Management of Placenta Percreta
Placenta percreta requires planned cesarean hysterectomy with the placenta left in situ at 34 0/7 to 35 6/7 weeks of gestation, performed by a multidisciplinary team at a Level III or IV maternal care facility with massive transfusion capability. 1
Delivery Location and Team Assembly
Transfer to a Level III or IV maternal care facility is mandatory if not already at one, as outcomes are significantly optimized when delivery occurs at centers experienced with placenta accreta spectrum. 1, 2
The multidisciplinary team must include:
- Maternal-fetal medicine specialists 1, 2
- Gynecologic oncology or female pelvic medicine surgeons 2
- Anesthesiology with massive transfusion experience 3, 2
- Neonatology 3, 2
- Blood bank with massive transfusion protocol capability 3, 2
- Interventional radiology (available but not routinely used) 2
Optimal Timing of Delivery
Schedule cesarean hysterectomy at 34 0/7 to 35 6/7 weeks of gestation in stable patients, as decision analysis demonstrates this window optimally balances neonatal outcomes against maternal hemorrhage risk. 1, 2
Do not delay delivery beyond 36 0/7 weeks, as approximately 50% of women with placenta accreta spectrum beyond 36 weeks require emergent delivery for hemorrhage. 2, 4
Earlier delivery is required for:
- Persistent bleeding 1
- Preeclampsia 1
- Labor or rupture of membranes 1
- Fetal compromise 1
- Developing maternal comorbidities 1
Preoperative Optimization
Coordinate with the blood bank for massive transfusion protocol activation, as blood loss can be massive (median 3,000 mL in immediate hysterectomy cases). 2, 5
Optimize hemoglobin preoperatively by:
- Evaluating and aggressively treating iron deficiency anemia 3, 2
- Using oral iron replacement 2
- Considering intravenous iron infusions 3, 2
- Considering erythropoietin-stimulating agents when indicated 2
Perform thorough preoperative evaluation including airway assessment, hemoglobin levels, and coagulation status. 3
Anesthetic Management
Neuraxial anesthesia (combined spinal-epidural) is preferred as it provides benefits including maternal awareness during delivery. 3
Prepare for massive transfusion with cell salvage technology available when possible. 3
Consider tranexamic acid to reduce blood loss. 3
Surgical Approach: The Gold Standard
The definitive management is planned cesarean hysterectomy with placenta left in situ. 1, 2
Critical Surgical Principles:
Never attempt placental removal, as this causes catastrophic hemorrhage. 2, 4
Deliver the fetus through a uterine incision that avoids the placenta when possible. 2
Ligate the umbilical cord close to the placenta and proceed directly to hysterectomy without attempting placental separation. 2
Have massive transfusion protocol activated and ready before beginning the procedure. 2
For cases with suspected bladder involvement, consider ureteric stent placement and collaboration with urologic surgeons. 4
Intraoperative Hemorrhage Management
If massive bleeding occurs, transfuse in 1:1:1 to 1:2:4 ratio (packed RBCs:FFP:platelets). 1, 3
Administer tranexamic acid to reduce blood loss. 3
Monitor fibrinogen levels closely and maintain maternal temperature >36°C for optimal clotting factor function. 4
Activate massive transfusion protocol early rather than late. 3
Be prepared for vasopressor support as needed. 3
Alternative Management: Delayed Hysterectomy (Selected Cases Only)
While immediate cesarean hysterectomy is the gold standard, delayed hysterectomy 4-6 weeks after delivery may be considered in highly selected cases where intraoperative assessment suggests it is feasible. 5
Evidence shows delayed hysterectomy results in:
- Significantly lower blood loss (median 750 mL vs 3,000 mL for immediate hysterectomy) 5
- Lower transfusion requirements (0 units vs 4 units median) 5
- Fewer patients requiring ≥4 units transfusion (14.2% vs 45%) 5
However, this approach requires:
- Fetal surgery technique for hysterotomy to minimize blood loss 5
- Leaving placenta completely in situ 5
- Close monitoring for complications 5
- Readiness for emergency hysterectomy if bleeding occurs 5
Conservative/expectant management is investigational and carries significant risks, including 22-42% still requiring hysterectomy, 28% developing infection/febrile morbidity, and 6% experiencing severe morbidity (sepsis, organ failure, death). 1, 2
Postoperative Care
Plan for potential ICU monitoring given risks of ongoing bleeding, fluid overload, and renal failure. 3, 2
Monitor for complications including:
- Renal failure 3
- Liver failure 3
- Infection 3
- Unrecognized injuries 3
- Pulmonary edema 3
- Disseminated intravascular coagulation 3
- Sheehan syndrome (postpartum pituitary necrosis) in cases with significant hypoperfusion 3
Maintain low threshold for reoperation if ongoing bleeding is suspected. 2
Monitor for delayed complications including infection and thromboembolic events. 2
Critical Pitfalls to Avoid
Never attempt manual placental removal, as this causes catastrophic hemorrhage and is the most common preventable error. 2, 4
Do not delay delivery beyond 36 weeks in a stable patient. 2
Do not deliver at a facility without massive transfusion capability and experienced surgical team. 2
If placenta percreta is encountered unexpectedly at delivery, temporarily pause the case until optimal surgical expertise can be mobilized, assuming maternal and fetal stability allow. 1, 3
If the delivering center lacks expertise and the patient is stable after fetal delivery, transfer to a facility that can perform the necessary level of care. 1