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Management of the placenta accreta spectrum (placenta

accreta, increta, and percreta)
Aut hors: Robert Resnik, MD, Robert M Silver, MD
Sect ion Editors: Charles J Lockwood, MD, MHCM, Deborah Levine, MD
Deput y Editor: Vanessa A Barss, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.

Lit erat ure review current t hrough: Dec 2019. | T his topic last updat ed: Nov 20, 2019.

INTRODUCTION

Management of pat ient s wit h placent a accret a spect rum (PAS; placent a accret a, incret a, or
percret a) varies widely in t he Unit ed St at es []. Alt hough t he impact of PAS on pregnancy out comes is
well described, no randomized t rials and few st udies have examined t he management of pregnancies
complicat ed by t his disorder. As a result , recommendat ions for it s management are based on case
series and report s, personal experience, expert opinion, and good clinical judgment .

The management of placent a accret a, incret a, and percret a will be discussed here and is essent ially
t he same, except when a percret a ext ends t o ext raut erine t issue. Unless ot herwise not ed, t he
following discussion of management of PAS applies t o all dept hs of placent al invasion. The clinical
feat ures and diagnosis of PAS are reviewed separat ely. (See "Clinical feat ures and diagnosis of
placent a accret a spect rum (placent a accret a, incret a, and percret a)".)

PRENATAL CARE

All pat ient s wit h suspect ed PAS should be counseled about t he diagnosis and pot ent ial sequelae (eg,
hemorrhage, blood t ransfusion, cesarean hyst erect omy, mat ernal int ensive care unit admission).
Consult at ion wit h a mat ernal-fet al medicine specialist is desirable, and t ransfer t o a Cent er of
Excellence for placent a accret a is st rongly advised [1]. At a minimum, in t he Unit ed St at es t he pat ient
should deliver at a facilit y where she can receive level III mat ernal care [2]. Some women may
consider pregnancy t erminat ion, but no dat a are available regarding whet her and how much t his may
reduce mat ernal risk.

For pat ient s wit h placent a previa-accret a, prenat al care follows t ypical guidelines for management of
placent a previa (see "Placent a previa: Management "):

● Correct ion of iron deficiency anemia, if present . (See "Anemia in pregnancy", sect ion on
'Treat ment of iron deficiency'.)

● Ant enat al cort icost eroids bet ween 23 and 34 weeks of gest at ion for pregnancies at increased
risk of delivery wit hin seven days (eg, ant epart um bleeding).

● Ant i-D immune globulin if vaginal bleeding occurs and t he pat ient is RhD-negat ive.

● Avoidance of pelvic examinat ion and rigorous act ivit y. Many clinicians recommend avoidance of
sexual act ivit y, alt hough any benefit is unproven.

● Considerat ion of bed rest and/or hospit alizat ion in t he t hird t rimest er in t he set t ing of vaginal
bleeding, cont ract ions, or residence at a remot e dist ance from a cent er of excellence for PAS.
Asympt omat ic women can be followed as out pat ient s as long as t hey are appropriat ely
counseled and can get t o t he hospit al rapidly if sympt oms develop [3].

Aut ologous donat ion is generally not useful because most pat ient s who require t ransfusion at delivery
require more unit s t han t hey can safely donat e prenat ally.

Nonst ress t est s and/or biophysical profile scores are not performed rout inely, but are used in
pregnancies t hat have st andard indicat ions for t hese t est s (eg, fet al growt h rest rict ion, preeclampsia,
oligohydramnios). (See "Overview of ant epart um fet al surveillance".)

Serial sonographic assessment of t he placent a is generally not useful aft er t he diagnosis of accret a,
incret a, or percret a has been made. However, a sonogram at 32 t o 34 weeks can precisely locat e t he
placent a and help t o assess t he likelihood of bladder involvement . This informat ion is useful for
surgical planning and delivery.

PREPARATION FOR DELIVERY

Components of preoperative planning — It is crit ical t o develop a plan preoperat ively for managing
women wit h a high likelihood of PAS. The goal is t o provide informat ion (informed consent ) and plan
int ervent ions t hat will reduce t he risk of massive hemorrhage, as well as it s subst ant ial morbidit y and
pot ent ial mort alit y. Cesarean hyst erect omy is usually performed because t he placent a cannot be
removed in any ot her way and, if left in sit u, subinvolut ion oft en result s in post part um hemorrhage.
Specific component s of preoperat ive planning and care t hat should be addressed include [4]:

● Informed consent – Discussion of pot ent ial int raoperat ive complicat ions and int ervent ions (eg,
severe hemorrhage, blood t ransfusion, injury t o or part ial resect ion of bladder and bowel,
hyst erect omy t o cont rol bleeding, risk of post operat ive vesico-vaginal fist ula).

● Multidisciplinary care team – Management by a mult idisciplinary t eam and delivery in a t ert iary
care facilit y improve out comes and lower complicat ion rat es [5-7]. We schedule a
mult idisciplinary conference wit h all t he key care part icipant s at least t wo weeks prior t o planned
delivery t o ensure t hat all necessary preparat ions are complet ed and management plans
implement ed.

