Materiały źródłowe

• #1 Placenta accreta – Symptoms & causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/placenta-accreta/symptoms-causes/syc-20376431

  Placenta accreta is considered a high-risk pregnancy complication. If the condition is diagnosed during pregnancy, you’ll likely need an early C-section delivery followed by the surgical removal of your uterus (hysterectomy). […] Placenta accreta poses a major risk of severe vaginal bleeding (hemorrhage) after delivery. The bleeding can cause a life-threatening condition that prevents your blood from clotting normally (disseminated intravascular coagulopathy), as well as lung failure (adult respiratory distress syndrome) and kidney failure. A blood transfusion will likely be necessary. […] If placenta accreta causes bleeding during your pregnancy, you might need to deliver your baby early.

• #1 Placenta Accreta Spectrum | ACOG

  https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum

  Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. […] The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). […] Optimal management involves a standardized approach with a comprehensive multidisciplinary care team accustomed to management of placenta accreta spectrum. […] Delivery in highly experienced maternity centers that have this type of coordinated care team and the ability to garner additional expertise and resources in cases of severe hemorrhage appears to improve outcomes.

• #1 Placenta accreta – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/placenta-accreta/diagnosis-treatment/drc-20376436

  If your health care provider suspects placenta accreta, he or she will work with you to develop a plan to safely deliver your baby. […] In the case of extensive placenta accreta, a C-section followed by the surgical removal of the uterus (hysterectomy) might be necessary. This procedure, also called a cesarean hysterectomy, helps prevent the potentially life-threatening blood loss that can occur if there’s an attempt to separate the placenta. […] Your health care provider will discuss the risks and potential complications associated with placenta accreta. He or she might also also discuss the possibility of your: […] During your C-section, your health care provider will deliver your baby through an initial incision in your abdomen and a second incision in your uterus. After the delivery, a member of your health care team will remove your uterus with the placenta still attached to prevent severe bleeding.

• #1 Placenta Accreta | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/27260

  Placenta accreta spectrum is best managed when it has been diagnosed antenatally. Many steps can be undertaken to minimize risks. The American College of Obstetricians and Gynecologists (ACOG) has recommended delivery between 34 0/7 and 35 6/7 weeks of gestation via cesarean hysterectomy to optimize neonatal maturity and minimize the risk of maternal bleeding. […] Before delivery, there should be a consideration for transfer to a Placenta Accreta Center of Excellence (PACE) or a level 3 or 4 center for delivery. Outcomes have been improved by delivery at these facilities due to the availability of a large, interprofessional team. […] Cesarean sections are typically performed in a manner that allows for easy conversion to hysterectomy. This includes dorsal lithotomy positioning and a vertical skin incision. The uterine incision should be made in a manner that would avoid the placenta. After the delivery of the neonate, if the placenta does not deliver spontaneously, the current recommendation is to leave the placenta, close the hysterotomy, and perform a hysterectomy. This approach minimizes the risk of hemorrhage.

• #1 Placenta Accreta: Symptoms, Risk Factors, & Treatment | University of Utah Health | University of Utah Health

  https://healthcare.utah.edu/womens-health/pregnancy-birth/placenta-accreta

  The standard treatment for placenta accreta is to deliver by C-section at 34-36 weeks of pregnancy. Our goal is to avoid labor so you don’t have heavy bleeding. […] Patients at U of U Health have two treatment options: […] Procedural management: Your maternal-fetal medicine specialist delivers the baby through C-section. Then they perform a hysterectomy to remove your uterus, cervix, and the placenta. This is the traditional treatment approach for placenta accreta. […] Conservative management: U of U Health doctors are national leaders in more conservative treatment options. They lead studies funded by the National Institutes of Health (NIH) to research alternative treatments. We offer conservative management through the study. Your maternal-fetal medicine specialist delivers your baby through C-section. Then they leave the placenta inside your uterus. The placenta goes away slowly over about 2-5 months. Some of it exits your body through blood and fluid. Your body reabsorbs some of it. About 80% of patients who choose this treatment avoid hysterectomy.

• #1

  https://journals.lww.com/mfm/fulltext/2021/10000/placenta_accreta_spectrum__conservative_management.7.aspx

  Placenta accreta spectrum is a complication of pregnancy, which poses a great risk on maternal health. Historically, hysterectomy was the modality of treatment of such condition, but an approach towards a more conservative management has been in the light recently. This includes several methods with varying rates of success and complications. Expectant management is effective in up to 78%80% of the cases. The extirpative method is associated with a high risk of postpartum hemorrhage. The success of the one-step conservative procedure depends on the degree of placental invasion, and the triple-P procedure appears to be successful but requires an interdisciplinary approach. Adjuvant treatment options can be tailored according to individual cases, and these include methotrexate injection, uterine devascularization and hysteroscopic resection of retained placental tissues. Follow up after conservative management is crucial to detect complications early, and it can be done by ultrasound, Doppler examination, and trending human chorionic gonadotropin levels. Conservative management of placenta accreta spectrum can preserve future fertility but should only be done in hospitals with enough experience as it carries a high risk of maternal complications.

