Placenta Accreta Part II: Management

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After last week’s initial episode, we talk through some pearls for management. Keeping it simple today:

  • Antenatal care considerations:

    • Pelvic rest, avoid travel - don’t get into a bad situation!

    • Prenatal care is fairly routine.

    • Hospitalization practices will vary by region and level of resources — i.e., admission for proximity. Bleeding should prompt admission, likely until delivery.

    • Sweet spot for delivery typically between 34-35’6 weeks, though some centers pushing towards 36+ weeks.

      • However, as Dr. Einerson mentions, the worst thing you can do is end up in an emergent delivery scenario with these patients!

    • Don’t forget about using late preterm steroids!

  • Cesarean hysterectomy tips:

    • Collins 2019 paper on evidence-based management. Don’t deliver too late!

    • Multidisciplinary / interdisciplinary care leads to less morbidity.

    • Ureteral stents: if you need them to identify ureters to safely perform surgery.

    • Some tips from our guests:

      • Approach through VML skin incision, though Maylard / Cherney incisions are also reasonable. Fundal hysterotomy (typically) to avoid messing with the placenta.

      • Decrease blood flow before addressing the bladder - they often take the uterine vessels before developing the bladder.

      • Arterial catheters such as the REBOA are to be used in experimental settings only, and are associated with serious complications.

      • If bleeding - the most experienced operators need to be there.

      • Bipolar vessel sealing devices (such as LigaSure) are helpful!

  • Conservative management?

    • To be done only on an experimental basis at this time! Reasonable to examine in a trial for a number of reasons.

    • Methotrexate does NOT work for retained placenta — MTX kills rapidly dividing cells, not stagnant cells left behind.

  • Patient resources / advocacy: