VOLUME 40  •  NUMBER 5 March 31, 2020

TOPICS IN
OBSTETRICS & GYNECOLOGY Practical CE Newsletter for Clinicians

Placenta Accreta: A Practical Review

Megan E. Ross, MD, MPH, and Meredith J. Alston, MD
Learning Objectives: After participating in this continuing education activity, the provider should be better able to:
1. Describe risk factors for placenta accreta spectrum disease.
2. Initiate intrapartum management strategies for placenta accreta spectrum that will optimize patient outcomes.
3. Counsel patients regarding the risks and benefits of both definitive and uterine-conserving management of placenta
accreta spectrum.
Key Words: Placenta accreta spectrum, Placenta accreta

Placenta accreta spectrum (PAS) is a highly morbid and subtypes involve the absence of placental decidua basalis.
potentially fatal complication of pregnancy. The frequency Placenta accreta occurs when trophoblastic villi are attached
of this condition has increased eightfold since 1970.1 The to the myometrial surface. Placenta increta occurs when villi
incidence of placenta accreta is now estimated at 1 in 272 invade into the myometrium. The villi in placenta percreta
to 533 deliveries in the United States.2-4 There is a 40% risk reach the level of the uterine serosa or penetrate through it.1,6
of needing massive transfusion (>10 units of packed red
blood cells) and a 7% mortality rate associated with PAS.5 Incidence and Risk Factors
PAS is also the most common reason to perform both peri- As noted earlier, current estimates of PAS incidence vary
partum and cesarean hysterectomy.1,5 As such, obstetrician from 1 in 272 to 533 deliveries in the United States.2-4 The
gynecologists must be able to identify risk factors for PAS, frequency of PAS in 1970 was estimated at 1 in 4000 deliv-
be familiar with its associated morbidities, and implement eries with increase to 1 in 2500 deliveries in the 1980s and
strategies for PAS recognition, triage, and appropriate man- further increase to current levels thereafter.1 The dramatic
agement to achieve optimal patient outcomes. increase in the incidence of PAS is strongly associated with
the increased rates of cesarean delivery, and there is a clear
Definition of Placenta Accreta Spectrum relationship between the number of prior cesarean deliver-
PAS encompasses 3 different subtypes dependent on ies undergone by a woman and the subsequent diagnosis of
depth of trophoblast invasion into the myometrial wall. All PAS.7 Other risk factors for PAS include uterine instrumen-
tation of any kind (myomectomy, uterine curettage,
myomectomy, and endometrial ablation), uterine artery
Dr. Ross is a Resident, and Dr. Alston is Associate Professor, Department of
Obstetrics and Gynecology, University of Colorado School of Medicine, 12631 embolization, manual extraction of the placenta, and in
E 17th Ave, B198-6, Room 4007, Aurora, CO 80045; E-mail: megan.ross@ vitro fertilization pregnancies.8,9 The presence of placenta
cuanschutz.edu. previa with a history of prior cesarean delivery is a particu-
The authors, faculty, and staff in a position to control the content of this larly strong risk factor for PAS and increases with the num-
CME/CNE activity, and their spouses/life partners (if any), have disclosed that
they have no financial relationships with, or financial interests in, any commer- ber of prior cesarean delivery (3%, 11%, 40%, 61%, and
cial organizations relevant to this educational activity. 67% for the first through fifth prior cesarean deliveries,
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evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. This CME activity expires on March 30, 2022.
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1
Topics in Obstetrics & Gynecology March 31, 2020