The mult idisciplinary t eam includes mat ernal-fet al medicine specialist s, anest hesiologist s,
neonat ologist s, int ervent ional radiologist s, and blood bank and nursing personnel. It is desirable t o
have a surgeon in t he operat ing room who has ext ensive experience wit h wide dissect ion of t he
paramet rium and explorat ion of t he ret roperit oneum in t he event t his expert ise is required for
cont rol of bleeding, bladder resect ion, and/or isolat ion, part ial resect ion, and/or reimplant at ion of
t he uret ers. Some obst et rician-gynecologist s have t his experience; general surgeons, urologist s,
and vascular surgeons also have expert ise in t his area. A urogynecologist , urologist , or
gynecologic oncologist should be consult ed in cases where t here is expect ed bladder
involvement or if t he surgeon does not have t he requisit e surgical expert ise.

If an appropriat e mult idisciplinary t eam and support services are not available at t he sit e t he
pat ient plans delivery, she should be t ransferred t o a t ert iary facilit y t hat has t he capabilit y t o
most effect ively manage major int raoperat ive hemorrhage and provide post operat ive int ensive
care.

● Scheduled delivery – Delivery should be scheduled for opt imal availabilit y of necessary
personnel and facilit ies. Planned delivery is associat ed wit h less int raoperat ive blood loss t han
emergency delivery []. However, a subst ant ial percent age of pat ient s develop complicat ions
leading t o delivery earlier t han planned []. (See 'Scheduled' below and 'Unscheduled' below.)

Delivery in an operat ing room wit h capabilit y for fluoroscopy avoids t he need t o t ransfer pat ient s
t o t he radiology depart ment when procedures by int ervent ional radiologist s are indicat ed [].

● Intravenous access – At least t wo large bore int ravenous cat het ers should be placed.

● Thromboembolism prophylaxis – Pneumat ic compression devices should be placed as surgery,

major hemorrhage, and blood t ransfusion all increase t he risk of post part um venous t hrombosis.
● Blood products – The Blood Bank should be not ified and adequat e red blood cells, fresh frozen
plasma, cryoprecipit at e, and plat elet s should be available at delivery as t he median est imat ed
blood loss of 2.5 t o 7.8 lit ers has been report ed [6,8-10]. The magnit ude of blood loss is difficult
t o predict ant epart um [11]. In one ret rospect ive series of 66 pat ient s wit h placent a accret a, 95
percent received t ransfusions and t he range of blood component usage was 0 t o 46 red blood
cell unit s, 0 t o 48 random-donor plat elet unit equivalent s, 0 t o 64 plasma unit s, and 0 t o 30
cryoprecipit at e unit s. The mean red blood cell use was 10±9 unit s; median 6.5 unit s [12].

A massive hemorrhage prot ocol is useful for managing laborat ory evaluat ion and t ransfusion
(algorit hm 1).

Use of int raoperat ive cell salvage should be considered. (See "Post part um hemorrhage:
Management approaches requiring laparot omy", sect ion on 'Role of int raoperat ive cell salvage'.)

Counseling and opt ions for pat ient s who refuse blood t ransfusion are discussed in det ail
separat ely. (See "The approach t o t he pat ient who declines blood t ransfusion".)

● Drugs

• Tranexamic acid inhibit s fibrin degradat ion and reduces t he risk of deat h due t o post part um
bleeding. However, efficacy specifically in PAS (eit her as t reat ment for act ive bleeding or as
a prophylact ic agent ) is uncert ain. (See "Post part um hemorrhage: Medical and minimally
invasive management ", sect ion on 'Administ er t ranexamic acid'.)

• Use of recombinant VIIa for cont rol of obst et ric hemorrhage is under invest igat ion and use
specifically for bleeding from placent a accret a has not been widely report ed. (See
"Post part um hemorrhage: Medical and minimally invasive management ", sect ion on
'Recombinant fact or VIIa'.)

● Bladder – A t hree-way Foley cat het er and uret eral st ent s should be available in case t hey are
needed t o assess int egrit y of t he urinary t ract . This is crit ical in cases of bladder resect ion.
Preoperat ive placement of uret eric st ent s may be most useful in women wit h a percret a, given
t he likelihood t hat hyst erect omy will be complicat ed [3]. However, t hey are of unproven efficacy
and very rarely can be associat ed wit h complicat ions [13].

Rout ine preoperat ive cyst oscopy is not recommended [3].

● Anesthesia – General anest hesia is most commonly performed [14]. Regional anest hesia,
t ypically wit h cont inuous epidural, has been used successfully in scheduled deliveries [14].
However, t he t eam should be prepared t o convert t o general anest hesia if necessary [15].
 ● Positioning – Placing t he pat ient in a lit hot omy posit ion or wit h legs flat on t he t able but
separat ed provides access t o t he vagina and cervix, which can facilit at e hyst erect omy [3]. It is
also import ant t o be able t o assess bleeding t hrough t he vagina t hat may occur int raoperat ively.
Such bleeding may not be appreciat ed in t he abdominal cavit y unt il t he pat ient has cardiovascular
decompensat ion.

