What is the management approach for a pregnant woman with suspected placenta accreta?

Management of Placenta Accreta Spectrum

Immediate Referral and Delivery Planning

All pregnant women with suspected placenta accreta spectrum must be referred immediately to a Level III or IV maternal care facility with a comprehensive multidisciplinary team, and delivery should be planned at 34 0/7 to 35 6/7 weeks of gestation. 1, 2, 3

The cornerstone of management is planned cesarean hysterectomy with the placenta left in situ, as any attempt at placental removal causes catastrophic hemorrhage and must be avoided under all circumstances. 1, 3

Risk Stratification and Diagnosis

High-Risk Populations Requiring Evaluation

• Previous cesarean delivery with placenta previa represents the highest risk scenario, with risk increasing from 3% with one prior cesarean to 67% with five or more cesarean deliveries 1
• Additional risk factors include advanced maternal age, multiparity, prior uterine surgeries, curettage, Asherman syndrome, and in vitro fertilization 1, 4

Diagnostic Approach

• Transvaginal ultrasound is the primary diagnostic modality, with key findings including loss of the clear zone, myometrial thinning, placental lacunae, and hypervascularity 5, 6
• MRI may be helpful for posterior placenta or suspected placenta percreta to define anatomy and plan surgical approach 4, 7
• Never perform digital cervical examination until placenta previa has been excluded, as this can trigger catastrophic hemorrhage 2, 4, 3

Delivery Timing

Delivery must occur between 34 0/7 and 35 6/7 weeks of gestation in stable patients, as this window optimally balances neonatal prematurity risks against maternal hemorrhage risk. 4, 3

• Do not delay delivery beyond 36 weeks, as approximately 50% of women with placenta accreta spectrum beyond this gestational age require emergent delivery for hemorrhage 4, 3
• Administer antenatal corticosteroids when delivery is planned before 37 weeks 4, 3
• Earlier delivery is indicated for persistent bleeding, preeclampsia, labor, rupture of membranes, or fetal compromise 4

Essential Facility Requirements

The delivery facility must have immediately available:

• Maternal-fetal medicine subspecialists and experienced pelvic surgeons 1, 3
• Urologists (for potential bladder involvement) and interventional radiologists 3
• Obstetric anesthesiologists and critical care specialists 1, 3
• Blood bank with massive transfusion protocols capable of providing large-volume transfusion 1, 4, 3
• Strong nursing leadership experienced in managing high-level postpartum hemorrhage 1

Preoperative Optimization

• Maximize hemoglobin values using oral or intravenous iron supplementation during pregnancy 4, 3
• Notify the blood bank in advance and ensure massive transfusion protocol is ready 4, 3
• Consider ureteric stent placement if bladder involvement is suspected 4, 3
• Coordinate preoperatively with all subspecialists including anesthesiology, neonatology, and surgical teams 4

Surgical Management

Standard Surgical Approach

• Make the uterine incision away from the placenta when possible after inspecting the uterus 4
• Deliver the fetus expeditiously 3
• Leave the placenta in situ - do not attempt removal 1, 4, 3
• Proceed immediately to cesarean hysterectomy 3

Critical Intraoperative Measures

• Activate massive transfusion protocol early 3
• Maintain patient temperature above 36°C, as clotting factors function poorly at lower temperatures 2, 4, 3
• Consider tranexamic acid (1 gram IV over 10 minutes) to reduce blood loss 2, 3
• Transfuse packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio during acute hemorrhage 4, 3
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 4, 3
• Monitor baseline coagulation studies including platelet count, prothrombin time, partial thromboplastin time, and fibrinogen levels 4, 3

Management of Unexpected Intraoperative Diagnosis

If placenta accreta spectrum is encountered unexpectedly without prior diagnosis:

• Immediately pause the procedure and alert anesthesia 3
• Mobilize optimal surgical expertise 3
• Never attempt manual placental removal - this causes profuse hemorrhage 2, 3
• Transfer to a facility capable of performing cesarean hysterectomy if current facility lacks capabilities 3

Emergency Transfer Protocol

For patients with placenta percreta and vaginal bleeding:

• Establish large-bore IV access and begin crystalloid resuscitation 2
• Type and crossmatch blood immediately; activate massive transfusion protocol if significant bleeding present 2
• Obtain baseline labs including complete blood count, coagulation panel, fibrinogen, and platelet count 2
• Direct departmental notification to the receiving facility is mandatory to allow mobilization of the multidisciplinary team before patient arrival 2
• Provide gestational age, diagnosis confirmation, number of prior cesarean deliveries, current hemodynamic status, estimated blood loss, blood products administered, current hemoglobin, and estimated time of arrival 2
• Do not delay transfer waiting for the patient to "stabilize" unless she is in active hemorrhagic shock requiring immediate intervention 2

Postoperative Care

• Intensive hemodynamic monitoring in an ICU setting is essential in the early postoperative period 4, 3
• Maintain vigilance for ongoing bleeding with a low threshold for reoperation if suspected 4, 3
• Monitor for Sheehan syndrome (postpartum pituitary necrosis) in cases with significant hypoperfusion 3
• Ensure adequate iron supplementation and follow-up of hemoglobin levels 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, as it carries a 28.6% recurrence risk in subsequent pregnancies. 3

Critical Pitfalls to Avoid

• Never attempt manual placental removal - this is the most common cause of catastrophic hemorrhage 2, 3
• Never perform digital pelvic examination until placenta previa is excluded 3
• Never delay delivery beyond 36 weeks in stable patients 3
• Never deliver at a facility lacking massive transfusion capabilities 3
• Do not assume the patient can arrange her own transport for emergency transfer 2