respectively).7,10 PAS occurs extremely the Society of Gynecologic Oncology, and

Editors
William Schlaff, MD
Professor and Chair,
Department of Obstetrics
and Gynecology, Thomas
Jefferson Medical College,
Philadelphia, Pennsylvania
Lorraine Dugoff, MD
Professor and Chief, Division of
Reproductive Genetics,
Department of Obstetrics
and Gynecology, University
of Pennsylvania Perelman
School of Medicine,
Philadelphia, Pennsylvania
Founding Editors
Edward E. Wallach, MD
Roger D. Kempers, MD
Associate Editors
Meredith Alston, MD
Denver, Colorado
Nancy D. Gaba, MD
Washington, DC
Veronica Gomez-Lobo, MD
Washington, DC
Star Hampton, MD
Providence, Rhode Island
Enrique Hernandez, MD
Philadelphia, Pennsylvania
Bradley S. Hurst, MD
Charlotte, North Carolina
Jeffrey A. Kuller, MD
Durham, North Carolina
Peter G. McGovern, MD
New York, New York
Owen Montgomery, MD
Philadelphia, Pennsylvania
rarely in women with no known risk fac-
tors, although conditions thought to contrib-
ute to PAS include submucosal fibroids,
adenomyosis, and bicornuate uterus.6
Antenatal Diagnosis
Given the potential for morbidity and
mortality associated with PAS, antenatal
diagnosis of PAS is key in planning safe
deliveries for women with this condition.
Antenatal diagnosis of PAS is associated
with a higher rate of antenatal corticosteroid
administration and a lower volume of intra-
operative blood loss.11 Ultrasound is the
primary diagnostic imaging modality for
PAS. Ultrasonographic features of PAS
include placental lakes, loss of the so-called
“clear space” between placenta and myome-
trium, abnormal bladder-uterine interface,
reduced myometrial thickness underlying
the placenta (<1 mm), and gross invasion of
the placenta into the myometrial wall, uter-
ine serosa, or bladder.3 Among these, the
presence of placental lakes is the most sensi-
tive ultrasonographic sign of PAS.3,12
Although ultrasound is a useful tool to
evaluate for presence of PAS, it is not per-
fect. Ultrasound sensitivity in detecting
PAS ranges from 53% to 74%, with speci-
ficity ranging from 70% to 94%.12 Suspected
PAS cases can be further evaluated with
MRI to assess for extensive invasion and
develop a surgical plan. However, MRI is
not routinely used for screening patients for
abnormal placentation, and is considerably
more expensive than obstetric ultrasound.1,3
Delivery Planning
In a joint statement, the American College
of Obstetricians and Gynecologists (ACOG),
The continuing education activity in Topics in Obstetrics & Gynecology is intended for obstetricians, gynecologists, advanced practice
nurses, and other health care professionals with an interest in the diagnosis and treatment of obstetric and gynecological conditions.
the Society for Maternal-Fetal Medicine
recommend that patients with suspected
PAS be evaluated and managed at tertiary
care facilities with multidisciplinary accreta
teams due to decreased maternal morbidity
in the delivery setting.3 Management of PAS
by dedicated multidisciplinary teams is
associated with lower composite scores of
morbidity, lower incidence of massive trans-
fusion, and fewer reoperations for bleeding
complications.5,13 Management of obstetric
hemorrhage in high-volume tertiary care set-
tings is also associated with lower maternal
mortality.14
Emergent delivery and cesarean hyster-
ectomy for patients with PAS are associ-
ated with increased blood loss and need
for transfusion, higher volume of blood
transfusion, and need for intensive care
admission.11,15,16 To minimize the maternal
morbidity of emergent delivery and bal-
ance the neonatal morbidity of prematu-
rity, the recommended gestational age for
delivery is 34 to 35 weeks in pregnancy
affected by PAS.3,17 In light of this, antena-
tal corticosteroids should be administered
in anticipation of preterm delivery to pro-
mote fetal lung maturation.3 Amniocentesis
to confirm fetal lung maturity is not indi-
cated at this gestational age, given the
indication for delivery is for maternal
concerns.1,3
Preoperative Planning
As mentioned earlier, multidisciplinary
teams dedicated to the care of patients with
PAS have been shown to reduce maternal
morbidity. ACOG recommends that these
teams include maternal-fetal medicine phy-
sicians, pelvic surgeons with appropriate

