What is the management and treatment of placenta accreta in a pregnant patient?

Management and Treatment of Placenta Accreta Spectrum

The definitive treatment for placenta accreta spectrum is planned cesarean hysterectomy with the placenta left in situ, performed at 34 0/7 to 35 6/7 weeks gestation at a level III or IV maternal care facility with a multidisciplinary team, because attempting to remove the placenta causes catastrophic hemorrhage. 1

Delivery Timing

Deliver between 34 0/7 and 35 6/7 weeks of gestation for stable patients. 2, 1 This narrow window exists because:

• Waiting beyond 36 weeks results in approximately 50% of patients requiring emergent delivery for hemorrhage 2, 1
• Earlier delivery increases neonatal morbidity from prematurity 1
• Administer antenatal corticosteroids when delivery is planned before 37 weeks 1

Facility Requirements

Delivery must occur at a level III or IV maternal care facility with the following immediately available resources 2, 1:

• Maternal-fetal medicine subspecialists 1
• Experienced pelvic surgeons 1
• Urologists 1
• Interventional radiologists 1
• Obstetric anesthesiologists 1
• Critical care specialists 1
• Blood bank with massive transfusion protocols 3, 2, 1
• ICU capabilities 2, 1

This level of care is essential because placenta accreta spectrum is considered a high-risk condition with serious associated morbidities, including severe hemorrhage, increased maternal mortality, and frequent need for hysterectomy. 3

Preoperative Optimization

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

• Verify exact surgical suite location and capabilities 1
• Confirm all necessary consultations have occurred 1
• Notify the blood bank in advance of scheduled delivery 1
• Consider ureteric stent placement if bladder involvement is suspected 1

Surgical Technique

The standard approach is cesarean hysterectomy with the placenta left in place rather than attempting placental delivery, which causes catastrophic hemorrhage. 3, 2, 1, 4 The surgical steps are:

• Make the uterine incision away from the placenta when possible 1
• Deliver the fetus 1
• Leave the placenta in situ—do not attempt removal 1, 4
• Proceed immediately to hysterectomy 1

Critical Intraoperative Management

Activate massive transfusion protocol early without waiting for laboratory confirmation if significant bleeding is present 1. Additional intraoperative measures include:

• Maintain patient temperature >36°C, as clotting factors function poorly at lower temperatures 1
• Consider tranexamic acid to reduce blood loss 1
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 1
• Monitor baseline coagulation studies 1

Management of Unexpected Diagnosis at Delivery

If placenta accreta spectrum is encountered unexpectedly without prior diagnosis, immediately pause the case. 1 Then:

• Alert anesthesia 1
• Mobilize optimal surgical expertise 1
• Transfer the patient to a facility capable of performing cesarean hysterectomy if necessary 1
• Never attempt manual placental removal 1

This scenario represents a critical pitfall, as placenta accreta spectrum is underdiagnosed and can result in massive hemorrhage, disseminated intravascular coagulation, surgical injury, multisystem organ failure, and death. 5

Postoperative Care

Transfer to ICU for intensive hemodynamic monitoring. 1 Specific monitoring includes:

• Maintain vigilance for ongoing bleeding with a low threshold for reoperation 1
• Monitor for complications including ongoing bleeding, fluid overload, renal failure, and liver failure 1
• Watch for Sheehan syndrome (postpartum pituitary necrosis) in cases with significant hypoperfusion 1

Conservative (Uterine-Sparing) Management

Conservative 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

Critical Pitfalls to Avoid

Never perform the following actions 1:

• Never attempt manual placental removal 1
• Never perform digital pelvic examination until placenta previa is excluded 1
• Never delay delivery beyond 36 weeks in stable patients 1
• Never deliver at a facility lacking massive transfusion capabilities 1

Risk Factor Context

Understanding risk factors helps identify patients requiring this intensive management approach. The most significant risk is placenta previa with prior cesarean deliveries, present in 49% of placenta accreta spectrum cases. 2 The risk increases dramatically from 3% with placenta previa alone to 11%, 40%, 61%, and 67% for the first, second, third, fourth, and fifth or more cesarean deliveries, respectively. 3 This combination creates abnormal placental location overlying a uterine scar where abnormal invasion is most likely to occur. 2