● Postoperative care – An int ensive care unit bed should be available for post operat ive care, if
needed. (See 'Post operat ive care' below.)

Endovascular intervention for hemorrhage control — Prophylact ic endovascular int ervent ion wit h
a balloon cat het er, art erial embolizat ion, or a combinat ion of t he t wo may be used t o decrease
hemorrhage during or aft er deliveries of pregnancies wit h abnormal placent al implant at ion. Choice is
dependent on t he operat or’s expert ise and t he available equipment . The value of endovascular
int ervent ion remains cont roversial and it is not possible t o predict which pat ient s are most likely t o
benefit from t his procedure [3]. Unt il a large mult icent er randomized t rial is performed, t he value of
t he procedure will not be clear. Some of t he cont ribut ors (RR, CL) t o t his t opic use a prophylact ic
balloon cat het ers, and ot hers (RS) do not .

In a met a-analysis of endovascular int ervent ional radiology procedures before surgery in over 950
pregnancies wit h PAS, t he int ervent ion was associat ed wit h reduced blood loss (mean difference
-1.02 L, 95% CI -1.60 t o -0.43 L) and a reduced risk of blood loss ≥2.5 L (odds rat io 0.18, 95% CI 0.04-
0.78), which did not t ranslat e int o a st at ist ically significant reduct ion in red cell t ransfusion; evidence
was very low qualit y [16]. Approximat ely 5 percent of pat ient s had procedure-relat ed complicat ions. A
meaningful comparison among t echniques was not possible because of t he small number of cases for
some t echniques.

● Risks – While cat het er relat ed complicat ions have been report ed in small observat ional series,
reliable dat a on complicat ion rat es in t his clinical set t ing are not available. However, t he risk of a
vascular complicat ion wit h percut aneous coronary art ery int ervent ion using femoral art ery
access, an analogous procedure, is approximat ely 3 percent [17-20]. Groin or ret roperit oneal
hemat oma is t he most common, most not requiring t ransfusion. Rare cases of t hrombot ic and
embolic complicat ions requiring st ent placement and/or art erial bypass have been report ed in
pat ient s undergoing delivery using endovascular hemorrhage cont rol [18].

● Planning – If prophylact ic endovascular int ervent ion is planned, t he pat ient should undergo
delivery on a fluoroscopy t able so t hat t he procedure can be performed int raoperat ively
immediat ely aft er delivery of t he infant .

● Procedure – Preoperat ively under fluoroscopic guidance, an angiographer insert s a cat het er int o
each femoral art ery and guides it t o t he desired t arget vessel. For embolizat ion, an agent t hat
 allows for t emporary vessel occlusion (eg, Gelfoam) is deployed aft er delivery of t he infant .

For balloon occlusion, balloon-t ipped cat het ers are int roduced int o t he t arget art ery. Aft er
delivery of t he newborn, t he balloons can be inflat ed int ermit t ent ly for up t o 20 minut es t o
reduce bleeding in t he operat ive field, which facilit at es placement of clamps and sut ures and
decreases t ot al blood loss. Use of a pressure manomet er-endoflat or allows inflat ion and deflat ion
of t he balloons t o pressure wit hout t he use of fluoroscopy [21]. The cat het ers may be left in sit u
for several hours post operat ively, and used for select ive embolizat ion of small pelvic vessels if
post operat ive bleeding occurs. They are removed under fluoroscopic guidance. In a modificat ion
of t his st andard approach, t he balloon-t ipped cat het ers are placed before surgery, t he ut erine
and abdominal incisions are closed aft er t he infant is delivered, and t he pat ient is t ransferred t o
t he angiography unit for embolizat ion of t he ut eroplacent al bed [22]. The pat ient is t hen
immediat ely ret urned t o t he operat ing room for hyst erect omy. In eight cases in which t his st aged
procedure was ut ilized, blood loss was significant ly less t han t hat in pat ient s undergoing
hyst erect omy wit hout embolizat ion (mean 553 mL versus 4517 mL). This approach requires
furt her st udy t o det ermine safet y and efficacy compared wit h t he st andard approach.

Prophylact ic use of resuscit at ive endovascular balloon occlusion of t he aort a (REBOA) has been
described in a small number of women wit h abnormal placent at ion. Because experience in t he
obst et ric set t ing is ext remely limit ed [23-28] and t he pot ent ial for morbidit y is high, we are not
using it unt il adequat e dat a of safet y and efficacy in pregnant and post part um pat ient s are
available. Use of REBOA in nonobst et ric set t ings is reviewed separat ely. (See "Endovascular
met hods for aort ic cont rol in t rauma", sect ion on 'REBOA t echnique'.)

