Management of the morbidly adherent placenta (placenta accreta, increta, and percreta)
- Robert Resnik, MD
Robert Resnik, MD
- Professor of Reproductive Medicine
- UCSD School of Medicine
- Robert M Silver, MD
Robert M Silver, MD
- Professor of Obstetrics and Gynecology
- University of Utah School of Medicine
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Director of Ob/Gyn Ultrasound
- Department of Radiology
- Beth Israel Deaconess Medical Center
Management of patients with a morbidly adherent placenta (placenta accreta, increta, or percreta) varies widely in the United States [1,2]. Although the impact of a morbidly adherent placenta on pregnancy outcomes is well-described, no randomized trials and few studies have examined the management of pregnancies complicated by this disorder. As a result, recommendations for its management are based on case series and reports, personal experience, expert opinion, and good clinical judgment.
The management of placenta accreta, increta, and percreta will be discussed here and is essentially the same, except when a percreta extends to extrauterine tissue. Unless otherwise noted, the following discussion of management of placenta accreta applies to all depths of placental invasion. The clinical features and diagnosis of the morbidly adherent placenta are reviewed separately. (See "Clinical features and diagnosis of the morbidly adherent placenta (placenta accreta, increta, and percreta)".)
All patients with suspected placenta accreta should be counseled about the diagnosis and potential sequelae (eg, hemorrhage, blood transfusion, cesarean hysterectomy, maternal intensive care unit admission). Consultation with a maternal-fetal medicine specialist is desirable, and transfer to a center of excellence for placenta accreta is strongly advised.
For patients with placenta previa-accreta, prenatal care follows typical guidelines for management of placenta previa (see "Management of placenta previa"):
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- Esakoff TF, Handler SJ, Granados JM, Caughey AB. PAMUS: placenta accreta management across the United States. J Matern Fetal Neonatal Med 2012; 25:761.
- Jolley JA, Nageotte MP, Wing DA, Shrivastava VK. Management of placenta accreta: a survey of Maternal-Fetal Medicine practitioners. J Matern Fetal Neonatal Med 2012; 25:756.
- American College of Obstetricians and Gynecologists. ACOG Committee opinion #529. Placenta accreta. Obstet Gynecol 2012; 120:207.
- Publications Committee, Society for Maternal-Fetal Medicine, Belfort MA. Placenta accreta. Am J Obstet Gynecol 2010; 203:430.
- Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care. Obstet Gynecol 2011; 117:331.
- Shamshirsaz AA, Fox KA, Salmanian B, et al. Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach. Am J Obstet Gynecol 2015; 212:218.e1.
- Grosvenor, A, Silver, R, Porter, TF, Zempolich, K. Optimal Management of Placenta Accreta. Am J Obste Gynecol 2007; 195. Abstr No. 238. p. S82.
- Warshak CR, Ramos GA, Eskander R, et al. Effect of predelivery diagnosis in 99 consecutive cases of placenta accreta. Obstet Gynecol 2010; 115:65.
- Tikkanen M, Paavonen J, Loukovaara M, Stefanovic V. Antenatal diagnosis of placenta accreta leads to reduced blood loss. Acta Obstet Gynecol Scand 2011; 90:1140.
- Eller AG, Porter TF, Soisson P, Silver RM. Optimal management strategies for placenta accreta. BJOG 2009; 116:648.
- Bowman ZS, Manuck TA, Eller AG, et al. Risk factors for unscheduled delivery in patients with placenta accreta. Am J Obstet Gynecol 2014; 210:241.e1.
- Pri-Paz S, Fuchs KM, Gaddipati S, et al. Comparison between emergent and elective delivery in women with placenta accreta. J Matern Fetal Neonatal Med 2013; 26:1007.
- Sadashivaiah J, Wilson R, Thein A, et al. Role of prophylactic uterine artery balloon catheters in the management of women with suspected placenta accreta. Int J Obstet Anesth 2011; 20:282.
- Wright JD, Pri-Paz S, Herzog TJ, et al. Predictors of massive blood loss in women with placenta accreta. Am J Obstet Gynecol 2011; 205:38.e1.
- Stotler B, Padmanabhan A, Devine P, et al. Transfusion requirements in obstetric patients with placenta accreta. Transfusion 2011; 51:2627.
- Elagamy A, Abdelaziz A, Ellaithy M. The use of cell salvage in women undergoing cesarean hysterectomy for abnormal placentation. Int J Obstet Anesth 2013; 22:289.
- Albright CM, Rouse DJ, Werner EF. Cost savings of red cell salvage during cesarean delivery. Obstet Gynecol 2014; 124:690.
- Taylor NJ, Russell R. Anaesthesia for abnormally invasive placenta: a single-institution case series. Int J Obstet Anesth 2017; 30:10.
- Estella NM, Berry DL, Baker BW, et al. Normovolemic hemodilution before cesarean hysterectomy for placenta percreta. Obstet Gynecol 1997; 90:669.