• #1 Placenta accreta – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/placenta-accreta/diagnosis-treatment/drc-20376436

  Rarely, the uterus and placenta might be kept intact, allowing the placenta to dissolve over time. However, this approach can have serious complications, including: […] In addition, limited research suggests that women who are able to avoid hysterectomy after having placenta accreta are at risk of complications, including recurrent placenta accreta, with later pregnancies. […] After the hysterectomy, you’ll no longer have menstrual cycles or be able to get pregnant. Ask your health care provider about what to expect during your recovery, the length of recovery and how the surgery might affect your recovery after giving birth.

• #1 Placenta Accreta Spectrum | ACOG

  https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum

  When possible, recognition of the need for such care, coordinated antenatal transfer or co-management up until time of delivery, combined with delivery at large regional maternity centers, holds promise to minimize adverse outcomes. […] The antenatal diagnosis of placenta accreta spectrum is critical because it provides an opportunity to optimize management and outcomes. […] Planned delivery at a center experienced with this condition is recommended whenever possible. […] The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). […] The value of preoperative ureteric stent placement in cases with noted bladder involvement is unclear and is left to a case-by-case evaluation.

• #1 Placenta Accreta: Types, Risks, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/17846-placenta-accreta

  Placenta accreta is a condition where the placenta (the food and oxygen source for a fetus) grows too deeply into the wall of your uterus. […] Treatment usually involves an early Cesarean delivery (C-section) followed by a hysterectomy to minimize the risk of severe complications. […] Treatment of placenta accreta can vary. If your provider diagnoses it before delivery, theyll monitor you closely for the rest of your pregnancy. […] A Cesarean hysterectomy is when your uterus is removed at the time of a C-section delivery. […] Most healthcare providers will recommend a C-section between 34 and 37 weeks gestation if there are no complications. […] You cant prevent placenta accreta. […] The outlook is generally good when pregnancy care providers diagnose placenta accreta during pregnancy. […] If your obstetrician removes your uterus, youll lose the ability to become pregnant again. […] Your healthcare provider makes every attempt to save your uterus; however, the risks of doing so may be too high.

• #1 Placenta Accreta: Causes, Symptoms, Treatment and Recovery

  https://www.webmd.com/baby/what-is-placenta-accreta

  The exact treatment for your condition will depend on how firmly your placenta is attached. You should plan on having your baby in a hospital. This will allow your medical team to provide any emergency medical treatment that you or your baby might need particularly emergency blood transfusions if you start to lose too much blood. […] In most cases, youll need to have a combination C-section and hysterectomy called a Cesarean hysterectomy. This removes your entire uterus along with your placenta. Afterward, you wont be able to have more children. […] If you want to have more children, your doctor might try to only remove parts of your placenta, leaving some of it attached to your uterus. Theres a chance that your placenta will dissolve and be reabsorbed into your body over time. […] The most dangerous scenario would be having a vaginal birth without realizing that you have placenta accreta. In this case, youd need immediate emergency attention to deal with the life-threatening amounts of blood that you may lose. Your medical team will need to act quickly to find the best treatment method. […] Placenta accreta cant be reversed, but it can be managed. Depending on your condition, your doctor may recommend bed rest, schedule a C-section to ensure a safer delivery, and, in some cases, do a hysterectomy after you give birth to lower your chances of severe bleeding.

• #1 Management of placenta accreta spectrum

  https://pmc.ncbi.nlm.nih.gov/articles/PMC10183858/

  In the surgical treatment of PSA, hysterotomy and fetal extraction should be performed outside the invaded uterine area, usually in the uterine fundus. […] If surgical treatment of PAS is impossible or at high risk for uncontrollable bleeding, maintenance of the placenta in situ with counseling about the inherent risks is an acceptable approach. […] The treatment of PAS must be defined in a preoperative plan and instituted by a multidisciplinary team. […] Surgical planning should include reserve of blood components, selection of the most experienced professionals available, review of the invaded genital vascular region and definition of anesthetic technique and laparotomic incision. […] Excision with uteroplacental segmental excision followed by restoration of the uterine anatomy (conservative surgery), should be preferred to hysterectomy.

• #1 Placenta Accreta | Duke Health

  https://www.dukehealth.org/treatments/obstetrics-and-gynecology/placenta-accreta

  We prepare for any complications in delivery by involving our obstetric anesthesiologists, fetal diagnosticians, and blood transfusion specialists leading up to your delivery. […] The main risks of placenta accreta include heavy bleeding before and during delivery and damage to your organs during a cesarean section. […] Your care team will also include interventional radiologists, perinatologists (high-risk pregnancy doctors), and neonatologists. […] You will deliver by a scheduled cesarean section. This usually takes place around week 34 of your pregnancy. […] Your care team will walk you through the process of delivery and your cesarean section. […] After your baby is delivered, your doctor will block the blood supply to your uterus to minimize blood loss during a hysterectomy to remove your uterus.

• #1 Placenta accreta spectrum: Management – UpToDate

  https://www.uptodate.com/contents/placenta-accreta-spectrum-management

  For patients with placenta previa-accreta, prenatal care follows typical guidelines for management of placenta previa; however, the combination of PAS and placenta previa is associated with an increased risk of severe maternal and surgical morbidities compared with PAS alone. Management includes: Correction of iron deficiency anemia, if present.