DELIVERY

Unscheduled — A subst ant ial percent age of pat ient s develop complicat ions, such as pret erm
premat ure rupt ure of membranes, pret erm labor, or ant epart um bleeding, leading t o delivery earlier
t han planned. Women wit h act ive bleeding should be delivered wit hout a delay t o administ er ant enat al
cort icost eroids [29].

Alt hough out comes are st ill favorable wit h emergency delivery in cent ers of excellence [10,30],
planned delivery before 34 weeks may be reasonable for women at high risk of emergency delivery
before 34 t o 35 weeks (t he usual gest at ional age for scheduled delivery) [30].

Scheduled — The opt imum gest at ional age for scheduled delivery is cont roversial, and high-qualit y
dat a are lacking. The risks of pret erm birt h must be weighed against t he risk of complicat ions, such as
bleeding, leading t o emergency delivery under subopt imal circumst ances.
We advise elect ive delivery bet ween 34+0 and 35+6 weeks of gest at ion in st able (no bleeding or
pret erm labor) pat ient s, in agreement wit h t he American College of Obst et ricians and Gynecologist s
[2]. Ant enat al cort icost eroids are administ ered according t o st andard guidelines. (See "Ant enat al
cort icost eroid t herapy for reduct ion of neonat al respirat ory morbidit y and mort alit y from pret erm
delivery".)

Most women wit h no bleeding, cont ract ions, or rupt ure of membranes remain st able t hrough 36 weeks
of gest at ion [31]. For t hose who become unst able bet ween 34 and 36 weeks, out comes wit h
emergency delivery st ill appear t o be favorable in cent ers of excellence [10]. Therefore, we
individualize t iming of planned delivery wit hin t his int erval based on clinical sympt oms, obst et ric
hist ory (eg, prior pret erm birt h), cervical lengt h, and logist ical considerat ions (dist ance from a cent er
of excellence). Delivery beyond 36 weeks is not advised because t he favorable effect s of expect ant
management on fet al mat urat ion at t his gest at ional age decrease and are small compared wit h t he
increasing and subst ant ial mat ernal risk if labor leads t o hemorrhage.

This approach is support ed by st udies report ing favorable out comes at 34 t o 35 weeks of gest at ion,
as well as a decision analysis concluding t hat 34 weeks gest at ion is opt imal [6,32,33]. The Societ y for
Mat ernal-Fet al Medicine recommends delivery bet ween 34 and 37 weeks of gest at ion for st able
women wit h placent a accret a [29]. An int ernat ional panel suggest ed delivery at ≥36+0 weeks in
asympt omat ic women (no bleeding, rupt ure of membranes, or pret erm labor) and no hist ory of pret erm
birt h [3]. They suggest ed delivery at around 34+0 weeks in women wit h a previous pret erm birt h,
mult iple episodes of minor bleeding, or a single episode of subst ant ial bleeding. As discussed above,
t he aut hors favor aiming for delivery closer t o 34 weeks of gest at ion (rat her t han 36 weeks) in most
cases, alt hough t he opt imal t iming of delivery remains cont roversial and individualized management is
appropriat e.

Surgical principles — A definit ive decision regarding conservat ive management or cesarean
hyst erect omy should be made preoperat ively. We, and ot hers [2,9,34,35], recommend cesarean
hyst erect omy wit h t he placent a left undist urbed in sit u when t he prenat al diagnosis of placent a
accret a is reasonably cert ain based on imaging st udies and/or clinical risk fact ors, part icularly in
women wit h placent al implant at ion at t he sit e of prior ut erine surgery (see "Clinical feat ures and
diagnosis of placent a accret a spect rum (placent a accret a, incret a, and percret a)"). This decreases
blood loss and associat ed complicat ions [9,32]. In addit ion, we ensure comprehensive blood product
replacement and consider int ervent ional radiologic t echniques (eg, placement of prophylact ic
occlusion balloon cat het ers in bot h int ernal iliac art eries, ut erine art ery embolizat ion) t o decrease
blood loss. (See 'Endovascular int ervent ion for hemorrhage cont rol' above.)

In cases where a placent a accret a has been dist urbed at delivery and is hemorrhaging, conservat ive
measures are rarely effect ive and endanger t he pat ient by delaying performance of hyst erect omy.
During t he delay, massive hemorrhage can lead t o a downward spiral charact erized by hypoperfusion
of all organ syst ems, hypot hermia, coagulopat hy, and met abolic acidosis. (See 'Unexpect ed placent a
accret a' below.)

Procedure

Cesarean hysterectomy — We t ypically make a vert ical midline skin incision or a Cherney incision
(figure 1); however, ot hers may choose t o make a t ransverse incision (eg, Pfannenst iel) in cases wit h a
low likelihood of int raoperat ive complicat ions (eg, post erior placent a not ext ending t o t he serosa) [3].
The pelvis is inspect ed for signs of percret a and t he locat ion of any collat eral blood supply before
proceeding wit h t he ut erine incision.

