What is the management for a 27-year-old woman, gravida 3 para 2, at 37 weeks gestation with a breech fetus and an anterior placenta that is densely adherent to the uterine wall after a repeat cesarean delivery (C-section)?

From the Guidelines

The patient should undergo immediate hysterectomy due to the inability to remove the placenta and the high risk of life-threatening hemorrhage, as this is the most effective way to prevent catastrophic morbidity and mortality, as recommended by the American Journal of Obstetrics and Gynecology 1.

Key Considerations

• The patient's risk factors for placenta accreta include previous cesarean deliveries and an anterior placenta in the current pregnancy, which increase the likelihood of placenta accreta spectrum, as noted in the American Journal of Obstetrics and Gynecology 1.
• The absence of prenatal care prevented earlier diagnosis, which typically occurs via ultrasound during routine prenatal visits, highlighting the importance of regular prenatal care in identifying high-risk pregnancies, as discussed in the American Journal of Obstetrics and Gynecology 1.
• Placenta accreta occurs when there is abnormal invasion of placental tissue into the myometrium due to defects in the decidua basalis, often at sites of previous uterine scarring, as explained in the American Journal of Obstetrics and Gynecology 1.

Management

• Prior to surgery, blood products should be prepared, including packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate, to minimize the risk of hemorrhage, as recommended by the American Journal of Obstetrics and Gynecology 1.
• The surgical team should include experienced obstetricians, anesthesiologists, and possibly urologists or gynecologic oncologists, to ensure optimal management of potential complications, as noted in the American Journal of Obstetrics and Gynecology 1.
• Intravenous access with large-bore catheters should be established, and fluid resuscitation initiated, to maintain hemodynamic stability, as discussed in the American Journal of Obstetrics and Gynecology 1.

Conservative Management

• While conservative management with leaving the placenta in situ and methotrexate therapy exists, hysterectomy remains the definitive treatment in cases of severe adherence to prevent catastrophic hemorrhage, as recommended by the American Journal of Obstetrics and Gynecology 1.
• Methotrexate use in expectant management of placenta accreta spectrum is not recommended due to potential maternal hematologic and nephrologic toxicities, as noted in the American Journal of Obstetrics and Gynecology 1.

From the Research

Diagnosis and 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, a complex obstetric complication associated with high maternal morbidity 2.
• The main cause of placenta accreta spectrum is uterine surgery, particularly uterine scar secondary to cesarean delivery, which can lead to abnormal invasion of the placenta into the uterine myometrium 2, 3.
• Prenatal ultrasound signs of placenta accreta spectrum include the disappearance of the normal uteroplacental interface, extreme thinning of the underlying myometrium, and vascular changes within the placenta and placental bed 2, 4.
• Accurate and timely antenatal diagnosis is essential to improve outcomes, and management should be planned and executed by a multidisciplinary team in a specialist center with surgical expertise and immediate availability of blood products and other necessary resources 3, 5.

Treatment Options

• Traditional management of abnormal invasion of placenta has been a peripartum hysterectomy, but more conservative techniques, such as intentional retention of the placenta, partial myometrial excision, and the 'Triple P procedure', have been developed to reduce morbidity and mortality 3.
• The use of methotrexate in conservative treatment of placenta accreta spectrum disorders has been reported, but high-quality evidence is lacking, and the benefits and risks of this approach need to be carefully weighed 6.
• In cases where placenta accreta is diagnosed during childbirth, forced removal of the placenta should be avoided, and conservative treatment or cesarean hysterectomy may be considered 5.

Multidisciplinary Approach

• Management of placental abnormalities requires a multidisciplinary team approach, including obstetricians, anesthesiologists, and other specialists, to ensure optimal outcomes for both mother and baby 3, 5.
• Delivery should be planned in a suitable structure with access to necessary resources, including blood products, interventional radiology, and intensive care units 3, 5.