What is the optimal management for placenta percreta in a woman with prior cesarean deliveries and placenta previa?

Optimal Management of Placenta Percreta

For a woman with prior cesarean deliveries and placenta previa diagnosed with placenta percreta, the standard of care is planned cesarean hysterectomy at 34 0/7 to 35 6/7 weeks gestation at a Level III/IV maternal care facility, with the placenta left in situ after fetal delivery—manual placental removal is absolutely contraindicated due to catastrophic hemorrhage risk. 1, 2, 3

Understanding Your Patient's Risk Profile

Your patient faces the highest-risk scenario in obstetrics. With placenta previa overlying a prior cesarean scar, she has entered a risk gradient that escalates dramatically: 11% risk with one prior cesarean, 40% with two, 61% with three, and 67% with five or more cesareans. 2, 3, 4 Placenta percreta—complete transmural invasion through the myometrium into bladder, bowel, or parametrial structures—carries a 44% failure rate if conservative management is attempted and a 17% severe adverse complication rate including sepsis, organ failure, or death. 1, 2

Antenatal Diagnosis and Imaging Strategy

Use gray-scale ultrasound as your first-line diagnostic tool (90.7% sensitivity, 96.9% specificity). 1, 2, 3 Look specifically for:

• Multiple placental lacunae (the most strongly associated finding) 1, 2
• Loss of the normal hypoechoic retroplacental zone 1, 2, 3
• Retroplacental myometrial thickness <1 mm 1, 2
• Disruption at the uterine serosa-bladder interface 1, 2, 3
• Direct extension of placental tissue into bladder or other organs (pathognomonic for percreta) 1, 2

Add color Doppler imaging to identify turbulent lacunar blood flow, increased subplacental vascularity, gaps in myometrial blood flow, and bridging vessels from placenta to uterine margin. 1, 2

Critical caveat: Absence of ultrasound abnormalities does NOT exclude placenta percreta—clinical risk factors (previa + prior cesarean) remain equally important predictors. 1, 2, 3 No combination of ultrasound findings reliably predicts depth of invasion. 1, 2

Reserve MRI for specific scenarios: posterior placenta previa, suspected percreta with organ involvement, or equivocal ultrasound findings—it is not a first-line modality. 2, 3

Delivery Planning: Timing and Location

Deliver at exactly 34 0/7 to 35 6/7 weeks gestation if hemodynamically stable. 2, 3, 4 This window balances neonatal maturity against maternal hemorrhage risk—approximately 50% of women who wait beyond 36 weeks require emergent delivery for hemorrhage. 2, 3

Deliver earlier than 34 weeks only if: persistent bleeding, preeclampsia, labor onset, membrane rupture, fetal compromise, or development of maternal comorbidities. 2

Mandatory facility requirements: Level III or IV maternal care center with immediate access to all resources below. 1, 2, 3

Assembling Your Multidisciplinary Team

Before delivery, confirm availability of:

• Maternal-fetal medicine physician (team leader) 2, 3, 4
• Gynecologic oncologist (essential for grade 3E percreta—these are the most experienced pelvic surgeons) 2, 5
• Urologic surgeon (for suspected bladder involvement) 1, 2, 5
• Interventional radiologist (for potential embolization or REBOA) 2, 5
• Obstetric anesthesiologist (experienced in massive transfusion) 2, 3
• Blood bank with massive transfusion protocol (1:1:1 to 1:2:4 ratio of packed RBCs:FFP:platelets) 1, 2
• ICU capabilities 2, 3, 4
• Neonatology team 2

Preoperative Optimization

Correct anemia during pregnancy with oral or IV iron supplementation. 2 Administer antenatal corticosteroids when delivery is planned before 37 weeks. 2

Notify blood bank early for anticipated large-volume transfusion needs. 2 Consider preoperative ureteric stent placement on a case-by-case basis if bladder involvement is suspected. 1

Controversial adjuncts with uncertain benefit: Prophylactic iliac artery balloon catheter placement showed no benefit in a small randomized trial and carries risks of arterial damage, occlusion, and infection—routine use is not recommended. 1 However, resuscitative endovascular balloon occlusion of the aorta (REBOA) is considered ideal for grade 3E disease when available. 2, 5

Surgical Technique: Step-by-Step Approach

Patient positioning: Dorsal lithotomy allows impromptu access to vagina and bladder with optimal pelvic visualization. 1

Skin incision: Use vertical midline incision for best access and visualization, or wide transverse incisions (Maylard or Cherney). 1

Inspect the uterus after peritoneal entry to discern placental invasion level and location—this guides your uterine incision approach. 1 Consider cystoscopy if bladder involvement is suspected on direct visualization. 1, 5

Make the uterine incision away from the placenta whenever possible—sometimes a nontraditional incision is necessary. 1, 2

After fetal delivery, rapidly close the uterine incision and verify that the placenta will not spontaneously deliver. 1

Do NOT attempt manual placental removal under any circumstances—this precipitates catastrophic hemorrhage. 1, 2, 3 Leave the placenta in situ and proceed immediately to hysterectomy. 1, 2

Perform total hysterectomy (not supracervical) because lower uterine segment or cervical bleeding frequently precludes supracervical approach. 1 Expect extensive vascular engorgement with challenging anatomy—this is why the most experienced pelvic surgeons must be involved from the outset. 1

Hemorrhage Management Protocol

Activate massive transfusion protocol immediately if bleeding is brisk. Transfuse packed RBCs, FFP, and platelets in a 1:1:1 to 1:2:4 ratio. 1, 2

Maintain maternal core temperature >36°C to preserve coagulation factor activity. 2

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

Conservative Management: When Is It Ever Appropriate?

For placenta percreta specifically, conservative management fails in 44% of cases and causes severe complications in 17%. 1, 2 The American College of Obstetricians and Gynecologists considers conservative or expectant management investigational and recommends it only for carefully selected cases after thorough counseling about uncertain benefits and substantial risks. 1, 2

If you encounter unexpected percreta at delivery without prior diagnosis and the patient is stable after fetal delivery: Pause the case, alert anesthesia, and transfer the patient to a facility with appropriate expertise rather than attempting hysterectomy without optimal resources. 1

Planned delayed hysterectomy approach (cesarean delivery with placenta left in situ, followed by interval hysterectomy at ~4 weeks) has been proposed for grade 3E disease when immediate safe resection is not feasible, but this remains investigational. 5

Common Pitfalls to Avoid

Never rely solely on imaging—even with negative ultrasound, the presence of placenta previa plus prior cesarean mandates full preparation for percreta at delivery. 2, 3

Never attempt manual placental removal if you encounter a retained placenta without a plane of separation—immediately prepare for possible hysterectomy and activate your multidisciplinary team. 2

Never delay delivery beyond 36 weeks in stable patients—the hemorrhage risk outweighs neonatal benefit. 2, 3

Never perform this surgery without a gynecologic oncologist for grade 3E percreta—these cases require the most experienced pelvic surgeons available. 2, 5

Pathologic Confirmation and Quality Improvement

Pathologic diagnosis requires absence of decidua basalis with direct placental attachment to or invasion through the myometrium. 2 However, 18-29% of clinically diagnosed cases lack histopathologic confirmation after hysterectomy, though many show uterine wall thinning <3 mm. 2

Establish feedback loops from pathology to radiology and surgical teams to evaluate diagnostic accuracy and improve future management outcomes. 2