention when sepsis is present
• Inadequate antibiotic coverage
• Failure to involve multidisciplinary team
• Attempting placental removal in a non-tertiary center when sepsis is present

While conservative approaches to placenta accreta may be considered in carefully selected cases to preserve fertility, the presence of sepsis represents a contraindication to conservative management due to the high risk of septic shock and maternal mortality 1, 3.