An int raoperat ive ult rasound examinat ion is useful t o map t he placent al edge and det ermine t he best
posit ion for t he hyst erot omy incision, which should avoid t ransect ing t he placent a. We make a vert ical
hyst erot omy at least t wo fingerbreadt hs above t he placent al edge; leaving a myomet rial margin
bet ween t he placent a and incision helps t o prevent disrupt ion of t he placent a during opening or
closing of t he ut erus.

Aft er delivery of t he infant , t he cord is cut , t he ut erine incision is rapidly closed t o decrease blood
loss, and hyst erect omy is performed. Even in t he absence of ext raut erine involvement by a percret a,
t he procedure is oft en difficult because of ext ensive paramet rial vascular engorgement and friable
t issues. Management of peripart um hyst erect omy is discussed separat ely. (See "Peripart um
hyst erect omy for management of hemorrhage".)

Prophylact ic oxyt ocin is not rout inely administ ered aft er delivery because it may lead t o part ial
placent al separat ion and, in t urn, increased bleeding [3]. However, if t he placent a has been most ly or
complet ely removed or bleeding is already heavy, t hen ut erot onic drugs should be given. Management
of post part um hemorrhage is discussed separat ely. (See "Post part um hemorrhage: Management
approaches requiring laparot omy".)

We avoid int ernal iliac (hypogast ric) art ery ligat ion because it is t ime consuming, operat or dependent ,
ineffect ive (wit hout hyst erect omy) for cont rolling pelvic hemorrhage in up t o 60 percent of cases
[36-38], and precludes use of select ive pelvic angiography and embolizat ion if needed subsequent ly.
(See "Management of hemorrhage in gynecologic surgery", sect ion on 'Int ernal iliac art ery ligat ion'.)

Management of placenta percreta with bladder invasion — Placent a percret a wit h bladder

invasion may require part ial cyst ect omy. In one review of 54 cases of placent a percret a invading t he
bladder, part ial cyst ect omy was performed in 24 of t he 54 pat ient s []. Ideally, a urogynecologist ,
urologist , or gynecologic oncologist should be consult ed when t he bladder is involved. Cyst oscopy or
int ent ional cyst ot omy at surgery is oft en helpful for assessing t he degree of bladder, and possible
uret eral, involvement [].

CONSERVATIVE MANAGEMENT OF PLACENTA ACCRETA

Ut erine conservat ion may be considered when t he pat ient very much want s t o preserve her fert ilit y.
She should be counseled ext ensively regarding t he risks of hemorrhage, infect ion, possible need for
int ra- or post operat ive lifesaving hyst erect omy, and even deat h, as well as subopt imal out comes
(including recurrence or hemorrhage []) in fut ure pregnancies. Ut erine conservat ion is also considered
when hyst erect omy is t hought t o have an unaccept ably high risk of hemorrhage or injury t o ot her
organs, which may be mit igat ed by leaving t he placent a in sit u [].

Uterine conservation with the placenta left in situ — In t his approach (called expect ant
management ), t he placent a is left in sit u aft er delivery of t he newborn and ligat ion of t he cord at it s
placent al insert ion sit e. The hyst erot omy is closed in t he st andard way; ut erot onic drugs, compression
sut ures, int raut erine balloon t amponade, ut erine art ery embolizat ion, and/or ut erine art ery ligat ion are
used, as needed, t o manage post part um hemorrhage, but not prophylact ically [3,39]. Adjunct ive
t herapy wit h met hot rexat e t herapy has been t ried, wit h no convincing evidence t hat it improves any
out come in t hese cases and clear evidence of drug-relat ed harms (eg, pancyt openia, nephrot oxicit y);
it should not be used [3]. Delayed hyst eroscopic resect ion of placent al remnant s has been used
successfully t o expedit e resolut ion of t he placent a or t reat delayed bleeding and/or pelvic pain, but
experience is limit ed [40-42]. Delayed-int erval hyst erect omy is anot her opt ion, part icularly for
pat ient s wit h placent a percret a, but experience is limit ed [43,44] and expert s have recommended
against it [3].

The immediat e complicat ions, as well as long-t erm out comes, of women who undergo ut erine
conservat ion indicat e t hat t his approach should be at t empt ed only rarely, in fully informed pat ient s, or
as part of approved clinical t rials. This is consist ent wit h a Commit t ee Opinion of t he American
College of Obst et ricians and Gynecologist s [].

