A pregnant woman with placenta percreta diagnosed by MRI presenting with vaginal bleeding at a facility lacking capability for management—what should the physician do?

Management of Placenta Percreta with Vaginal Bleeding at an Inadequate Facility

Refer the patient immediately with direct notification to the receiving department, ensuring stabilization measures are in place during transfer. 1

Immediate Physician Responsibilities

The American College of Obstetricians and Gynecologists explicitly states that when placenta accreta spectrum (including percreta) is encountered at a facility lacking expertise and the patient is stable after delivery of the fetus, the patient should be transferred to a facility that can perform the necessary level of care. 1 This principle applies even more urgently when the patient presents before delivery with active bleeding.

Why Option A (Refer with Notifying Department) is Correct

• Direct physician-to-physician communication with the receiving tertiary center is mandatory to ensure appropriate resources are mobilized before the patient arrives. 1
• The receiving facility needs advance notice to assemble the multidisciplinary team including maternal-fetal medicine subspecialists, gynecologic oncologists or experienced pelvic surgeons, urologists, interventional radiologists, obstetric anesthesiologists, and blood bank personnel capable of massive transfusion protocols. 1
• Placenta percreta requires delivery at a level III or IV maternal care center with considerable experience, as outcomes are significantly improved with coordinated multidisciplinary care. 1

Pre-Transfer Stabilization Protocol

Before transport, the referring physician must:

• Establish large-bore intravenous access (two sites minimum) for rapid fluid and blood product administration. 2, 3
• Activate massive transfusion protocol and begin transfusion if significant bleeding is present, without waiting for laboratory results. 2, 3
• Obtain baseline laboratory studies including complete blood count, type and crossmatch for at least 4-6 units of packed red blood cells, coagulation panel, platelet count, and fibrinogen level. 2
• Maintain maternal temperature above 36°C during stabilization, as clotting factors function poorly at lower temperatures. 2, 3
• Consider tranexamic acid administration (1 gram IV over 10 minutes) to reduce blood loss during transfer. 2, 3

Critical Communication Elements

When notifying the receiving department, provide:

• Gestational age and confirmation of placenta percreta diagnosis by MRI 1
• Current hemodynamic status and volume of vaginal bleeding 1
• Prior cesarean deliveries or uterine surgeries (risk increases 7-fold after one cesarean, up to 56-fold after three cesareans) 4
• Blood products administered and current laboratory values 1
• Estimated time of arrival 1

Why Other Options Are Inadequate

Option B (Refer upon patient's request) is dangerous and inappropriate because it delays life-saving transfer and places the burden of decision-making on a patient who may not understand the severity of her condition. 1

Option C (Discharge with referral form) is medically negligent for a patient with active vaginal bleeding and placenta percreta, as she requires continuous monitoring and immediate access to resuscitation during transport. 1, 2

Option D (Discharge and tell her to go to tertiary hospital) is equally negligent because it provides no medical oversight during transfer and no coordination with the receiving facility. 1

Common Pitfalls to Avoid

• Do not attempt cesarean delivery at an inadequate facility even if bleeding worsens—temporary measures including abdominal packing and tranexamic acid infusion should be used while arranging emergent transfer. 2
• Do not delay transfer waiting for "optimal" stabilization—placenta percreta can deteriorate rapidly, and transfer should occur as soon as basic resuscitation is initiated. 1
• Do not assume the patient can self-transport—medical transport with monitoring and resuscitation capability is essential. 1, 2
• Failure to notify the receiving center in advance can result in catastrophic delays in assembling the necessary surgical team and blood products. 1