What is the recommended management for a pregnant patient with placenta percreta and coexisting adenomyosis?

Management of Placenta Percreta with Coexisting Adenomyosis

Pregnant patients with placenta percreta and adenomyosis require 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 and manual removal absolutely contraindicated. 1, 2, 3

Critical Understanding of the Combined Risk

Adenomyosis substantially amplifies the already severe risks of placenta percreta. Adenomyosis independently increases the risk of postpartum hemorrhage (adjusted OR 2.7), postpartum transfusion (adjusted OR 2.2), disseminated intravascular coagulation (adjusted OR 9.3), and sepsis (adjusted OR 2.7) in pregnancy. 4 When combined with placenta percreta—which already carries a 44% failure rate for conservative management and 17% severe adverse complication rate—the hemorrhagic and infectious risks become compounded. 1, 2

The presence of adenomyosis creates abnormal myometrial architecture that may complicate surgical planes during hysterectomy and increase intraoperative blood loss beyond the already substantial risk inherent to percreta cases. 4

Antenatal Diagnosis and Surveillance

Ultrasound Imaging (First-Line)

• Gray-scale ultrasound demonstrates 90.7% sensitivity and 96.9% specificity for placenta percreta detection. 1, 2

• Key diagnostic findings include:

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

• Color Doppler adds critical information: turbulent lacunar flow, increased subplacental vascularity, gaps in myometrial perfusion, and bridging vessels from placenta to uterine margin. 1, 2

Critical Diagnostic Caveat

Negative ultrasound findings do NOT exclude placenta percreta—clinical risk factors (placenta previa plus prior cesarean) remain equally important predictors. 1, 2 No combination of ultrasound features reliably predicts depth of invasion. 2

Role of MRI

• MRI is NOT recommended as initial imaging because its incremental value over ultrasound is uncertain. 1, 2
• Consider MRI selectively for posterior placenta previa, suspected organ involvement beyond bladder, or equivocal ultrasound findings. 2

Delivery Timing and Location

Deliver at exactly 34 0/7 to 35 6/7 weeks gestation in a Level III/IV maternal care facility. 1, 2, 3 This narrow window balances neonatal maturity against maternal hemorrhage risk—approximately 50% of patients remaining pregnant beyond 36 weeks require emergent delivery for hemorrhage. 2, 3

Indications for Earlier Delivery

• Persistent bleeding, preeclampsia, labor onset, membrane rupture, fetal compromise, or developing maternal comorbidities mandate delivery before 34 weeks. 5, 2

Antenatal Corticosteroids

• Administer when delivery is planned before 37 0/7 weeks gestation. 5, 3

Essential Multidisciplinary Team Assembly

The following specialists must be physically present and immediately available:

• Maternal-fetal medicine physician (team leader) 1, 2, 3
• Gynecologic oncologist (essential for grade 3E percreta disease—these surgeons have the most experience with radical pelvic surgery) 1, 2, 3
• Urologic surgeon (mandatory when bladder involvement suspected, which is common in percreta) 1, 2, 3
• Interventional radiologist (for possible embolization or REBOA) 1, 2, 3
• Obstetric anesthesiologist experienced in massive transfusion protocols 1, 2, 3
• Blood bank prepared for massive transfusion with 1:1:1 to 1:2:4 ratio of packed RBCs:FFP:platelets 1, 2, 3
• Neonatology team for 34-35 week infant 5, 3
• ICU capabilities for postoperative hemodynamic monitoring 3

Delivering at a facility lacking these resources significantly increases maternal morbidity and mortality. 1

Preoperative Optimization

Hematologic Preparation

• Maximize hemoglobin using oral or intravenous iron supplementation throughout pregnancy. 5, 3
• Notify blood bank in advance of scheduled delivery date to ensure adequate product availability. 5, 3
• Autologous blood donation and hemodilution strategies are not routinely recommended. 5

Surgical Planning

• Consider prophylactic ureteric stent placement if bladder invasion is suspected on imaging. 2, 3
• Prophylactic iliac artery balloon catheter placement is NOT recommended—a small randomized trial showed no benefit and documented risks of arterial injury. 2
• Verify exact surgical suite location, confirm all consultations completed, and ensure massive transfusion protocol is activated before incision. 3