The prolonged course and significant risks of ut erine conservat ion wit h t he placent a left in sit u were
illust rat ed by a syst emat ic review of 10 cohort st udies and 50 case series or case report s describing
434 pat ient s wit h placent a accret a, incret a, or percret a managed conservat ively (expect ant
management , ut erine art ery embolizat ion, met hot rexat e t herapy, hemost at ic sut ures, art erial ligat ion,
balloon t amponade) [45]. The following short -t erm out comes were report ed, but dat a were not
available for all out comes in all st udies:

● Severe vaginal bleeding: 53 percent

● Sepsis: 6 percent
 ● Secondary hyst erect omy: 19 percent (range 6 t o 31 percent )
● Deat h: 0.3 percent (range 0 t o 4 percent )
● Subsequent pregnancy: 67 percent (range 15 t o 73 percent )

In t he largest st udy, which included 167 women wit h placent a accret a managed conservat ively using a
variet y of modalit ies [46], 131 women (78 percent ) ret ained t heir ut erus, 18 women required
hyst erect omy wit hin 24 hours of delivery because of hemorrhage, and 18 women underwent
hyst erect omy because of complicat ions at a median 39 days aft er delivery (range 9 t o 105 days). Ten
women experienced severe morbidit y, including sepsis, vesicout erine fist ula, and/or ut erine necrosis. In
women who ret ained t heir ut erus, placent al resorpt ion was observed on follow-up at a median of 13.5
weeks (range 4 t o 60 weeks). However, 25 percent of t hese women underwent hyst eroscopy,
curet t age, or bot h t o remove ret ained placent al t issue at a median of 20 weeks post part um (range 2
t o 45 weeks).

Long-t erm reproduct ive out comes following conservat ive management appear t o be subopt imal, but
dat a are limit ed []. Alt hough t here appears t o be an increased risk of developing int raut erine synechiae,
most women who desire anot her pregnancy are able t o conceive and are at increased risk of recurrent
placent a accret a. This is expect ed since t he underlying abnormalit y of t he endomet rium has not been
correct ed and can be worsened by post part um curet t age. A ret rospect ive mult icent er st udy of 96
women wit h a hist ory of conservat ive management of placent a accret a (ie, ut erine preservat ion)
observed t hat 8 had severe int raut erine synechiae and were amenorrheic []. In t hree cases series wit h
9, 21, and 30 deliveries aft er conservat ive management of placent a accret a, recurrent placent a
accret a was not ed in 12 of t he 60 subsequent deliveries (20 percent , range 13 t o 29 percent ) [].

Anot her considerat ion is t hat it is not possible t o be cert ain t hat women undergoing conservat ive
management t ruly had morbidly adherent placent a since t hey do not have hist ologic confirmat ion
aft er hyst erect omy. These women may comprise a different populat ion at less risk for serious
bleeding t han women requiring hyst erect omy. For example, cases of morbidly adherent placent a
managed conservat ively had lower rat es of prior cesarean delivery and previa t han t hose managed
wit h hyst erect omy [5,6,32,46].

Uterine conservation with placental resection — Ut erine conservat ion wit h placent al resect ion may
be successful wit hout excessive risk in t wo clinical set t ings:

● Focal accreta – Focal accret a may be suspect ed on t he basis of imaging findings ant epart um or
det ect ed int rapart um because of hemorrhage and/or a part ially ret ained placent a at delivery.
There are a few report s describing cases of successful ut erine conservat ion in t hese cases [47-
49]. Pot ent ial candidat es for t his approach are women wit h a clearly delineat ed focal area of
morbidly adherent placent a (adherent area <50 percent of t he ant erior surface of t he ut erus [3])
 and an accessible border of healt hy myomet rium [39]. Management involves oversewing t he
bleeding sit es or removing a small wedge of ut erine t issue cont aining t he focally adherent
placent a (placent al-myomet rial en bloc excision and repair).

Anot her approach t o ut erine conservat ion wit h placent al resect ion is t he t riple P procedure [50].
This involves pelvic devascularizat ion as well as removal of part of t he ut erus [50]. It has only
been report ed in a small number of cases.

● Fundal or posterior placenta accreta – In cont rast t o ant erior placent a accret a, t he aut hors'
experience is t hat ut erine conservat ion may be possible for a post erior or fundal accret a, since
bleeding aft er removal of placent a accret a in t hese locat ions is more readily cont rolled
medically, wit h int ervent ional radiology, and wit h conservat ive surgery. The opt ion for a (relat ively)
easy hyst erect omy is st ill available if bleeding cannot be adequat ely cont rolled by t hese ot her
measures.

Recurrence in future pregnancies — PAS occurs in 22 t o 29 percent of fut ure pregnancies of

women successfully managed conservat ively [3]. Women who choose t o become pregnant again
should be aware of t his risk and consult wit h a mat ernal-fet al medicine specialist early in pregnancy t o
facilit at e diagnosis and management .

UNEXPECTED PLACENTA ACCRETA

● Cesarean delivery – Some cases of placent a accret a are first recognized at cesarean delivery,
t ypically repeat cesarean delivery. Upon ent ering t he perit oneal cavit y, t he surgeon may make t he
diagnosis of PAS if one or more of t he following are seen:

• Placent al t issue invading t he lower ut erine segment , serosa, or bladder.

• Increased and t ort uous vascularit y along t he serosa of t he lower ut erine segment . Vessels
may run cranio-caudally in t he perit oneum.

• A bluish/purple and markedly dist ended lower ut erine segment bulging t oward t he pelvic
sidewalls.