• #1 Optimal strategies for conservative management of placenta accreta: a review of the literature

  https://www.jstage.jst.go.jp/article/jsshp/3/1/3_19/_html/-char/en

  A scheduled delivery is desirable as it is associated with reduced blood loss. […] The choice of anesthetic technique must be made by anesthesiologists. […] Interventional radiology can save lives and even preserve the uterus in cases of massive obstetric hemorrhage. […] The following three main strategies involving cesarean section are advocated in the management of placenta accreta. […] The first strategy is to extirpate both the uterus and the placenta, which is termed a cesarean hysterectomy. […] The second strategy is to preserve the uterus but extirpate the placenta. […] An alternative to the two previous strategies is the preservation of both the uterus and the placenta. […] Conservative management includes leaving the placenta in situ, partly or entirely without forced placental removal, awaiting either spontaneous resorption or expulsion.

• #1 Placenta Accreta Pregnancy Complication – Brigham and Women’s Hospital

  https://www.brighamandwomens.org/obgyn/maternal-fetal-medicine/pregnancy-complications/placenta-accreta

  Placenta accreta is usually diagnosed with an ultrasound. […] Surgery is the most common and effective treatment for accreta. After the birth of the baby, this usually involves either the surgical removal of the placenta, or a hysterectomy to remove the uterus along with the accreta. The ovaries are almost always left in place if a hysterectomy is performed. This will prevent the mother from going into menopause. […] In some cases, the majority of the placenta is removed surgically but a portion is left attached to the uterus to avoid a hysterectomy. This involves some medical risks and requires close follow-up with an experienced provider. […] It’s important to consult with a specialist who has experience with placenta accreta to help manage and care for your pregnancy. If possible, the delivery should occur at a specialized center where the staff is well trained and has experience with accreta deliveries, and where you will have access to a multidisciplinary team of specialists as needed. […] Discuss your options for delivery with your obstetrician and develop a detailed birth plan. A scheduled delivery is preferred, but be sure to also create a plan for an emergency delivery.

• #1 Uterine sparing techniques in placenta accreta – MedCrave online

  https://medcraveonline.com/OGIJ/uterine-sparing-techniques-in-placenta-accreta.html

  The Triple-P procedure involves perioperative placental localization and delivery of the fetus via transverse uterine incision above the upper border of the placenta; pelvic devascularization; and placental non-separation with myometrial excision and reconstruction of the uterine wall. […] Uterine Artery Ligation (UAL): Uterine artery ligation is crucial step for success of uterine preservation in many patients, with a total success rate of 78.9%. […] The success rate for uterine compression sutures ranging from 68% to 100% with an overall success rate of 92%. […] Conservative treatment in management of placenta accreta had changed greatly from the conventional leaving placenta in situ which had a lot of complications to uterine sparing techniques that have less operative time and lesser complications. […] These techniques are based on either resection of placental endometrial implantation site or compression sutures with pelvic devascularization or combination of both.

• #1 Uterine sparing techniques in placenta accreta – MedCrave online

  https://medcraveonline.com/OGIJ/uterine-sparing-techniques-in-placenta-accreta.html

  These are techniques developed to preserve uterus and future fertility which is crucially linked to societal status and self-esteem: […] Conservative management: It is the expectant management by leaving placenta in situ for spontaneous resorption and autolysis. […] The role of adjuvant methotrexate in cases of conservative management is uncertain. […] Follow up is made by -HCG level and Ultrasound or MRI. […] Although some cases succeeded and placenta was expulsed spontaneously, the great majority had hysterectomy either promptly or later on due to hemorrhage or infection. […] Local resection of placental implantation site: Placenta accreta and placenta increta can be safely and successfully treated, in some well-selected cases, by resection of the placental implantation site and repair of uterine defect. This method provides immediate therapy, reduces blood loss and preserves fertility.

• #1 Placenta Accreta Spectrum | ACOG

  https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum

  Prophylactic tranexamic acid given at the time of delivery after cord clamping may reduce the risk of hemorrhage with placenta accreta spectrum. […] Several other clotting factors may help in cases of refractory bleeding. […] The use of interventional radiology to embolize the hypogastric arteries in cases of persistent or uncontrolled hemorrhage may be useful. […] In addition to leaving the placenta in situ, investigators have used adjunctive measures to diminish blood loss, hasten placental reabsorption, or both. […] Taking these limited published data together, and the accepted approach of hysterectomy to treat placenta accreta spectrum, conservative management or expectant management should be considered only for carefully selected cases of placenta accreta spectrum after detailed counseling about the risks, uncertain benefits, and efficacy and should be considered investigational.

• #1 Management and Outcome of Women with Placenta Accreta Spectrum and Treatment with Uterine Artery Embolization

  https://www.mdpi.com/2077-0383/13/4/1062

  Management and Outcome of Women with Placenta Accreta Spectrum and Treatment with Uterine Artery Embolization […] Uterine artery embolization (UAE) is a safe approach to the standardization of complex PAS cases. […] The embolization of the uterine artery for women diagnosed with PAS is safe. Anemia management and the implementation of blood conservation strategies are crucial in women undergoing UAE for the management of PAS. […] Uterine artery embolization (UAE) is an alternative to caesarean HE, allowing preservation of the uterus and improvement of PPH, recommended by several national and international guidelines. […] Recent studies have reported that pelvic artery catheterization and embolization are safe and effective to prevent HE in women with PAS. […] The aim of UAE is to prevent PPH.

