What is the recommended approach for delivering a pregnant patient with a succenturiate lobe placenta?

Delivery Management of Succenturiate Lobe Placenta

Primary Recommendation

Succenturiate lobe placenta does not require specialized delivery planning or cesarean hysterectomy like placenta accreta spectrum, but demands meticulous inspection of the placenta after delivery to ensure complete removal of all lobes and connecting vessels to prevent postpartum hemorrhage and retained placental tissue. 1

Antenatal Surveillance and Risk Assessment

• Confirm the diagnosis with ultrasound to identify the location of the succenturiate lobe, assess for velamentous cord insertion, and exclude vasa previa, as these associated conditions significantly increase hemorrhagic risk 2, 1
• Screen for vasa previa specifically, as the vessels connecting the succenturiate lobe to the main placenta are vulnerable to compression and laceration 3, 1
• Assess for placenta previa or low-lying placental lobes, which may complicate delivery planning 2
• Recognize that succenturiate placenta is associated with increased risk of fetal distress, abruptio placentae, and non-reassuring fetal status during labor 3, 1

Mode of Delivery Decision

• Vaginal delivery is appropriate if no contraindications exist (such as vasa previa, placenta previa, or fetal distress) 2
• Cesarean delivery is indicated for standard obstetric indications including fetal compromise, arrest of labor, or if vasa previa is present 2, 3
• The presence of succenturiate lobe alone does not mandate cesarean delivery, unlike placenta accreta spectrum 4

Critical Intrapartum Management

• Alert the delivery team about the succenturiate placenta diagnosis before delivery to ensure heightened awareness for potential complications 1
• Monitor continuously for fetal distress, as the connecting vessels are vulnerable to compression during labor 3, 1
• Prepare for potential hemorrhage by ensuring large-bore IV access and having blood products readily available, given the increased risk of postpartum hemorrhage 1
• If abruption occurs (particularly of the succenturiate lobe), proceed to immediate cesarean delivery regardless of gestational age if fetal compromise or maternal instability develops 3

Essential Third Stage Management

• After placental delivery, perform meticulous gross examination to identify all lobes and ensure complete removal 2, 1
• Inspect for connecting vessels between the main placenta and succenturiate lobe, which typically traverse through membranes 2, 5
• If vessels are seen extending to torn membranes without an attached lobe, suspect retained succenturiate lobe and proceed to manual exploration of the uterus 1
• Manually explore the uterine cavity if there is any suspicion of retained placental tissue, as retained succenturiate lobes are a significant complication 1
• Consider ultrasound examination of the uterus if uncertainty exists about complete placental removal 1

Hemorrhage Prevention and Management

• Administer prophylactic uterotonics (oxytocin) immediately after delivery of the infant, as the risk of postpartum hemorrhage is significantly elevated 1
• Have additional uterotonic agents available (methylergonovine, carboprost, misoprostol) for management of atony or hemorrhage 1
• If excessive bleeding occurs (≥1,500 mL), re-dose prophylactic antibiotics 6
• Activate massive transfusion protocol early if significant hemorrhage develops, using a 1:1:1 ratio of packed red blood cells:fresh frozen plasma:platelets 6, 7

Postpartum Monitoring

• Monitor closely for delayed postpartum hemorrhage in the immediate postpartum period, as retained placental fragments can cause late bleeding 1
• Maintain vigilance for signs of infection if retained placental tissue is suspected 1
• Ensure hemoglobin monitoring and iron supplementation if significant blood loss occurred 8

Common Pitfalls to Avoid

• Do not confuse succenturiate placenta with placenta accreta spectrum – the former does not require cesarean hysterectomy or specialized multidisciplinary surgical planning 4
• Do not assume the placenta is complete after delivery of what appears to be an intact placenta – the succenturiate lobe may separate and be retained 1
• Do not delay manual exploration if torn vessels are visible at the membrane edge, as this indicates a retained lobe requiring immediate removal 1
• Do not underestimate hemorrhage risk – the incidence of postpartum hemorrhage is significantly higher with succenturiate placenta compared to normal placentas 1