Christopher M. Morosky, MD
Farmington, Connecticut
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2
 March 31, 2020 Topics in Obstetrics & Gynecology
expertise, neonatologists, and anesthesiologists.3 Other con­
sultants should be included as the clinical scenario dictates
(eg, urologists). Close coordination with the blood bank is
also strongly recommended, as the risk of transfusion is
high.3 The evidence for preoperative placement of ureteral
stents is mixed; ACOG recommends an individualized
approach for patients with suspected bladder involvement.3
Similarly, the value of preoperative intravascular catheteri-
zation or balloon placement is unclear; ACOG recommends
against routine use of these measures.3
Intraoperative Management
Given the risk of hemorrhage, adequate vascular access
should be obtained preoperatively (large-bore venous
access, possible central venous access).1 Blood products
sufficient to support a patient through a massive hemor-
rhage should be available at the time of surgical start.1
Having autologous red cell salvage equipment in the oper-
ating room should be considered.1,3,18 Capabilities for rapid
laboratory assessment of the patient’s blood counts and
clotting status should be available.1 Perioperative antibiot-
ics should be administered and appropriately redosed based
on standard guidelines based on blood loss and length of
procedure.19 Lower extremity sequential compression
devices should be used as prophylaxis against venous
thromboembolism.1 Dorsal lithotomy positioning with a
left lateral tilt should be considered in case access to the
vagina or bladder is required.3 Equipment needed to warm
the patient to prevent temperature-associated coagulopathy
should be available.1 There is no standard anesthetic
approach for surgical management of PAS, and the decision
to use regional or general anesthesia should be determined
by the anesthesiology team.
In general, the recommended surgical management of
PAS is planned cesarean hysterectomy.1,3 In patients who
strongly desire uterine conservation, alternate approaches
can be undertaken after appropriate preoperative coun-
seling. These approaches will be discussed separately.
Adequate surgical exposure is paramount; vertical mid-
line, Maylard, and Cherney incisions should be consid-
ered.1,3,18 The hysterotomy incision should be made in a
manner that avoids disrupting the placenta to extent possi-
ble.1,3 Following delivery and after ensuring that the pla-
centa will not deliver spontaneously, most clinicians then
quickly close the hysterotomy incision and proceed with
hysterectomy.3 Total hysterectomy is preferred to supracer-
vical hysterectomy but may not always be surgically feasi-
ble.18 Forcible attempts at removal of the placenta should be
avoided, as they are associated with greater risk of hemor-
rhage and higher overall morbidity.3,11,15 Cystoscopy can be
considered on a case-by-case basis, with the knowledge that
peripartum hysterectomy carries a risk of bladder injury 9
times higher and a risk of ureteral injury 5 times higher than
nonobstetric hysterectomy.20 Surgical techniques for refrac-
tory hemorrhage include hypogastric artery ligation, arterial
embolization performed by interventional radiology if
patient stability allows, manual aortic compression or bal-
loon tamponade, and pelvic packing.3
3
In the event of hemorrhage, blood products should be
given in a fixed ratio (typically 1:1:1 for packed red blood
cells, fresh frozen plasma, and platelets, respectively) con-
sistent with a massive transfusion protocol.3 Tranexamic
acid administration to combat fibrinolysis can be consid-
ered either on an as-needed or a prophylactic basis.3,18
Hypofibrinogenemia with fibrinogen levels less than 200
mg/dL is a significant risk factor for postpartum hemor-
rhage and can be corrected with administration of cryopre-
cipitate or fibrinogen concentrates.3
Given that many patients with PAS are undiagnosed
before their delivery, it is not always possible to mobilize a
multidisciplinary team or plan for care of the patient in a
tertiary setting. Thus, it is critical that all obstetricians be
knowledgeable regarding the management of PAS.
Alternate Management Approaches
Alternate management strategies for PAS can be broadly
divided into categories of expectant management, uterine
preservation, and delayed planned hysterectomy.3,18
Expectant management entails leaving the placenta in
situ.3,21 In expectant management, the umbilical cord is
ligated proximally near the cord insert, and the placenta is
left undisturbed. Case series of this approach show need for
eventual hysterectomy in 22% to 42% of expectantly man-
aged patients.3,21 In the largest case series of expectant
management to date, placental resorption occurred in 75%
of cases at a median of 13.5 weeks from delivery.22
Hysteroscopic resection of placental tissue or uterine curet-
tage was required in 29% of cases in this series.22 The most
common causes for hysterectomy in this series after
attempted expectant management were hemorrhage (early
or delayed) and maternal sepsis.22
Six percent of patients in this series experienced signifi-
cant morbidity, such as sepsis, septic shock, venous throm-
boembolism, uterine necrosis, and fistula formation.22 Due
to the length of time needed for placental resorption, this
approach requires extensive follow-up and should not be
offered to patients unable to comply with these requirements.
Uterine preservation is a conservative management strat-
egy in which the placenta is removed and uterus is left in
situ.3,21 As stated earlier, the risk of attempted placental
removal in PAS is massive hemorrhage, and the forcible
removal of the placenta should always be avoided.21
However, manual removal, curettage, or surgical excision
of the placenta is possible in patients with limited or focal
areas of placental adherence. Hemorrhage management
strategies in those patients include placement of an intrau-
terine balloon for tamponade and resection of the adherent
area with subsequent closure.3 Evidence describing the
effectiveness of these approaches is limited.3
Delayed planned hysterectomy is a nonconservative man-
agement option for patients with highly invasive PAS.18 After
cesarean delivery, the umbilical cord is ligated proximally,