• #1 Medical treatment of placenta accreta with methotrexate – PubMed

  https://pubmed.ncbi.nlm.nih.gov/3739639/

  Placenta accreta is a rare condition and is associated with considerable maternal morbidity and mortality. Though the surgical approach of hysterectomy is a definitive therapy, there are occasions when conservation of the uterus is desired by the patient. We report a case of placenta accreta successfully treated with intravenous methotrexate. After 2 weeks of treatment no signs of placenta could be visualized on ultrasound examination of the uterus. The patient was discharged after 15 days and has since been well. Such therapy may be useful in exceptional cases in institutions with adequate facilities for careful monitoring and management of the patient.

• #1 Management strategies for patients with placenta accreta spectrum disorders who underwent pregnancy termination in the second trimester: a retrospective study | BMC Pregnancy and Childbirth | Full Text

  https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1935-6

  To promote the passing of the implanted placenta and reduce the risk of heavy hemorrhaging and infection, we prescribed certain adjuvant treatments, including UAE, methotrexate (MTX) chemotherapy, traditional Chinese medicine and mifepristone, followed by curettage under ultrasound guidance. […] Prophylactic intravenous or oral antibiotics were administered to prevent infection-related complications. […] In our series, UAE, MTX chemotherapy, traditional Chinese medicine, and/or mifepristone followed by curettage under ultrasound guidance were viable adjuvant treatments in the fertility-preserving approach. […] The role of MTX in treating PAS disorders remains controversial because of its uncertain function and possible side effects, and additional evidence of its efficacy and safety is required. […] In the present study, curettage was performed in 42.3% of patients, and all operations went smoothly with little bleeding. […] The management strategies for patients with PAS disorders who undergo pregnancy termination in the second trimester should be comprehensive and individualized.

• #1 Management of placenta accreta spectrum

  https://pmc.ncbi.nlm.nih.gov/articles/PMC10183858/

  The strategies described above offer the advantage of one-step surgical resolution. […] In situations where the surgical management of PAS is considered high risk or impossible for uncontrollable hemorrhage, maintaining the placenta in situ is an acceptable and exceptional conduct, even if associated with several risks. […] Intraoperative cell salvage can be used to rapidly supply large amounts of autologous blood during surgical management of PAS, helping to reduce allogeneic blood transfusion. […] When available, endovascular radiological interventions can be used to reduce bleeding in the surgical field. […] Maternal morbidity is demonstrably lower among pregnant women with PAS treated in specialized centers with proven experience.

• #1 Treatment of Placenta Previa & Placenta Accreta Spectrum

  https://www.iaso.gr/en/maternity-gynecology-clinic/services/maternity-clinic/center-of-excellence-for-placenta-accreta-spectrum

  The introduction of the Cell-Saver aims at restricting heterologous blood transfusion, meaning blood transfusion from a donor, and, therefore, any possible impact on the patient. […] In the event that the patient does not wish to receive heterologous blood transfusion, such as Jehovah’s witnesses. […] During a C-section in cases of Placenta Accreta, there is massive and rapid blood loss. Immediate transfusion is necessary. In many cases, more than 10 blood units are necessary, which must be transfused rapidly. The Intraoperative Autotransfusion System offers large quantities of blood immediately and allows surgeons to treat the case in the best possible manner and apply the conservative uterine preservation approach, wherever possible.

• #1 Chitosan: A new tool for managing Placenta Accreta Spectrum Disorders with uncontrolled hemorrhage

  https://www.oatext.com/chitosan-a-new-tool-for-managing-placenta-accreta-spectrum-disorders-with-uncontrolled-hemorrhage.php

  Purpose: Placenta accreta spectrum disorder (PASD) is a rare but life-threatening complication of pregnancy. We aimed to describe the use of Chitosan impregnated gauze when managing PASD complicated by uncontrolled bleeding. […] Conclusion: chitosan is an effective and safe treatment modality in management of life-threatening hemorrhage caused by abnormal placentation when conventional treatment had failed particularly in case of coagulopathy. It can be interesting to consider in isolated health centers, unexperienced teams, or /and unexpected cases. […] Chitosan is a new effective therapeutic arsenal to treat uncontrolled hemorrhage secondary to abnormal placentation when conventional resources have failed. It can be an ultimate solution to stop bleeding, temporize to transfer the patient or to correct hemostasis. It is inexpensive, easy to apply and has no side effects. Chitosan is interesting to consider in the management of this high-risk condition especially in isolated health centers, unexperienced teams or /and unexpected cases.

• #1 Adjunctive Treatment of Placenta Accreta Spectrum | SpringerLink

  https://link.springer.com/chapter/10.1007/978-3-031-10347-6_9

  This chapter covers the role of interventional radiology, high intensity focused ultrasound, and other modalities that may enhance success of primary management of placenta accreta spectrum. […] High-intensity focused ultrasound in management of placenta accreta spectrum: A systematic review. […] High-intensity focused ultrasound treatment of placenta accreta after vaginal delivery: a preliminary study. […] High-intensity focused ultrasound combined with hysteroscopic resection for the treatment of placenta accreta. […] High-intensity focused ultrasound combined procedures treatment of retained placenta accreta with marked vascularity after abortion or delivery. […] Medical treatment of placenta accreta with methotrexate. […] Conservative treatment of placenta increta with methotrexate. […] Maternal outcome after conservative treatment of placenta accreta. […] Conservative management of morbidly adherent placenta: a case report and review of literature.