- Bouret JM, Yannoulopoulos B, Sandoval C, et al. [Indications and results of autotransfusion. Normovolemic hemodilution in gynecology-obstetrics]. Rev Fr Gynecol Obstet 1990; 85:455.
- Grange CS, Douglas MJ, Adams TJ, Wadsworth LD. The use of acute hemodilution in parturients undergoing cesarean section. Am J Obstet Gynecol 1998; 178:156.
- Nagy CJ, Wheeler AS, Archer TL. Acute normovolemic hemodilution, intraoperative cell salvage and PulseCO hemodynamic monitoring in a Jehovah's Witness with placenta percreta. Int J Obstet Anesth 2008; 17:159.
- Kreimeier U, Messmer K. Perioperative hemodilution. Transfus Apher Sci 2002; 27:59.
- Lilker SJ, Meyer RA, Downey KN, Macarthur AJ. Anesthetic considerations for placenta accreta. Int J Obstet Anesth 2011; 20:288.
- Dubois J, Garel L, Grignon A, et al. Placenta percreta: balloon occlusion and embolization of the internal iliac arteries to reduce intraoperative blood losses. Am J Obstet Gynecol 1997; 176:723.
- Paull JD, Smith J, Williams L, et al. Balloon occlusion of the abdominal aorta during caesarean hysterectomy for placenta percreta. Anaesth Intensive Care 1995; 23:731.
- Kidney DD, Nguyen AM, Ahdoot D, et al. Prophylactic perioperative hypogastric artery balloon occlusion in abnormal placentation. AJR Am J Roentgenol 2001; 176:1521.
- Ojala K, Perälä J, Kariniemi J, et al. Arterial embolization and prophylactic catheterization for the treatment for severe obstetric hemorrhage*. Acta Obstet Gynecol Scand 2005; 84:1075.
- Chou MM, Hwang JI, Tseng JJ, Ho ES. Internal iliac artery embolization before hysterectomy for placenta accreta. J Vasc Interv Radiol 2003; 14:1195.
- Angstmann T, Gard G, Harrington T, et al. Surgical management of placenta accreta: a cohort series and suggested approach. Am J Obstet Gynecol 2010; 202:38.e1.
- Ballas J, Hull AD, Saenz C, et al. Preoperative intravascular balloon catheters and surgical outcomes in pregnancies complicated by placenta accreta: a management paradox. Am J Obstet Gynecol 2012; 207:216.e1.
- Dilauro MD, Dason S, Athreya S. Prophylactic balloon occlusion of internal iliac arteries in women with placenta accreta: literature review and analysis. Clin Radiol 2012; 67:515.
- Salim R, Chulski A, Romano S, et al. Precesarean Prophylactic Balloon Catheters for Suspected Placenta Accreta: A Randomized Controlled Trial. Obstet Gynecol 2015; 126:1022.
- Omar HR, Sprenker C, Alvey E, et al. The value of occlusive balloons in the management of abnormal placentation: A retrospective study. J Obstet Gynaecol 2016; 36:333.
- Shrivastava V, Nageotte M, Major C, et al. Case-control comparison of cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for placenta accreta. Am J Obstet Gynecol 2007; 197:402.e1.
- Sewell MF, Rosenblum D, Ehrenberg H. Arterial embolus during common iliac balloon catheterization at cesarean hysterectomy. Obstet Gynecol 2006; 108:746.
- Greenberg JI, Suliman A, Iranpour P, Angle N. Prophylactic balloon occlusion of the internal iliac arteries to treat abnormal placentation: a cautionary case. Am J Obstet Gynecol 2007; 197:470.e1.
- Barth WH Jr, Kwolek CJ, Abrams JL, et al. Case records of the Massachusetts General Hospital. Case 23-2011. A 40-year-old pregnant woman with placenta accreta who declined blood products. N Engl J Med 2011; 365:359.
- Robinson BK, Grobman WA. Effectiveness of timing strategies for delivery of individuals with placenta previa and accreta. Obstet Gynecol 2010; 116:835.
- Spong CY, Mercer BM, D'alton M, et al. Timing of indicated late-preterm and early-term birth. Obstet Gynecol 2011; 118:323.
- Belfort MA. Indicated preterm birth for placenta accreta. Semin Perinatol 2011; 35:252.
- American College of Obstetricians and Gynecologists. ACOG committee opinion no. 560: Medically indicated late-preterm and early-term deliveries. Obstet Gynecol 2013; 121:908. Reaffirmed 2017.
- D'Antonio F, Palacios-Jaraquemada J, Lim PS, et al. Counseling in fetal medicine: evidence-based answers to clinical questions on morbidly adherent placenta. Ultrasound Obstet Gynecol 2016; 47:290.
- Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol 2006; 107:927.
