What techniques can reduce blood loss in placenta accreta?

Techniques to Reduce Blood Loss in Placenta Accreta Spectrum

Planned cesarean hysterectomy with the placenta left in situ at 34-36 weeks of gestation at a level III or IV maternal care center with a multidisciplinary team is the most effective approach to reduce blood loss in placenta accreta spectrum. 1, 2

Preoperative Planning and Preparation

• Multidisciplinary Team Assembly:

  • Maternal-fetal medicine specialist
  • Experienced pelvic surgeon (often gynecologic oncologist)
  • Anesthesiologist
  • Blood bank personnel
  • Interventional radiologist (when available)
  • Urologist (if bladder involvement is suspected) 2

• Timing of Delivery:

  • Schedule delivery at 34 0/7-35 6/7 weeks of gestation in stable patients
  • Earlier delivery may be necessary with persistent bleeding, preeclampsia, labor, membrane rupture, or fetal compromise
  • Delivery after 36 weeks significantly increases risk of emergency surgery due to hemorrhage 1, 2

• Blood Bank Preparation:

  • Notify blood bank in advance
  • Implement massive transfusion protocol with ratio of 1:1:1 to 1:2:4 (packed red cells:fresh frozen plasma:platelets)
  • Maintain fibrinogen levels >200 mg/dL
  • Consider cell salvage with leukocyte depletion filter if available 2

Surgical Techniques

• Standard Surgical Approach:

  • Position patient in dorsal lithotomy
  • Consider vertical skin incision or wide transverse incision
  • Inspect uterus after peritoneal entry
  • Make uterine incision away from placenta when possible
  • Do not attempt to remove placenta after delivery of fetus
  • Proceed with hysterectomy with placenta left in situ 1, 2

• Hemorrhage Control Measures:

  • Administer 1g IV tranexamic acid within 3 hours of delivery (can repeat after 30 minutes if bleeding persists) 2
  • Consider temporary internal iliac artery occlusion in selected cases (though evidence is controversial) 1
  • Preoperative placement of ureteric stents may be beneficial in cases with bladder involvement 1

Importance of Planned vs. Emergency Delivery

Elective (planned) cesarean hysterectomy is associated with significantly lower blood loss compared to emergent procedures. Studies show patients undergoing planned procedures required an average of 1.9 units of packed red blood cells compared to 7.83 units in emergency cases 3. Only 50% of elective cases required transfusion, while 100% of emergency cases needed blood products 3.

Anesthetic Considerations

• Regional anesthesia is safe for cesarean delivery in women with placenta accreta when hemodynamically stable 4
• Invasive monitoring (arterial line, central venous catheter) should be considered for all cases 5
• Be prepared to convert to general anesthesia if significant bleeding occurs 5

Alternative Management Approaches

Conservative or expectant management (leaving placenta in situ without hysterectomy) should be considered only in carefully selected cases:

• Failure rates are high (44% in placenta percreta, 7% in less extensive defects) 2
• Sepsis is an absolute contraindication to conservative management 2
• These approaches should be considered investigational and require detailed counseling about risks 1, 2

Common Pitfalls to Avoid

1. Attempting placental removal: This significantly increases hemorrhage risk and should be avoided 1

2. Delaying delivery beyond 36 weeks: Approximately 50% of women with placenta accreta spectrum require emergency delivery for hemorrhage after 36 weeks 1, 2

3. Inadequate blood product preparation: Ensure massive transfusion protocol is in place before surgery begins 2

4. Failure to assemble complete multidisciplinary team: Outcomes are optimized when all relevant specialists are involved 6

5. Inadequate preoperative imaging: Ultrasound is the primary diagnostic tool, but MRI may be helpful in ambiguous cases 7