• #1 Placenta Accreta | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/27260

  Close monitoring of hemodynamic status and blood loss should be performed. ACOG recommends monitoring blood loss, hemoglobin, electrolytes, blood gas, and coagulation factors to objectively determine the need for transfusion. […] After the procedure, ACOG recommends admission to the intensive care unit to closely monitor for signs of bleeding, hypoperfusion, and fluid overload from resuscitation. […] In patients with unknown placenta accreta, there are typically two management routes. First, suppose the accreta is discovered before hysterotomy. In that case, the procedure should be paused until the appropriate help has arrived, blood products have been ordered, and the anesthesia team has been made aware. […] For those wishing to preserve future fertility, conservative management or expectant management can also be considered. In conservative management, the placenta or uteroplacental tissue is removed without the removal of the uterus.

• #1

  https://journals.lww.com/mfm/fulltext/2021/10000/placenta_accreta_spectrum__conservative_management.7.aspx

  The use of MTX, a cytotoxic agent, has been suggested in the conservative treatment of PAS in multiple studies. […] Uterine devascularization can be achieved through several techniques such as iliac artery embolization, bilateral uterine or hypogastric iliac ligation and balloon occlusion in an attempt to prevent secondary postpartum hemorrhage and possibly accelerate placental resolution. […] Hysteroscopy has been suggested as an adjunct method to shorten the period of placental elimination after conservative treatment in PAS, especially in women who present with pelvic pain and persistent vaginal bleeding. […] Follow up after conservative management of PAS is essential for identifying women at risk of complications and intervening early when any of these arise. […] Future fertility in the cases of conservative management of PAS seems to be minimally affected.

• #1 Placenta Accreta Spectrum Prophylactic Therapy for Hyperfibrinolysis with Tranexamic Acid

  https://www.mdpi.com/2077-0383/13/1/135

  Placenta accreta spectrum (PAS) is associated with high maternal morbidity. […] Therefore, cesarean hysterectomy (CS-HE) is considered the gold standard of treatment. […] Expectant management (EM), leaving the placenta in situ after the delivery of the fetus without any manipulation of the placenta, is associated with a more than 50% reduction in blood loss and need for transfusions. […] We aimed to report on the prevention and management of hyperfibrinolysis with TXA during EM of PAS. […] The outcome of hyperfibrinolysis management with TXA therapy was defined as normalization of coagulation screening and prevention or cessation of vaginal bleeding. […] The mean day of onset of hyperfibrinolysis and initiation of treatment with TXA was post-operative day 45. […] The maximum dose of TXA was 1.5 g t.i.d.

• #1 Optimal strategies for conservative management of placenta accreta: a review of the literature

  https://www.jstage.jst.go.jp/article/jsshp/3/1/3_19/_html/-char/en

  A conservative treatment of placenta accreta was first described in English literature in 1948. […] Recently, this approach has been frequently attempted in Europe and the United States, because conservative management is superior to the other two strategies in avoiding severe peripartum hemorrhage and adjacent organ damage as well as preserving fertility. […] The key prerequisites to success are meticulous advance preparations with appropriate resources and facilities. […] Close surveillance is recommended for patients in conservative management. […] The potential risks include: delayed massive hemorrhage, infection, sepsis, coagulopathy, persistent bleeding, and pelvic pain. […] Successful conservative treatment for placenta accreta can allow subsequent pregnancies. […] The decision on whether to opt for conservative management should be based on the degree of invasion, patients desire for future fertility, and the resources and facilities available for management of placenta accreta.

• #1 National Accreta Foundation — How to Choose a Hospital for your Placenta Accreta Delivery | Placenta Accreta Center of Excellence

  https://www.preventaccreta.org/hospital

  When it comes to a life-threatening, high-risk pregnancy condition like placenta accreta spectrum, the quality of care received matters greatly. […] Doctors and specialists with experience in the care of placenta accreta and appropriate surgical expertise is critical. […] Accreta moms have an increased risk for hemorrhage and surgical complications, and an accreta surgery can be best managed by specialists and a multidisciplinary team. […] Accreta moms are at risk for massive hemorrhage and there’s a high chance (up to 90%) that a blood transfusion will be required, often in large quantities. […] There is the potential need for accreta moms to require admission to an intensive care unit after surgery, so it’s essential that the hospital is equipped to ensure they are ready in case critical care is needed.

• #1 Placenta Accreta

  https://www.cumedicine.us/services/placenta-accreta

  In less severe cases, a woman may not require a cesarean hysterectomy and a skilled surgeon may opt to leave portions of the placenta, with the hope it may detach itself later. […] According to ACOG, the limited amount of research indicates that women who have placenta accreta and do not have a hysterectomy after have a greater risk of complications in future pregnancies. This includes possible miscarriage, premature birth and recurrent placenta accreta. […] Possible complications after cesarean hysterectomy are typical of any surgery or C-section. These include risk of infection, bleeding, fever, scarring and urinary tract injury.