- Wong HS, Hutton J, Zuccollo J, et al. The maternal outcome in placenta accreta: the significance of antenatal diagnosis and non-separation of placenta at delivery. N Z Med J 2008; 121:30.
- Clark SL, Phelan JP, Yeh SY, et al. Hypogastric artery ligation for obstetric hemorrhage. Obstet Gynecol 1985; 66:353.
- Papp Z, Tóth-Pál E, Papp C, et al. Hypogastric artery ligation for intractable pelvic hemorrhage. Int J Gynaecol Obstet 2006; 92:27.
- Unal O, Kars B, Buyukbayrak EE, et al. The effectiveness of bilateral hypogastric artery ligation for obstetric hemorrhage in three different underlying conditions and its impact on future fertility. J Matern Fetal Neonatal Med 2011; 24:1273.
- Washecka R, Behling A. Urologic complications of placenta percreta invading the urinary bladder: a case report and review of the literature. Hawaii Med J 2002; 61:66.
- Bakri YN, Sundin T. Cystotomy for placenta previa percreta with bladder invasion. Urology 1992; 40:580.
- Vinograd A, Wainstock T, Mazor M, et al. A prior placenta accreta is an independent risk factor for post-partum hemorrhage in subsequent gestations. Eur J Obstet Gynecol Reprod Biol 2015; 187:20.
- Roeca C, Little SE, Carusi DA. Pathologically Diagnosed Placenta Accreta and Hemorrhagic Morbidity in a Subsequent Pregnancy. Obstet Gynecol 2017; 129:321.
- Fox KA, Shamshirsaz AA, Carusi D, et al. Conservative management of morbidly adherent placenta: expert review. Am J Obstet Gynecol 2015; 213:755.
- Legendre G, Zoulovits FJ, Kinn J, et al. Conservative management of placenta accreta: hysteroscopic resection of retained tissues. J Minim Invasive Gynecol 2014; 21:910.
- Hequet D, Morel O, Soyer P, et al. Delayed hysteroscopic resection of retained tissues and uterine conservation after conservative treatment for placenta accreta. Aust N Z J Obstet Gynaecol 2013; 53:580.
- Rein DT, Schmidt T, Hess AP, et al. Hysteroscopic management of residual trophoblastic tissue is superior to ultrasound-guided curettage. J Minim Invasive Gynecol 2011; 18:774.
- Steins Bisschop CN, Schaap TP, Vogelvang TE, Scholten PC. Invasive placentation and uterus preserving treatment modalities: a systematic review. Arch Gynecol Obstet 2011; 284:491.
- Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol 2010; 115:526.
- Provansal M, Courbiere B, Agostini A, et al. Fertility and obstetric outcome after conservative management of placenta accreta. Int J Gynaecol Obstet 2010; 109:147.
- Sentilhes L, Kayem G, Ambroselli C, et al. Fertility and pregnancy outcomes following conservative treatment for placenta accreta. Hum Reprod 2010; 25:2803.
- Amsalem H, Kingdom JC, Farine D, et al. Planned caesarean hysterectomy versus "conserving" caesarean section in patients with placenta accreta. J Obstet Gynaecol Can 2011; 33:1005.
- Eshkoli T, Weintraub AY, Sergienko R, Sheiner E. Placenta accreta: risk factors, perinatal outcomes, and consequences for subsequent births. Am J Obstet Gynecol 2013; 208:219.e1.
- Palacios Jaraquemada JM, Pesaresi M, Nassif JC, Hermosid S. Anterior placenta percreta: surgical approach, hemostasis and uterine repair. Acta Obstet Gynecol Scand 2004; 83:738.
- Chandraharan E, Rao S, Belli AM, Arulkumaran S. The Triple-P procedure as a conservative surgical alternative to peripartum hysterectomy for placenta percreta. Int J Gynaecol Obstet 2012; 117:191.
- Clausen C, Lönn L, Langhoff-Roos J. Management of placenta percreta: a review of published cases. Acta Obstet Gynecol Scand 2014; 93:138.
- Teixidor Viñas M, Belli AM, Arulkumaran S, Chandraharan E. Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure. Ultrasound Obstet Gynecol 2015; 46:350.
- Silver RM, Fox KA, Barton JR, et al. Center of excellence for placenta accreta. Am J Obstet Gynecol 2015; 212:561.
- PRENATAL CARE
- PREPARATION FOR DELIVERY
- Components of preoperative planning
- Balloon catheterization and arterial embolization
- Surgical principles
- - Cesarean hysterectomy
- - Management of placenta percreta with bladder invasion
- CONSERVATIVE MANAGEMENT OF PLACENTA ACCRETA
- Uterine conservation with the placenta left in situ
- Uterine conservation with placental resection
- UNEXPECTED PLACENTA ACCRETA
- POSTOPERATIVE CARE
- SUMMARY AND RECOMMENDATIONS