and the placenta is left in situ, just as in expectant manage-
ment of PAS. The goal of delay is to allow time for some
placental resorption, hopefully decreasing the morbidity of
eventual hysterectomy. After close monitoring, interval
Topics in Obstetrics & Gynecology March 31, 2020
hysterectomy is performed 3 to 12 weeks after delivery.18
Once again, data for this approach are limited.
Methotrexate is currently not recommended as a con-
servative management strategy for PAS. There are no data
demonstrating efficacy of this approach in producing pla-
cental resorption, and methotrexate has known renal and
hematologic risks. Furthermore, methotrexate is contraindi-
cated in breastfeeding.3,21
Once again, the standard of care for patients with PAS is
peripartum hysterectomy. Alternate approaches should only
be offered to selected patients after extensive counseling
about the risks of conservative management, including pos-
sible need for eventual and perhaps emergent hysterectomy,
delayed hemorrhage, need for additional surgical proce-
dures (including uterine curettage and hysteroscopic resec-
tion of placenta), and possibility of significant morbidity
related to conservative measures (eg, infection in expectant
management).3 All women who undergo conservative man-
agement should be informed that likelihood of recurrent
PAS in a future pregnancy is high.21
Practice Pearls
• Patients with major risk factors for PAS should be
carefully screened by obstetric ultrasound.
• Patients with suspicion for PAS on ultrasound may
undergo MRI if necessary to make or confirm the
diagnosis.
• Patients with PAS should be referred to tertiary care
centers with PAS expertise for delivery whenever
possible.
• Delivery for patients with PAS should be planned for
34 to 35 weeks’ gestational age.
• Antenatal corticosteroids should be given to patients
with PAS in anticipation of preterm delivery.
• PAS care teams should include maternal-fetal medicine,
an expert pelvic surgeon, anesthesiology, neonatology,
and any other services needed based on clinical
situation.
• Forcible attempts to remove the placenta in known
PAS cases should be avoided.
• The standard approach for PAS management is
peripartum hysterectomy.
• Appropriate blood products should be available for
every PAS surgical case.
• Alternative PAS management strategies should only be
offered to select candidates after thorough preoperative
counseling.
Conclusion
PAS is an increasingly frequent disorder of pregnancy
with the potential for severe morbidity and also maternal
mortality, largely related to the risk of massive obstetric
4
hemorrhage. The primary risk factor for PAS is a history of
cesarean delivery. Patients with risk factors should be care-
fully screened for PAS during their prenatal care with
obstetric ultrasound; MRI can be used as necessary as an
adjunctive imaging modality. Whenever possible, women
with known PAS should undergo planned cesarean hyster-
ectomy at a tertiary care center where an experienced PAS
team is available. Alternative management strategies should
only be undertaken in select patients after extensive coun-
seling on the pertinent risks.
REFERENCES
1. Silver RM, Branch DW. Placenta accreta spectrum. N Engl J Med. 2018;
378(16):1529-1536.
2. Mogos MF, Salemi JL, Ashley M, et al. Recent trends in placenta accreta in
the United States and its impact on maternal-fetal morbidity and healthcare-
associated costs, 1998-2011. J Matern Fetal Neonatal Med. 2016;29(7):1077-
1082.
3. ACOG. Obstetric Care Consensus No. 7: Placenta accreta spectrum. Obstet
Gynecol. 2018;132(6):e259-e275.
4. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year
analysis. Am J Obstet Gynecol. 2005(192):1458-1461.
5. 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-e9.
6. Jauniaux E, Chatraine F, Silver RM, et al. FIGO consensus guidelines on
placenta accreta spectrum disorders: Epidemiology. Int J Gynecol Obstet.
2018(140):265-273.
7. Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated
with multiple repeat cesarean deliveries. Obstet Gynecol. 2006;107(6):1226-
1232.
8. Esh-Broder E, Ariel I, Abas-Bashir N, et al. Placenta accreta is associated
with IVF pregnancies: a retrospective chart review. BJOG. 2011;118(9):1084-
1089.
9. Kaser DJ, Melamed A, Bormann CL, et al. Cryopreserved embryo transfer
is an independent risk factor for placenta accreta. Fertil Steril. 2015;103
(5):1176-1184.
10. Bowman ZS, Eller AG, Bardsley TR, et al. Risk factors for placenta accreta:
a large prospective cohort. Am J Perinatol. 2014;31:799-804.
11. Warshak CR, Ramos GA, Eskander R, et al. Effect of predelivery diagnosis in
99 consecutive cases of placenta accreta. Obstet Gynecol. 2010;115(1):65-69.
12. Bowman ZS, Eller AG, Kennedy AM, et al. Interobserver variability of
sonography for prediction of placenta accreta. J Ultrasound Med. 2014;33:
2153-2158.
13. 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(2):331-337.
14. Wright JD, Herzog TJ, Shah M, et al. Regionalization of care for obstetric
hemorrhage and its effect on maternal mortality. Obstet Gynecol. 2010;
115(6):1194-1200.
15. Eller AG, Porter TF, Soisson P, et al. Optimal management strategies for
placenta accreta. BJOG. 2009;116:648-654.
16. Briery CM, Rose CH, Hudson WT, et al. Planned vs. emergent cesarean
hysterectomy. Am J Obstet Gynecol. 2007;197(2):154.e1-.e5.
17. Robinson BK, Grobman WA. Effectiveness of timing strategies for delivery
of individuals with placenta previa and accreta. Obstet Gynecol. 2010;116(4):
835-842.
18. Allen L, Jauniaux E, Hobson S, et al. FIGO consensus guidelines on pla-
centa accreta spectrum disorders: Nonconservative surgical management.
Int J Gynecol Obstet. 2018;140:281-290.
19. ACOG. Practice Bulletin No. 195: prevention of infection after gynecologic
procedures. Obstet Gynecol. 2018;131(6):e172-e89.
20. Wright JD, Devine P, Shah M, et al. Morbidity and mortality of peripartum
hysterectomy. Obstet Gynecol. 2010;115(6):1187-1193.
21. Sentilhes L, Kayem G, Chandraharan E, et al. FIGO consensus guidelines
on placenta accreta spectrum disorders: conservative management. Int J
Gynecol Obstet. 2018;140:291-298.
22. Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conserva-
tive treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526-534.
March 31, 2020 Topics in Obstetrics & Gynecology

