Management of Placenta Accreta Spectrum
Definitive Recommendation
The gold standard management for placenta accreta spectrum is planned cesarean hysterectomy at 34 0/7 to 35 6/7 weeks gestation, performed at a Level III or IV maternal care facility, with the placenta left in situ and no attempt at placental removal. 1, 2, 3
Delivery Location and Timing
Transfer to a specialized center is mandatory. Delivery must occur at a Level III or IV maternal care facility with experience managing placenta accreta spectrum, as outcomes are significantly optimized at these centers. 1, 2, 3
Schedule delivery between 34 0/7 and 35 6/7 weeks gestation. Decision analysis demonstrates 34 weeks optimally balances neonatal outcomes against maternal hemorrhage risk. 2 Do not wait beyond 36 0/7 weeks, as approximately 50% of women beyond 36 weeks require emergent delivery for hemorrhage. 2
Multidisciplinary Team Assembly
Assemble a comprehensive team before delivery that includes: 1, 2
- Maternal-fetal medicine specialists
- Gynecologic oncology or female pelvic medicine surgeons (experienced pelvic surgeons)
- Anesthesiology with massive transfusion experience
- Neonatology
- Blood bank with massive transfusion protocol capability
- Interventional radiology (available but not routinely used for prophylactic vessel occlusion, as routine iliac artery balloon occlusion is not recommended due to lack of proven benefit and risk of complications) 1
Preoperative Optimization
Aggressively optimize hemoglobin preoperatively. Evaluate and treat iron deficiency anemia with oral iron replacement, consider intravenous iron infusions, and consider erythropoietin-stimulating agents when indicated. 2
Coordinate massive transfusion protocol with blood bank. Blood loss can be massive, and preparation is critical. 2, 3
Conduct thorough preoperative counseling reviewing planned surgical strategies, possible alternate approaches, and complications. 1
Surgical Approach
Critical Surgical Principles
Never attempt placental removal—this causes catastrophic hemorrhage. 1, 2, 4, 5 Forced placental removal results in profuse hemorrhage and is strongly discouraged. 1
- Position patient in dorsal lithotomy for vaginal and bladder access
- Use vertical skin incision or wide transverse incision (Maylard/Cherney) for optimal visualization
- Inspect uterus after peritoneal entry to discern placental invasion level and location
- Make uterine incision that avoids the placenta whenever possible (sometimes requires nontraditional incision)
- Deliver fetus
- Ligate umbilical cord close to placenta
- Rapidly close uterine incision without attempting placental separation
- Proceed directly to hysterectomy with placenta left in situ
Total hysterectomy is typically required because lower uterine segment or cervical bleeding frequently precludes supracervical hysterectomy. 1 Careful retroperitoneal dissection with attention to devascularization is required given overwhelming vascularity and tissue friability. 1
Consider cystoscopy if bladder involvement is suspected on direct visualization. 1
Intraoperative Hemorrhage Management
Activate massive transfusion protocol early. Transfuse in 1:1:1 ratio (packed RBCs:FFP:platelets). 2, 6
Administer tranexamic acid to reduce blood loss. 1, 2, 6
Monitor fibrinogen levels closely and maintain maternal temperature >36°C for optimal clotting factor function. 2
Use cell salvage technology when available. 1, 6
Maintain close monitoring of volume status, urine output, ongoing blood loss, and overall hemodynamics with frequent dialogue between surgical and anesthesia teams. 1
Unexpected Intraoperative Discovery
If placenta accreta spectrum is unexpectedly recognized at cesarean delivery: 1
- Pause the case if diagnosis is made before uterine incision and no extenuating circumstances mandate immediate delivery
- Alert anesthesia team and consider general anesthesia
- Obtain additional intravenous access
- Order blood products
- Alert critical care personnel
- Bring cell salvage technology into operative suite
- Do not proceed until circumstances are optimized
If discovered after uterus is already open and fetus delivered: 1
- Once placental removal clearly will not occur with usual maneuvers, perform rapid uterine closure
- Proceed to hysterectomy as judiciously as possible
- Mobilize appropriate resources concurrently
- If center cannot perform hysterectomy under optimal conditions and patient is stable, consider transfer with temporizing maneuvers (packing abdomen, tranexamic acid infusion, transfusion with locally available products)
Conservative/Expectant Management (NOT First-Line)
Conservative management is investigational and carries significant risks. 2 This includes either removing placenta/uteroplacental tissue without hysterectomy or leaving placenta partially/totally in situ. 1
Risks of conservative approaches: 2
- 22-42% still require hysterectomy
- 28% develop infection/febrile morbidity
- 6% experience severe morbidity (sepsis, organ failure, death)
If focal placental adherence exists, removal by manual extraction or surgical excision followed by defect repair has been associated with uterine preservation in some cases, with significantly less blood loss when defect is small. 1 However, randomized trials comparing this to hysterectomy are not available. 1
Recent case series show leaving placenta in situ resulted in 55% uterine preservation rate, but 45% required hysterectomy at median 5 weeks postpartum for hemorrhage, coagulopathy, endomyometritis, or pain. 7 Another 2024 study of a combined uterine-preserving technique showed 4.5-fold lower hysterectomy rate compared to historical controls, but this remains investigational. 8
Extensive counseling is mandatory before pursuing any conservative approach given the substantial failure and complication rates. 2
Postoperative Care
Plan for potential ICU monitoring given risks of ongoing bleeding, fluid overload, and renal failure. 2, 6
Maintain low threshold for reoperation if ongoing bleeding is suspected. 2
Monitor for delayed complications: 2, 6
- Infection and thromboembolic events
- Renal failure
- Liver failure
- Unrecognized injuries
- Pulmonary edema
- Disseminated intravascular coagulation
- Sheehan syndrome (postpartum pituitary necrosis from significant hypoperfusion)
Critical Pitfalls to Avoid
Never attempt manual placental removal—this causes catastrophic hemorrhage. 1, 2, 4, 5
Do not delay delivery beyond 36 weeks in a stable patient. 2
Do not deliver at a facility without massive transfusion capability. 2
Do not confuse placenta accreta spectrum with less serious placental abnormalities like placenta circumvallata, which does not require specialized delivery planning. 2, 9
Do not pursue conservative management without extensive counseling about the 22-42% hysterectomy rate and infection risks. 2
Do not routinely use prophylactic iliac artery balloon occlusion, as randomized controlled trials and case series show no benefit, with risks of arterial damage, occlusion, and infection. 1