• #1 Doctors save uterus in placenta accreta treatment | UT Physicians

  https://www.utphysicians.com/story/doctors-save-uterus-in-placenta-accreta-treatment/

  It was during her 20-week anatomy ultrasound when Monas OB-GYN discovered she had placenta accreta. […] Traditionally, placenta accreta treatment in the U.S. is a hysterectomy following the babys birth. […] In 2015, UT Physicians started the Placenta Accreta Program to offer another treatment option called conservative management. […] Through this program, the patient is allowed to go home after the baby is delivered with the placenta still inside the uterus. […] Choosing this treatment method comes with very strict protocols and rigorous follow-up. […] Choosing the conservative management option doesnt automatically mean the uterus will be preserved. […] Since the programs inception, 28 patients have chosen this option. Of those, 13 were able to safely deliver the placenta and avoid hysterectomy.

• #1

  https://journals.lww.com/mfm/fulltext/2021/10000/placenta_accreta_spectrum__conservative_management.7.aspx

  A commonly encountered issue among those cases is the high recurrence rate of placenta accreta which is reported to be 22.8%28.6% in subsequent pregnancies. […] Similar results regarding the effect of uterine devascularization and hysteroscopic resection of retained placenta on future fertility and recurrence of the condition are present. […] Studies have shown that bilateral internal iliac artery and uterine artery ligation and pelvic arterial embolization do not affect the vascular supply to the pelvis or future fertility, and this is probably due to the presence of an extensive collateral circulation. […] However, this method has been associated with maternal complications, and; therefore, it should only be an option in areas with adequate expertise and after extensive counseling of the patient.

• #1 Management of placenta accreta spectrum

  https://pmc.ncbi.nlm.nih.gov/articles/PMC10183858/

  Reducing caesarean section rates is the main preventive measure for the placenta accreta spectrum (PAS). […] Early diagnosis of PAS, adequate planning of surgical intervention and the use of effective techniques in intraoperative hemorrhagic control offer greater possibility of preserving life, the uterus and fertility. […] The treatment of PAS should be defined by a preoperative plan and performed in a tertiary service by a multidisciplinary experienced team. […] Maternal morbidity and mortality are lower among pregnant women with PAS treated in specialized centers. […] Placental non-removal should be routine in the surgical treatment of PAS. […] Surgical management of PSA should be performed by professionals with experience in advanced pelvic surgery and skill in dissection of the parametrium, retroperitoneum and pelvic floor, bladder reconstruction, ureter reimplantation and uterine compression suture techniques and uterine and pelvic devascularization.

• #1 National Accreta Foundation — What Do Accreta Patients Need to Know? | Placenta Accreta Patient FAQ | National Accreta Foundation

  https://www.preventaccreta.org/faq

  Placenta accreta spectrum is becoming increasingly common and is associated with significant morbidity and mortality. It is worth noting that even in the most optimal setting, substantial maternal morbidity and, occasionally, mortality occur. This is part of why it is so important to deliver at a hospital that is capable of managing accreta. […] Accreta literature has previously indicated that better outcomes are achieved at a placenta accreta center of excellence, or at facilities with experience and expertise in treating accreta. […] The ACOG SMFM Accreta Care Consensus states: Conservative management or expectant management should be considered only for carefully selected cases of placenta accreta spectrum after detailed counseling about the risks, uncertain benefits, and efficacy and should be considered investigational. If you are going down this path, do know that current literature DOES NOT recommend use of methotrexate for placental reabsorption due to the possibility of maternal harm.

• #1

  https://link.springer.com/article/10.1007/s13669-024-00395-w

  This review summarizes conservative management of placenta accreta spectrum (PAS) disorders, also termed leaving the placenta in situ. The discussion includes clinical considerations in deciding between cesarean-hysterectomy and conservative management, as well as intrapartum and postpartum conservative management techniques. […] A growing body of evidence supports conservative management of PAS for both reduction of morbidity and uterine preservation. Compared to cesarean-hysterectomy, conservative management of PAS is associated with lower maternal morbidity, including blood loss, transfusion, operative injury, and intensive care unit admission. However, intensive, long-term postpartum surveillance is required to monitor for complications such as infection, bleeding, and coagulopathy. These risks should be balanced with an individuals risk profile and personal desires provided by a multidisciplinary, experienced PAS care team.

• #1 Alternative Placenta Accreta Spectrum Treatment Can Improve Outcomes | Duke Health Referring Physicians

  https://physicians.dukehealth.org/articles/alternative-placenta-accreta-spectrum-treatment-can-improve-outcomes

  Placenta percreta is one of the most dangerous conditions a pregnant woman can face, carrying a high risk of catastrophic maternal hemorrhage and even mortality. Performing a hysterectomy at the time of cesarean delivery is the standard treatment but delaying the hysterectomy until several weeks after the delivery led to better outcomes in a select group of patients, according to a case series performed and reported by the Duke Maternal-Fetal Medicine (MFM) Team. […] The statement describes these results from delaying hysterectomy as an encouraging experimental approach when minimizing blood loss and tissue damage are the primary goals. Patients with placenta percreta are optimal candidates for this procedure because they have an increased risk of blood loss and tissue damage if hysterectomy is performed at the time of cesarean delivery.