Surgical Technique

Incision Strategy

• Use vertical midline skin incision (or wide transverse such as Maylard/Cherney) for optimal pelvic exposure. 2
• Make uterine incision away from placenta whenever feasible—typically high transverse or fundal incision. 2, 3

Intraoperative Sequence

1. Deliver fetus through uterine incision remote from placenta 2, 3
2. Rapidly close uterine incision 2
3. Leave placenta completely in situ—NEVER attempt manual removal (this causes catastrophic hemorrhage) 1, 2, 3
4. Proceed immediately to total hysterectomy (supracervical approach avoided because lower-segment bleeding is common) 2

Critical Surgical Principle

Manual placental removal is absolutely contraindicated and precipitates life-threatening hemorrhage. 1, 2, 3 This recommendation is reinforced across all major guidelines and represents the single most important surgical principle in percreta management.

Adjunctive Measures

• Resuscitative endovascular balloon occlusion of the aorta (REBOA) is considered ideal for grade 3E percreta when available. 2
• Activate massive transfusion protocol immediately for brisk bleeding. 2, 3
• Maintain maternal temperature >36°C to preserve coagulation factor activity. 1, 3
• Consider tranexamic acid to reduce blood loss. 1, 3
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL. 3

Hemorrhage Management Protocol

Transfuse packed red blood cells, fresh frozen plasma, and platelets in 1:1:1 to 1:2:4 ratio during massive hemorrhage. 1, 2, 3 Early activation of massive transfusion protocol—before hemodynamic instability—improves outcomes. 3

Special Considerations for Adenomyosis

The presence of adenomyosis creates additional surgical challenges:

• Abnormal myometrial architecture may obscure tissue planes during hysterectomy 4
• Expect higher baseline blood loss given adenomyosis-associated 2.7-fold increased postpartum hemorrhage risk 4
• Maintain heightened vigilance for DIC (9.3-fold increased risk with adenomyosis) 4
• Monitor closely for sepsis (2.7-fold increased risk with adenomyosis) in postoperative period 4

Conservative Management is NOT Appropriate

Conservative (uterine-sparing) management is contraindicated in placenta percreta with adenomyosis. Even in isolated percreta without adenomyosis, conservative management fails in 44% of cases requiring subsequent hysterectomy, with 17% severe adverse complication rate including sepsis, organ failure, or death. 1, 2 The addition of adenomyosis—which independently increases infection, hemorrhage, and DIC risk—makes conservative management unacceptably dangerous. 4

The American College of Obstetricians and Gynecologists classifies conservative management as investigational even in optimal candidates. 5, 3

Management of Unexpected Intraoperative Diagnosis

If placenta percreta is discovered unexpectedly at delivery:

1. Immediately pause the case after fetal delivery 5, 3
2. Alert anesthesia and activate massive transfusion protocol 5, 3
3. Mobilize optimal surgical expertise (gynecologic oncology, urology) 5, 3
4. Transfer patient to appropriate facility if current center lacks necessary resources and patient remains hemodynamically stable 5, 1

Never attempt hysterectomy without optimal resources and expertise. 5

Postoperative Care

• ICU-level hemodynamic monitoring is mandatory. 3
• Maintain low threshold for reoperation if ongoing bleeding suspected. 3
• Monitor for Sheehan syndrome (postpartum pituitary necrosis) in cases with significant hypoperfusion. 3
• Watch for delayed sepsis given adenomyosis-associated 2.7-fold increased sepsis risk. 4

Common Pitfalls to Avoid

• Never attempt manual placental removal 1, 2, 3
• Never delay delivery beyond 36 weeks in stable patients 2, 3
• Never deliver at facility lacking massive transfusion capabilities 1, 3
• Never rely solely on ultrasound—integrate clinical risk factors even with negative imaging 2
• Never underestimate the compounded hemorrhagic risk when adenomyosis coexists with percreta 4