What is the management of placenta accreta in a pregnant woman in the 3rd trimester?

Management of Placenta Accreta Spectrum in the Third Trimester

Deliver at 34 0/7 to 35 6/7 weeks gestation via planned cesarean hysterectomy with placenta left in situ, performed at a Level III/IV maternal care center by a multidisciplinary team. 1, 2

Delivery Timing

• Schedule delivery between 34 0/7 and 35 6/7 weeks gestation to balance neonatal prematurity risks against maternal hemorrhage risk 1, 2
• Never wait beyond 36 0/7 weeks as approximately 50% of patients require emergent delivery for catastrophic hemorrhage after this gestational age 1, 2
• Administer antenatal corticosteroids when delivery is planned before 37 weeks 2

Mandatory Facility Requirements

Delivery must occur at a Level III or IV maternal care facility with the following immediately available resources: 2

• Maternal-fetal medicine subspecialists 2
• Experienced pelvic surgeons capable of complex hysterectomy 2
• Urologists for potential bladder/ureteral involvement 2
• Interventional radiologists 2
• Obstetric anesthesiologists 2
• Critical care specialists 2
• Blood bank with massive transfusion protocol capability 2

Preoperative Optimization

Maximize hemoglobin before scheduled delivery using oral or intravenous iron supplementation 2

Coordinate multidisciplinary planning including: 2

• Notify blood bank in advance of scheduled delivery date 2
• Verify surgical suite location and capabilities 2
• Confirm all necessary consultations have occurred 2
• Consider ureteric stent placement if bladder involvement is suspected on imaging 2

Surgical Technique

The definitive surgical approach is cesarean hysterectomy with placenta left in situ: 3, 2

1. Make the uterine incision away from the placenta when anatomically possible 2
2. Deliver the fetus through this incision 2
3. Ligate the umbilical cord close to the placenta 1
4. Never attempt placental removal—this causes catastrophic hemorrhage 1, 2
5. Leave the placenta completely in situ 2
6. Proceed immediately to hysterectomy 2

Critical Intraoperative Management

Activate massive transfusion protocol early, before significant blood loss occurs 2

Maintain patient temperature >36°C as clotting factors function poorly at lower temperatures 2

Consider tranexamic acid (1 gram IV) to reduce blood loss 2

Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 2

Monitor baseline coagulation studies including fibrinogen and platelet count 2

Management of Unexpected Diagnosis at Delivery

If placenta accreta spectrum is encountered unexpectedly without prior diagnosis: 3, 2

1. Immediately pause the case after fetal delivery 3, 2
2. Alert anesthesia staff 3, 2
3. Mobilize optimal surgical expertise 3, 2
4. Transfer the patient to a facility capable of performing cesarean hysterectomy if current facility lacks expertise and patient is stable 3, 2
5. Never attempt manual placental removal 2

Postoperative Care

Intensive care monitoring is mandatory given the following risks: 1

• Ongoing hemorrhage requiring reoperation or interventional radiology 1
• Fluid overload from massive resuscitation 1
• Renal failure 1
• Liver failure 1
• Disseminated intravascular coagulation 1
• Unrecognized ureteral, bladder, or bowel injury 1
• Sheehan syndrome (postpartum pituitary necrosis) in cases with significant hypoperfusion 2

Alternative Management: Delayed Hysterectomy

Delayed interval hysterectomy (median 41 days post-cesarean) may be considered in highly selected cases with significantly improved outcomes compared to immediate hysterectomy: 1

• Blood loss: 900 mL at cesarean + 700 mL at delayed hysterectomy versus 3,500 mL with immediate removal 1
• Transfusion rate: 46% with no massive transfusions (>4 units) versus 100% transfusion rate with 42% requiring >10 units with immediate removal 1
• 23% of patients were able to have robotic hysterectomy, avoiding repeat laparotomy 3

However, this approach should be considered investigational and only attempted at experienced academic centers with detailed patient counseling about uncertain benefits and significant risks 3, 2

Conservative (Uterine-Sparing) Management

Conservative management should be considered investigational only and reserved for carefully selected cases after extensive counseling 3, 2

Recurrence risk is 28.6% in subsequent pregnancies among women who achieve pregnancy after conservative management 3, 2

This approach is not recommended for routine practice given uncertain efficacy and significant maternal risks 3

Critical Pitfalls to Avoid

Never attempt manual placental removal—this is the single most dangerous action and causes catastrophic hemorrhage 1, 2

Never perform digital pelvic examination until placenta previa is excluded, as this can trigger massive bleeding 2

Never delay delivery beyond 36 weeks in stable patients 1, 2

Never deliver at a facility lacking massive transfusion capabilities 2

Methotrexate is not recommended due to unproven benefit, maternal toxicity risk, and one reported death 1