What is the management plan for Placenta (placenta accreta, increta, or percreta)?

Management of Placenta Increta

Placenta increta (and all placenta accreta spectrum disorders) must be delivered at a Level III or IV maternal care center with a multidisciplinary team, with planned cesarean hysterectomy at 34 0/7 to 35 6/7 weeks gestation, leaving the placenta in situ without attempting removal. 1, 2

Preoperative Planning and Referral

Immediate referral to a Center of Excellence is critical upon antenatal diagnosis, as delivery at experienced centers with multidisciplinary teams reduces maternal morbidity by 53% compared to standard obstetric care. 1, 3

Essential Multidisciplinary Team Members

The care team must include: 1

• Maternal-fetal medicine specialists and experienced obstetricians
• Gynecologic oncologists or female pelvic medicine/reconstructive surgeons (for advanced pelvic surgical expertise)
• Urologists (for potential bladder involvement in increta/percreta)
• Interventional radiologists
• Obstetric anesthesiologists
• Critical care specialists
• Blood bank with massive transfusion protocol capability
• Neonatologists

Preoperative Optimization Checklist

Critical preoperative elements include: 1

• Maximize preoperative hemoglobin values
• Verify surgical suite capabilities (adequate surgical trays, urologic equipment, cell-saver availability)
• Coordinate blood bank scheduling with case timing
• Ensure intraoperative point-of-care testing availability
• Confirm critical care services engaged for postoperative period
• Identify primary service responsible for postoperative care

Timing of Delivery

Scheduled delivery should occur at 34 0/7 to 35 6/7 weeks gestation in stable patients, as this balances neonatal outcomes against maternal hemorrhage risk. 1, 2

• Do not wait beyond 36 0/7 weeks, as approximately 50% of women require emergent delivery for hemorrhage after this gestational age. 1, 2
• No amniocentesis is needed at 34-35 weeks, as pulmonary maturity data do not change delivery recommendations. 1
• Administer antenatal corticosteroids for fetal lung maturation when delivery is planned before 37 0/7 weeks. 1
• Earlier delivery is indicated for persistent bleeding, preeclampsia, labor, rupture of membranes, fetal compromise, or developing maternal comorbidities. 1

Surgical Management

The Critical Rule: Never Attempt Placental Removal

The single most dangerous action is attempting manual placental removal, which causes catastrophic hemorrhage. 2

Surgical Approach

The standard surgical technique involves: 2

• Deliver the fetus through a uterine incision that avoids the placenta when possible
• Ligate the umbilical cord close to the placenta
• Leave the placenta in situ
• Proceed directly to cesarean hysterectomy

Alternative: Delayed Interval Hysterectomy

For highly selected cases, delayed interval hysterectomy (median 41 days post-cesarean) significantly reduces blood loss compared to immediate hysterectomy: 2

• Blood loss: 900 mL at cesarean + 700 mL at delayed hysterectomy versus 3,500 mL with immediate removal
• Transfusion rate: 46% with no massive transfusions versus 100% transfusion rate with immediate removal
• This approach requires careful patient selection and close monitoring

Hemorrhage Management Protocol

Activate massive transfusion protocol early without waiting for laboratory results if significant bleeding occurs. 4

• Transfuse in fixed 1:1:1 ratio of packed red blood cells:fresh frozen plasma:platelets when massive transfusion is needed. 4
• Consider tranexamic acid to reduce blood loss. 4
• Monitor fibrinogen levels closely, as declining levels indicate consumption. 4
• Maintain maternal temperature above 36°C, as clotting factors function poorly at lower temperatures. 4

Additional Surgical Hemorrhage Control Techniques

If hemorrhage is uncontrolled, consider: 4

• Uterine compression sutures
• Hypogastric artery ligation
• Pelvic packing
• Interventional radiology embolization

Postoperative Management

Intensive care unit monitoring is essential given the high-risk nature of this condition. 4, 2

Critical Postoperative Monitoring

Monitor closely for: 4, 2

• Ongoing hemorrhage requiring reoperation or interventional radiology
• Fluid overload from massive resuscitation
• Renal failure
• Liver failure
• Disseminated intravascular coagulation
• Unrecognized ureteral, bladder, or bowel injury

Maintain a low threshold for reoperation if ongoing bleeding is suspected. 4

Special Considerations for Previable Diagnosis

When placenta increta is diagnosed in the previable period, counseling about pregnancy termination for maternal indications is important given significant risks of maternal morbidity and mortality, though no data quantify the magnitude of risk reduction. 1 Termination itself carries risks and should be performed by experienced providers. 1

Critical Pitfalls to Avoid

• Never attempt manual placental removal 2
• Never deliver at facilities without massive transfusion capability 2
• Never delay delivery beyond 36 weeks in stable patients 2
• Methotrexate is not recommended due to unproven benefit, maternal toxicity risk, and one reported death 2
• Do not proceed with surgery until circumstances are optimized - if placenta accreta spectrum is suspected intraoperatively and optimal surgical expertise is not present, pause the case until appropriate resources arrive 4

Limited Resource Settings

In centers with inadequate resources, stabilize the patient and transfer immediately to a tertiary care center. 4 Temporary stabilization measures include: 4

• Abdominal packing
• Tranexamic acid infusion
• Transfusion with locally available products