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Placenta Accreta (C-Obs 20)

College Statement
C-Obs 20
1st Endorsed: November 2003
Current: November 2011
Review: November 2014

 

Morbid adherence of the placenta to the uterine wall is a potentially life threatening obstetric complication that frequently requires interventions such as caesarean hysterectomy and high volume blood transfusion. With the rising caesarean delivery rate and increasing maternal age, the incidence of placenta accreta has significantly increased1.

Morbidly adherent placentation may be suspected when there is a placenta praevia in a woman with a history of  caesarean section or other uterine surgery1,2. Diagnosis can be difficult3, though accurate diagnosis antenatally allows for appropriate planning of delivery to minimise morbidity4. A number of studies have identified the efficacy of transvaginal ultrasound in the diagnosis of placenta accreta3,4,5. The ultrasound features of this condition have been described by Comstock3. Recent studies looking at the use of MRI have not demonstrated superiority of this modality over transvaginal ultrasound3,5.

Where there is a suspected or known, placenta accreta delivery should occur in a place with the necessary medical facilities and expertise to manage these high risk cases.  It is important to be cognisant of the risk of placental growth to the serosa of the uterus, and into adjacent organs such as the bladder in extreme circumstances.

Such facilities would include: access to “cellsaver”, an ability to cope with high volume blood transfusion, availability of other blood products (e.g. platelets, clotting factors) and appropriate specialised expertise (e.g. neonatal, senior obstetric and anaesthetic, haematological and intensive care). A multidisciplinary approach is required, including possible prior consultation with other medical specialists such as, urologists, gynaecological oncologists, vascular surgeon, intensivists, and interventional radiologists.

As with all women at risk of major obstetric haemorrhage, those with suspected placenta accreta should be encouraged to remain close to the planned hospital of confinement for the duration of the third trimester of pregnancy. An emergency contingency plan is strongly recommended.

The timing of the caesarean section should consider the desirability of performing it as an elective rather than an emergency procedure.  The caesarean section should therefore usually be undertaken at an earlier gestation than that for uncomplicated elective caesarean births or uncomplicated placenta praevia.

Three surgical management choices may be considered according to available expertise, geographical and individual circumstances:

  1. Delivery of the baby and attempted delivery of the placenta.  This is associated with a high likelihood of hysterectomy but not invariably so. If this option is chosen, the surgeon must be prepared to proceed promptly to hysterectomy if needed and the anaesthetist prepared for massive transfusion as bleeding may be considerable whilst the hysterectomy is being undertaken.
  2. Delivery of the baby via a uterine incision distant from the placenta, quick repair of the uterus and en bloc hysterectomy  OR
  3. Delivery of the baby via a uterine incision distant from the placenta, trimming of the cord close to insertion site, full repair of the uterus and conservative management. About two thirds of women will avoid a hysterectomy, one third will still require a hysterectomy because of uncontrollable bleeding, which may be delayed up to several weeks, and this approach also has a significant risk of infectious morbidity.  In addition, uncertainty as to the time of onset of secondary bleeding can tax available resources.  This has serious implications if the patient is returning to a remote area with little facility to cope with sudden severe haemorrhage.

Retrospective studies of pregnancy following conservative management of placenta accreta have reported reasonably good fertility rates and pregnancy outcomes but with an increased rate of recurrent placenta accreta (17-29%)8,9.

Consideration of ureteric stenting should be made particularly when there is a suspicion of placenta percreta.

Interventional radiology can be life saving and uterine sparing for the treatment of massive post partum haemorrhage. It can be useful in the management of haemorrhage from abnormal placentation after delivery. The role of radiological placement of balloon catheters prior to delivery in placenta accreta requires further evaluation6.

 

Reference

  1. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol. 1997 Jul;177(1):210-4.
  2. CA, Harding S, Matthews T, Dickinson JE. Is placenta accreta catching up with us? ANZJOG 2004: 77 (3); 210- 231
  3. Dwyer BK, Belogolovkin V, Tran L, Rao A, Carroll I, Barth R, Chitkara UJ.Prenatal Diagnosis of Placenta Accreta: Sonography or Magnetic Resonance Imaging. J Ultrasound Med. 2008:27(9):1275-1281
  4. Comstock CH. Antenatal diagnosis of placenta accreta: a review. Ultrasound Obstet Gynecol 2005; 26; 98-96
  5. McLean LA, Heilbrun ME, Eller AG, Kennedy AM, Woodward PJ. Assessing the role of Magnetic Resonance Imaging in the Management of Gravid Patients at Risk for Placenta Accreta. Acad Radiol 2011; 18: 1175 – 1180
  6. RCOG Green-top Guideline No. 27 Jan 2011 Placenta praevia, placenta praevia accreta and vas praevia: diagnosis and management
  7. Jyoti R, Robertson M. Imaging placenta accreta. O&G Magazine. 2010 Winter Edition; v.12 n2.
  8. Sentilhes L ,Kayem G, Ambroselli C et al, Fertility and pregnancy outcomes following conservative treatment for placenta accreta. Human Reproduction, Vol 25, No.11 pp.2803-2810, 2010
  9. Alanis M, Hurst B.S., Marshburn P.B.et al, Conservative Management of placenta increta with selective arterialisation preserves future fertility and results in favourable outcome in subsequent pregnancies. Fertility and Sterility Vol. 86, No. 5, November 2006, 1514.e3-7.

 

Links to other related College Statements

Guidelines for consent and the provision of information regarding proposed treatment (C-Gen 2)


Disclaimer

This College Statement is intended to provide general advice to Practitioners. The statement should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient.

The statement has been prepared having regard to general circumstances. It is the responsibility of each Practitioner to have regard to the particular circumstances of each case, and the application of this statement in each case. In particular, clinical management must always be responsive to the needs of the individual patient and the particular circumstances of each case.

This College statement has been prepared having regard to the information available at the time of its preparation, and each Practitioner must have regard to relevant information, research or material which may have been published or become available subsequently.

Whilst the College endeavours to ensure that College statements are accurate and current at the time of their preparation, it takes no responsibility for matters arising from changed circumstances or information or material that may have become available after the date of the statements.

 
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