• #2 Management of placenta accreta spectrum

  https://pmc.ncbi.nlm.nih.gov/articles/PMC10183858/

  Reducing caesarean section rates is the main preventive measure for the placenta accreta spectrum (PAS). […] Early diagnosis of PAS, adequate planning of surgical intervention and the use of effective techniques in intraoperative hemorrhagic control offer greater possibility of preserving life, the uterus and fertility. […] The treatment of PAS should be defined by a preoperative plan and performed in a tertiary service by a multidisciplinary experienced team. […] Maternal morbidity and mortality are lower among pregnant women with PAS treated in specialized centers. […] Placental non-removal should be routine in the surgical treatment of PAS. […] Surgical management of PSA should be performed by professionals with experience in advanced pelvic surgery and skill in dissection of the parametrium, retroperitoneum and pelvic floor, bladder reconstruction, ureter reimplantation and uterine compression suture techniques and uterine and pelvic devascularization.

• #2 Placenta Accreta: Types, Risks, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/17846-placenta-accreta

  Placenta accreta is a condition where the placenta (the food and oxygen source for a fetus) grows too deeply into the wall of your uterus. […] Treatment usually involves an early Cesarean delivery (C-section) followed by a hysterectomy to minimize the risk of severe complications. […] Treatment of placenta accreta can vary. If your provider diagnoses it before delivery, theyll monitor you closely for the rest of your pregnancy. […] A Cesarean hysterectomy is when your uterus is removed at the time of a C-section delivery. […] Most healthcare providers will recommend a C-section between 34 and 37 weeks gestation if there are no complications. […] You cant prevent placenta accreta. […] The outlook is generally good when pregnancy care providers diagnose placenta accreta during pregnancy. […] If your obstetrician removes your uterus, youll lose the ability to become pregnant again. […] Your healthcare provider makes every attempt to save your uterus; however, the risks of doing so may be too high.

• #2 Placenta Accreta Spectrum | ACOG

  https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum

  Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. […] The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). […] Optimal management involves a standardized approach with a comprehensive multidisciplinary care team accustomed to management of placenta accreta spectrum. […] Delivery in highly experienced maternity centers that have this type of coordinated care team and the ability to garner additional expertise and resources in cases of severe hemorrhage appears to improve outcomes.

• #2 Placenta accreta spectrum – Wikipedia

  https://en.wikipedia.org/wiki/Placenta_accreta_spectrum

  Treatment may be delivery by caesarean section and abdominal hysterectomy if placenta accreta is diagnosed before birth. Oxytocin and antibiotics are used for post-surgical management. When there is partially separated placenta with focal accreta, removal of placenta may be reasonable if maternal status is stable. If it is important to save the woman’s uterus (for future pregnancies) then resection around the placenta may be successful. Conservative treatment can also be uterus sparing but may not be as successful and has a higher risk of complications. Techniques include: […] Leaving the placenta in the uterus and curettage of uterus. Methotrexate has been used in this case. […] In cases where there is invasion of placental tissue and blood vessels into the bladder, it is treated in similar manner to abdominal pregnancy and manual placental removal is avoided. However, this may eventually need hysterectomy and/or partial cystectomy.

• #2 Placenta Accreta

  https://www.cumedicine.us/services/placenta-accreta

  In less severe cases, a woman may not require a cesarean hysterectomy and a skilled surgeon may opt to leave portions of the placenta, with the hope it may detach itself later. […] According to ACOG, the limited amount of research indicates that women who have placenta accreta and do not have a hysterectomy after have a greater risk of complications in future pregnancies. This includes possible miscarriage, premature birth and recurrent placenta accreta. […] Possible complications after cesarean hysterectomy are typical of any surgery or C-section. These include risk of infection, bleeding, fever, scarring and urinary tract injury.

• #2 Placenta Accreta and Advanced Obstetric Surgical Program

  https://www.massgeneral.org/obgyn/treatments-and-services/placenta-accreta-program

  The most important element for treatment of placenta accreta spectrum and for all anticipated complex delivery is advanced planning with a group of experienced specialists in a hospital with high surgical volumes. […] Women with placenta accreta in particular often need to deliver early due to complications associated with the disorder, so a planned delivery may be recommended, usually between 34 and 36 weeks. […] A coordinated team effort is important because it helps prevent associated surgical complications, such as hemorrhage and/or injury to the nearby organs such as the bladder. […] Our specialized planning ensures that we can assemble the proper team to facilitate a safe delivery for both the mothers and babies in our care. […] Specialized planning ensures that we can assemble the proper team to facilitate a safe delivery for you and your baby and our team works in sync from start to finish.

• #2 Placenta Accreta Spectrum (PAS) | OHSU

  https://www.ohsu.edu/womens-health/placenta-accreta-spectrum-pas

  Experts from across OHSU come together to plan for and deliver your baby if you are diagnosed with placenta accreta spectrum. In this serious condition, the placenta grows into the wall of the uterus and does not separate after your baby’s birth. […] In almost every case, we recommend an early delivery via C-section and a hysterectomy (removal of your uterus). In rare cases, we can safely avoid a hysterectomy. However, without a hysterectomy you may have complications after delivery and in future pregnancies. […] Because PAS makes childbirth dangerous, we usually recommend your delivery be: Planned in advance based on your condition and its severity, and your health history. We also plan in advance to make sure all members of your care team members are available for you and your baby. […] Early, usually between 34 and 36 weeks of pregnancy. Going into labor could lead to bleeding and an emergency delivery. A planned early delivery reduces these risks.

