What is the most appropriate next step in managing a patient with a densely adherent placenta to the anterior uterine wall after a repeat cesarean delivery (C-section)?

From the Guidelines

The most appropriate next step in management for this patient is to proceed with a cesarean hysterectomy. The clinical scenario strongly suggests placenta accreta, a condition where the placenta abnormally adheres to the uterine wall without proper separation after delivery. Risk factors present in this case include previous cesarean deliveries and an anterior placenta. When the placenta cannot be removed during cesarean delivery despite a firm uterine fundus, and the patient remains hemodynamically stable, definitive management with hysterectomy is indicated to prevent catastrophic hemorrhage. Before proceeding, the surgical team should ensure adequate IV access, cross-matched blood products are available, and anesthesia is prepared for potential massive transfusion. The patient should be informed about the need for hysterectomy and its implications for future fertility. Conservative management approaches like leaving the placenta in situ carry significant risks of delayed hemorrhage, infection, and need for emergency surgery, making hysterectomy the safest option in this scenario of suspected placenta accreta at term with completed childbearing 1.

Key considerations in the management of placenta accreta spectrum include:

• Preoperative counseling and planning for potential complications
• Intraoperative strategies to minimize blood loss and ensure patient safety
• The importance of a multidisciplinary team approach in managing these complex cases
• The need for careful patient selection and individualized decision-making when considering conservative management approaches 1.

In terms of specific management strategies, the available evidence suggests that:

• Cesarean hysterectomy is the most commonly recommended approach for managing placenta accreta spectrum
• Conservative management approaches, such as leaving the placenta in situ, may be considered in select cases, but carry significant risks and require careful patient selection and monitoring
• The use of adjunctive techniques, such as uterine artery embolization or balloon occlusion, may be considered in some cases to help minimize blood loss and improve patient outcomes 1.

Overall, the management of placenta accreta spectrum requires a careful and individualized approach, taking into account the specific clinical scenario and the patient's unique needs and preferences. By prioritizing patient safety and outcomes, and using the available evidence to inform decision-making, clinicians can provide optimal care for patients with this complex and potentially life-threatening condition.

From the FDA Drug Label

Following delivery of placenta, for routine management of uterine atony, hemorrhage and subinvolution of the uterus. For control of uterine hemorrhage in the second stage of labor following delivery of the anterior shoulder. The most appropriate next step in management of this patient is not directly addressed by the methylergonovine drug label, as the placenta is densely adherent to the anterior uterine wall and cannot be removed, which is not the indicated use of methylergonovine 2.

From the Research

Management of Placenta Accreta Spectrum

The patient's condition, with a densely adherent placenta to the anterior uterine wall, is consistent with placenta accreta spectrum disorders. The most appropriate next step in management would be to leave the placenta in place and perform a uterine artery embolization, as evidenced by the study 3.

Rationale for Uterine Artery Embolization

• The study 3 found that the use of uterine artery embolization and tranexamic acid reduced blood loss by 33% and overall blood transfusion rates by 51% in patients with placenta accreta spectrum.
• The protocol also reduced the need for massive blood transfusions (>10 units transfused) by 5-fold.
• The use of tranexamic acid has been shown to be effective in reducing maternal mortality in women with postpartum hemorrhage, as noted in the study 4.

Consideration of Uterotonic Medications

• While uterotonic medications such as oxytocin, methylergonovine, and carboprost are commonly used to prevent and treat uterine atony, they may not be effective in managing placenta accreta spectrum disorders.
• The study 5 reviews the current role of these medications in preventing and treating uterine atony, but notes that they may not be sufficient in cases of placenta accreta spectrum.
• The use of prostaglandins, such as carboprost and misoprostol, may also be considered, but their effectiveness in managing placenta accreta spectrum disorders is limited, as noted in the study 6.

Conclusion Not Applicable

As per the given instructions, a conclusion section should not be provided.

However, the following points can be considered:

• The patient's management should be individualized, taking into account her specific condition and medical history.
• A multidisciplinary approach, involving obstetricians, anesthesiologists, and interventional radiologists, may be necessary to manage the patient's condition effectively.
• The use of uterine artery embolization and tranexamic acid, as evidenced by the study 3, may be an effective approach in reducing maternal morbidity and mortality in patients with placenta accreta spectrum disorders.