What is the treatment for placenta accreta?

Treatment of Placenta Accreta Spectrum

Primary Treatment Approach

The definitive treatment for placenta accreta spectrum is planned cesarean hysterectomy with the placenta left in situ—attempts to remove the placenta cause catastrophic hemorrhage and must be avoided. 1, 2

Delivery Timing and Location

Delivery must occur at 34 0/7 to 35 6/7 weeks of gestation at a level III or IV maternal care facility. 2, 3 This specific timing window is critical because:

• Waiting beyond 36 weeks results in approximately 50% of patients requiring emergent delivery for hemorrhage 2, 3
• Earlier delivery increases neonatal morbidity from prematurity 3
• Antenatal corticosteroids should be administered when delivery is planned before 37 weeks 3

Essential Multidisciplinary Team Requirements

The facility must have immediately available: 1, 2

• Maternal-fetal medicine subspecialists 1, 2
• Experienced pelvic surgeons (gynecologic oncologists or female pelvic medicine and reconstructive surgeons) 1
• Urologists (for potential bladder involvement) 1, 3
• Interventional radiologists 1
• Obstetric anesthesiologists 1, 4
• Critical care specialists 1
• Blood bank with massive transfusion protocols (1:1:1 to 1:2:4 ratio of packed RBCs:FFP:platelets) 1, 3, 4
• Strong nursing leadership experienced in high-level postpartum hemorrhage 1

Preoperative Optimization

Maximize hemoglobin values before delivery using oral or intravenous iron supplementation. 1, 3, 4 Additional preoperative steps include:

• Verify exact surgical suite location and capabilities 1
• Confirm all necessary consultations have occurred 1
• Notify blood bank in advance of scheduled delivery 1, 3
• Consider ureteric stent placement if bladder involvement suspected 3
• Ensure cell-saver technology is available 4

Surgical Technique

The standard surgical approach is: 1, 2

1. Make the uterine incision away from the placenta when possible 3
2. Deliver the fetus 3
3. Leave the placenta in situ—do not attempt removal 1, 2, 3
4. Proceed immediately to hysterectomy 1
5. Consider dorsal lithotomy positioning for optimal surgical access 3

Critical Intraoperative Management

• Activate massive transfusion protocol early 4
• Maintain patient temperature >36°C as clotting factors function poorly at lower temperatures 3
• Consider tranexamic acid to reduce blood loss 4
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 3
• Monitor baseline coagulation studies (platelet count, PT, PTT, fibrinogen) 3

Management of Unexpected Diagnosis at Delivery

If placenta accreta spectrum is encountered unexpectedly at delivery without prior diagnosis, immediately pause the case, alert anesthesia, and mobilize optimal surgical expertise. 1 If the delivering center lacks expertise and the patient is hemodynamically stable after fetal delivery:

• Transfer the patient to a facility capable of performing cesarean hysterectomy 1
• Do not attempt placental removal during stabilization 1, 3

Postoperative Care

• Intensive hemodynamic monitoring in ICU setting 3
• Maintain vigilance for ongoing bleeding with low threshold for reoperation 3
• Monitor for complications including renal failure, liver failure, infection, pulmonary edema, and disseminated intravascular coagulation 4
• Watch for Sheehan syndrome (postpartum pituitary necrosis) in cases with significant hypoperfusion 4

Conservative Management Considerations

Conservative (uterine-sparing) management should be considered investigational and only attempted in carefully selected cases after detailed counseling about uncertain benefits and significant risks. 1 This approach:

• Carries a 28.6% recurrence risk in subsequent pregnancies 1
• Should only be considered when cesarean hysterectomy is not immediately necessary 1
• Requires extensive patient counseling about hemorrhagic risks 1

Common Pitfalls to Avoid

• Never attempt manual placental removal—this causes profuse hemorrhage 1, 2, 3
• Never perform digital pelvic examination until placenta previa is excluded 3
• Never delay delivery beyond 36 weeks in stable patients 2, 3
• Never deliver at a facility lacking massive transfusion capabilities 1, 2
• Delayed recognition of placenta accreta at delivery can be catastrophic—maintain high index of suspicion in patients with placenta previa and prior cesarean deliveries 4