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 Topics in Obstetrics & Gynecology March 31, 2020

Continuing Education Quiz: Volume 40, Number 5

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1. In a 32-year-old G4P3 with a history of 3 cesarean deliveries, 6. During preoperative counseling with the patient described in
imaging is concerning for PAS. The community hospital has no question 1, you explain that the procedure will be a cesarean
blood blank. The delivery plan for this patient should be hysterectomy. The patient asks about her options. You explain
A. cesarean delivery at 39 weeks with plan for patient that these options are not recommended but include which
transfer if necessary of the following?
B. cesarean delivery at 39 weeks at a tertiary care institution A. Placement of an intrauterine balloon
C. preoperative betamethasone administration and cesar- B. Expectant management of the placenta with uterine
ean delivery at 39 weeks at a tertiary care institution preservation after delivery of the baby
D. preoperative corticosteroid administration and cesarean C. Delayed planned hysterectomy
delivery at 34 to 35 weeks at a tertiary care institution D. All of the above
2. Peripartum care for the patient described in question 1 7. Tranexamic acid can be used either prophylactically or
should involve therapeutically.
A. an experienced pelvic surgeon A. True
B. a maternal fetal medicine specialist B. False
C. an anesthesiologist
D. all of the above 8. Intraoperative management includes which one of the
following approaches to hysterotomy?
3. Preoperative coordination for the patient described in A. Incising through the placenta to facilitate removal
question 1 may also include discussion with B. Incision placement to avoid incising the placenta
A. the blood bank C. Low-transverse uterine incision regardless of placental
B. the urology team location
C. the neonatology team D. A classical uterine incision regardless of placental
D. all of the above location
4. Preoperative coordination with the anesthesiologist for the 9. The planned procedure for the patient described in
patient described in question 1 includes a discussion of question 1 is a cesarean hysterectomy. During the proce-
planned resuscitation in the event of massive hemorrhage. dure, significant hemorrhage is encountered. Which of the
The correct ratio of packed red blood cells/platelets/fresh following is an option to assist in managing the blood loss?
frozen plasma is A. Hypogastric artery ligation
A. 2:1:1 B. Embolization in interventional radiology if the patient is
B. 1:1:1 clinically stable
C. 1:1:2 C. Pelvic packing
D. 3:1:2 D. All of the above
5. Which of the following surgical incision types facilitates 10. Aggressive attempts should be made to remove the
exposure? placenta when PAS is suspected.
A. Vertical midline A. True
B. Maylard B. False
C. Cherney
D. All of the above