What is the best course of action for a pregnant woman with placenta percreta and vaginal bleeding, currently in a hospital that is not equipped to manage her condition?

Management of Placenta Percreta with Vaginal Bleeding in an Under-Resourced Hospital

You must immediately refer this patient to a Level III or IV maternal care facility with direct communication to the receiving department, ensuring coordinated transfer with stabilization measures in place. 1

Immediate Actions Required

The correct answer is A) Refer her with notifying department. This is the only medically and ethically appropriate option that prioritizes maternal mortality and morbidity reduction.

Why This is the Only Acceptable Approach

Placenta percreta with vaginal bleeding represents a life-threatening obstetric emergency that requires immediate coordinated transfer to a tertiary center. 1, 2 The American College of Obstetricians and Gynecologists explicitly states that placenta accreta spectrum diagnosed antenatally should be delivered at a Level III or IV center with considerable experience whenever possible to improve outcomes. 1

• Direct departmental notification is mandatory because this ensures the receiving facility can mobilize their multidisciplinary team (maternal-fetal medicine, gynecologic oncology, anesthesiology, interventional radiology, blood bank) before the patient arrives. 1

• Coordinated transfer improves survival compared to uncoordinated referral, as delivery in highly experienced maternity centers with coordinated care teams appears to improve outcomes. 1

Why Other Options Are Unacceptable

Option B (Refer upon patient's request) is medically negligent. This is not an elective situation where patient preference determines timing—this is a life-threatening condition requiring immediate specialized care. 1

Option C (Discharge with referral form) places the patient at catastrophic risk. Placenta percreta with active bleeding can rapidly progress to hemorrhagic shock. Discharging the patient to arrange her own transport is abandonment of care. 1

Option D (Discharge and tell her to go to tertiary hospital) is equally dangerous and represents failure to ensure safe transfer. The patient requires stabilization and coordinated handoff, not self-directed travel while bleeding. 1, 3

Stabilization Protocol During Transfer Preparation

While arranging transfer, you must simultaneously stabilize the patient:

• Establish large-bore IV access (two lines minimum) and begin crystalloid resuscitation. 3

• Type and crossmatch blood immediately and activate massive transfusion protocol if significant bleeding is present. 3

• Obtain baseline labs: complete blood count, coagulation panel, fibrinogen, platelet count. 3

• Maintain maternal temperature above 36°C as clotting factors function poorly at lower temperatures. 3, 4

• Consider tranexamic acid if hemorrhage is ongoing (1 gram IV over 10 minutes). 3

• Avoid digital cervical examination which can trigger catastrophic hemorrhage. 4

Critical Communication Elements

When notifying the receiving department, provide:

• Gestational age and diagnosis confirmation (placenta percreta on MRI with active vaginal bleeding)
• Number of prior cesarean deliveries (strongest risk factor for severity)
• Current hemodynamic status and estimated blood loss
• Blood products administered and current hemoglobin
• Estimated time of arrival

This allows the tertiary center to prepare the operating room, assemble the multidisciplinary team, and have blood products ready. 1, 2

The Evidence Base

The 2018 ACOG Obstetric Care Consensus on placenta accreta spectrum is unequivocal: stabilization and transfer at the time of delivery with a newly recognized accreta is a potential strategy in selected cases when maternal hemodynamic stability exists and the local facility lacks expertise to manage potential complications. 1 However, this requires coordinated transfer with direct communication, not patient self-referral.

Research demonstrates that even with optimal management at experienced centers, placenta percreta carries substantial morbidity risk, with median blood loss of 1,700-3,000 mL during cesarean hysterectomy. 5, 6 In under-resourced settings without multidisciplinary teams, outcomes are catastrophically worse. 7, 8

Common Pitfalls to Avoid

• Never attempt manual placental removal if emergency delivery occurs before transfer—this causes profuse hemorrhage. Leave the placenta in situ and proceed directly to hysterectomy only if hemorrhage is uncontrolled. 1, 2

• Do not delay transfer waiting for the patient to "stabilize" unless she is in active hemorrhagic shock requiring immediate intervention. Most cases can be safely transferred with appropriate IV access and monitoring. 1

• Do not assume the patient can arrange her own transport—this is a medical emergency requiring ambulance transfer with monitoring capability. 3