It is import ant t o dist inguish t hese findings from a placent a normally at t ached underneat h a
ut erine window (ut erine scar dehiscence). In t hese cases, t he ut erine t issue and vessels
appear normal.

Aft er delivery, PAS is suggest ed if light t ract ion on t he umbilical cord pulls t he ut erine wall
inward, wit hout placent al separat ion, and t he ut erus apart from t he placent al bed cont ract s.
 If PAS is suspect ed, it is import ant t o avoid or minimize manipulat ion of t he ut erus or sit es of
possible ext raut erine placent al ext ension as t his can precipit at e life-t hreat ening hemorrhage.
However, if t he diagnosis is uncert ain, t hen gent le digit al explorat ion for plane of cleavage can be
at t empt ed. The absence of a plane is diagnost ic.

We agree wit h an expert review t hat suggest ed t he following approach [1]. If t he pat ient is not
bleeding heavily, mot her and fet us are st able, and resources for managing t hese complicat ed
cases are not immediat ely available, t he ut erus can be covered wit h warm packs and furt her
surgery delayed unt il appropriat e personnel and ot her resources are available. If assembling t hese
resources is not possible locally, t he abdomen should be closed and t he pat ient expedit iously
t ransferred t o a facilit y t hat can manage t hese pat ient s, alt hough t he risk of massive hemorrhage
in t ransit must be considered.

Delivery of a compromised fet us t hrough a hyst erot omy far from t he placent a, followed by
closure of t he hyst erot omy wit h t he placent a left undist urbed, is an opt ion unt il appropriat e
personnel and resources for mat ernal care are available. Int raoperat ive ult rasound using a probe
wit h a st erile cover can indicat e t he placent al locat ion. If t here is no t ime for ult rasound
examinat ion, in most cases a hyst erot omy in t he post erior ut erus or fundus will avoid t he
placent a.

Women who are bleeding heavily or ot herwise unst able need t o be managed as opt imally as
allowed by t he clinical set t ing and available resources. This includes resuscit at ion wit h fluid and
blood product s, st andard surgical procedures for cont rolling hemorrhage, and pressure on
bleeding sit es (digit al, abdominopelvic packs); infrarenal aort ic compression or aort ic cross-
clamping can be used in an at t empt t o cont rol life-t hreat ening hemorrhage. Direct pressure on a
percret a should be avoided or applied caut iously as it may increase t he size of t he bleeding area.
A massive t ransfusion prot ocol is useful (algorit hm 1).

Int raoperat ive management of women wit h massive hemorrhage at cesarean delivery is
discussed in det ail separat ely. Key principles include: keeping t he pat ient warm, rapidly
t ransfusing red cells t o rest ore or maint ain adequat e circulat ory volume and t issue oxygenat ion,
and reversing or prevent ing coagulopat hy by administ ering fresh frozen plasma and plat elet s (eg;
1:1:1 or 1:2:4 rat io of packed red blood cells, fresh frozen plasma, and plat elet s) [2]. (See
"Post part um hemorrhage: Management approaches requiring laparot omy".)

● Vaginal delivery – Rarely, a focal or complet e placent a accret a is first recognized at t he t ime of
manual removal of a ret ained placent a aft er vaginal delivery. In t hese cases, t here is no plane of
cleavage bet ween t he myomet rium and eit her t he ent ire placent a or focal areas of t he placent a.
 Life-t hreat ening hemorrhage may occur. These pat ient s should receive fluids and t ransfusion, as
appropriat e, while being prepared for laparot omy and surgical management , as described above.

POSTOPERATIVE CARE

An int ensive care unit bed should be available for post operat ive care, if needed. These pat ient s may
require vent ilat or support due t o pulmonary edema from massive fluid resuscit at ion or fluid shift s, or
from acut e t ransfusion-relat ed lung injury []. Some pat ient s need vasopressor support and invasive
hemodynamic monit oring. Post operat ive bleeding may occur, and t he availabilit y of int ervent ional
radiology t o provide angiographic embolizat ion of deep pelvic vessels, t hus avoiding reoperat ion, can
safely enhance pat ient care. (See "Crit ical illness during pregnancy and t he peripart um period".)

SECOND-TRIMESTER PREGNANCY TERMINATION

In t he Unit ed St at es, management of PAS is planned cesarean hyst erect omy, even in cases of
second-t rimest er pregnancy t erminat ion. Small series have described prophylact ic umbilical art ery
embolizat ion followed by fet al ext ract ion via hyst erot omy or by medical induct ion or dilat ion and
ext ract ion [51,52]. In a few cases, t he placent a was removed, but in most cases, it was left in sit u,
wit h hyst eroscopic resect ion performed under ult rasound or laparoscopic guidance at a lat er dat e
when t he placent a was nonfunct ional (normal human chorionic gonadot ropin level and reduced blood
flow on Doppler at t he placent al int erface). However, it is unclear how many of t hese women act ually
had PAS. (See 'Ut erine conservat ion wit h t he placent a left in sit u' above.)

SOCIETY GUIDELINE LINKS

Links t o societ y and government -sponsored guidelines from select ed count ries and regions around
t he world are provided separat ely. (See "Societ y guideline links: Obst et ric hemorrhage".)

SUMMARY AND RECOMMENDATIONS

● It is crit ical t o develop a plan preoperat ively for managing women wit h a high likelihood of
placent a accret a spect rum (PAS). The plan should involve a mult idisciplinary t eam and scheduled
delivery in a facilit y wit h resources and personnel t o manage massive hemorrhage and
complicat ed pelvic surgery. (See 'Component s of preoperat ive planning' above.)
 ● Given t he risks of massive hemorrhage during at t empt ed placent al removal if accret a is present ,
we believe t hat recommending a cesarean hyst erect omy based on imaging findings is t he most
reasonable and safest approach t o management . We suggest scheduling cesarean hyst erect omy
and leaving t he placent a undist urbed in sit u (Grade 2C). (See 'Delivery' above.)

● Our approach is t o plan delivery bet ween 34+0 and 35+6 weeks of gest at ion in st able pat ient s.
We schedule t he procedure at a facilit y wit h personnel experienced in managing pelvic
hemorrhage and it s complicat ions. (See 'Delivery' above.)

● Ant enat al cort icost eroids are administ ered according t o st andard guidelines. (See "Ant enat al
cort icost eroid t herapy for reduct ion of neonat al respirat ory morbidit y and mort alit y from pret erm
delivery".)

● Prophylact ic endovascular int ervent ion wit h a balloon cat het er or art erial embolizat ion, if
available, may be used t o decrease hemorrhage during or aft er deliveries of pregnancies wit h
abnormal placent al implant at ion. (See 'Endovascular int ervent ion for hemorrhage cont rol' above.)

● In rare sit uat ions, ut erine conservat ion may be at t empt ed if fut ure childbearing is desired and
aft er ext ensive counseling regarding risks. (See 'Conservat ive management of placent a accret a'
above.)

Use of UpToDat e is subject t o t he Subscript ion and License Agreement .

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Topic 83129 Version 39.0
GRAPHICS
Sample massive transfusion algorithm

Texas Children's Pavilion for Women massive transfusion protocol.

MTP: m a ssive tra nsfusion protocol; PRBC: pa cked red blood cells; PCA: pa tient-controlled a na lgesia ; RRT: ra pid
response tea m ; BB: blood ba nk; Hg: hem oglobin; Hct: hem a tocrit; DIC: dissem ina ted intrava scula r coa gula tion; PT:
prothrom bin tim e; INR: interna tiona l norm a lized ra tio; PTT: pa rtia l throm bopla stin tim e; ABG: a rteria l blood ga s; RBC:
red blood cells; FFP: fresh frozen pla sm a ; OB: Obstetrics; Anes: Anesthesia ; OR: opera ting room ; CRNA: certified
registered nurse a nesthetist; Chrg: cha rge; RN: registered nurse; La b: la bora tory; Tech: technicia n; MD: m edica l doctor;
L&D: la bor a nd delivery; iCa : ionized ca lcium ; K: pota ssium ; Glu: glucose; PCA: pa tient ca re a ssista nt.
* Every two pa cka ges or ba sed on la b results.

Reproduced with permission. Accessed on February 19, 2013. Copyright © Evidence-Based Outcomes Center, 2013.
Quality and Outcomes Center, Texas Children's Hospital. This guideline was prepared by the Evidence-Based Outcomes
Center (EBOC) team in collaboration with content experts at Texas Children's Hospital Pavilion for Women. Development
of this guideline supports the TCH Quality and Patient Safety Program initiative to promote clinical guidelines and
outcomes that build a culture of quality and safety within the organization. Guideline recommendations are made from
the best evidence, clinical expertise and consensus, in addition to thoughtful consideration for the patients and families
cared for within the Integrated Delivery System. When evidence was lacking or inconclusive, content experts made
consensus recommendations. Expert consensus is implied when a reference is not otherwise indicated. The guideline is
not intended to impose standards of care preventing selective variation in practice that is necessary to meet the unique
needs of individual patients. The physician must consider each patient and family's circumstance to make the ultimate
judgment regarding best care.

Gra phic 91236 Version 5.0

Cherney incision

(A) Transverse incision of rectus sheath.

(B) Lower sheath is separated from rectus muscles. Tendons are exposed and incised 0.5 cm above
periosteum of symphysis.
(C) Tendons are sutured to lower rectus sheath above symphysis with permanent suture material.
(D) Sheath is closed in a continuous manner.

Courtesy of William J Mann, Jr, MD.

Gra phic 73105 Version 4.0

Contributor Disclosures
Robert Resnik, MD Other Financial Interest: Elsevier Publishing [Maternal-fetal medicine (Textbook
coeditor)]. Robert M Silver, MD Nothing to disclose Charles J Lockwood, MD, MHCM Nothing to
disclose Deborah Levine, MD Nothing to disclose Vanessa A Barss, MD, FACOG Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

Conflict of interest policy