• #2 National Accreta Foundation — What Do Accreta Patients Need to Know? | Placenta Accreta Patient FAQ | National Accreta Foundation

  https://www.preventaccreta.org/faq

  Placenta accreta spectrum is becoming increasingly common and is associated with significant morbidity and mortality. It is worth noting that even in the most optimal setting, substantial maternal morbidity and, occasionally, mortality occur. This is part of why it is so important to deliver at a hospital that is capable of managing accreta. […] Accreta literature has previously indicated that better outcomes are achieved at a placenta accreta center of excellence, or at facilities with experience and expertise in treating accreta. […] The ACOG SMFM Accreta Care Consensus states: Conservative management or expectant management should be considered only for carefully selected cases of placenta accreta spectrum after detailed counseling about the risks, uncertain benefits, and efficacy and should be considered investigational. If you are going down this path, do know that current literature DOES NOT recommend use of methotrexate for placental reabsorption due to the possibility of maternal harm.

• #2 Placenta Accreta Spectrum (PAS) | ColumbiaDoctors

  https://www.columbiadoctors.org/specialties/obstetrics-gynecology/our-centers/columbia-mothers-center/our-services/placenta-accreta-spectrum-pas

  The management of PAS is complex. At NYP/CUIMC, it involves a multidisciplinary team of experts familiar with this condition. These include maternal-fetal medicine specialists, gynecologic oncologists, anesthesiologists, neonatologists, urologists, interventional radiologists, vascular surgeons, maternal mental health clinicians, and intensivists. The blood bank plays a critical role and has the capacity to provide blood products to replace a massive hemorrhage at all times. […] Once a patient is diagnosed with PAS, their prenatal care is managed by the maternal-fetal medicine team at the Mothers Center. In addition, the patient will have individual consultations with the different members of the multidisciplinary team involved in her care. The patient may be recommended to be admitted to the antepartum unit for in-hospital observation until the day of her delivery. Psychological support and assistance with social services are provided as needed.

• #2 Placenta Accreta Spectrum | ACOG

  https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum

  When possible, recognition of the need for such care, coordinated antenatal transfer or co-management up until time of delivery, combined with delivery at large regional maternity centers, holds promise to minimize adverse outcomes. […] The antenatal diagnosis of placenta accreta spectrum is critical because it provides an opportunity to optimize management and outcomes. […] Planned delivery at a center experienced with this condition is recommended whenever possible. […] The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). […] The value of preoperative ureteric stent placement in cases with noted bladder involvement is unclear and is left to a case-by-case evaluation.

• #2

  https://journalonsurgery.org/articles/js-v3-1119.html

  According to the experience of our hospital, for patients with shallow placental implantation without penetrating the myometrium, uterine artery embolization can temporarily block the uterine blood supply and reduce the total amount of blood loss. […] Triple P procedure is a new uterus preserving surgical technique, which includes three steps: Partial location of placenta accreta before ultrasound or MRI examination before surgery; Selective internal iliac artery embolization or use of pelvic artery occlusion balloon catheter to lower blood supply to the placenta; The implanted placenta and its attached myometrium were removed without separation and the uterus was further repaired. […] Expectant management refers to the preservation of part or all of the placenta in situ. […] The number of PAS cases has increased exponentially in the last couple of years, and this data seems to increase further in the years ahead due to the increase of assisted reproductive technology and caesarean section.

• #2 Placenta Accreta Spectrum Prophylactic Therapy for Hyperfibrinolysis with Tranexamic Acid

  https://www.mdpi.com/2077-0383/13/1/135

  Placenta accreta spectrum (PAS) is associated with high maternal morbidity. […] Therefore, cesarean hysterectomy (CS-HE) is considered the gold standard of treatment. […] Expectant management (EM), leaving the placenta in situ after the delivery of the fetus without any manipulation of the placenta, is associated with a more than 50% reduction in blood loss and need for transfusions. […] We aimed to report on the prevention and management of hyperfibrinolysis with TXA during EM of PAS. […] The outcome of hyperfibrinolysis management with TXA therapy was defined as normalization of coagulation screening and prevention or cessation of vaginal bleeding. […] The mean day of onset of hyperfibrinolysis and initiation of treatment with TXA was post-operative day 45. […] The maximum dose of TXA was 1.5 g t.i.d.

• #2 Caring for the Placenta Accreta Patient – Brigham and Women’s Hospital

  https://www.brighamandwomens.org/obgyn/maternal-fetal-medicine/for-medical-professionals/caring-for-the-placenta-accreta-patient

  In addition to an experienced obstetrician, accreta patients are usually managed by a high-risk OB anesthesia team. […] Delivery should be planned on a unit with 24-hour access to full blood bank services and a massive transfusion protocol. […] Cesarean section with hysterectomy has been the standard of care for most patients with a significant accreta. All patients with suspected accreta should be prepared for this possibility. […] Patients who have undergone conservative management, or who have a focal accreta diagnosed postpartum, are sometimes treated with methotrexate. This is based on experience using the medication for early abnormal (ectopic) pregnancies. […] After a complicated delivery, accreta patients are at risk for persistent coagulopathy and anemia, thromboembolism, and renal, cardiac and other organ dysfunction. Patients require close monitoring, sometimes in an intensive care setting. […] Established in 2008, our team has cared for hundreds of women with uterine and placental disorders, including placenta accreta. We offer accreta consultation and delivery planning, and focus on individualized care based on each patients particular circumstances.

• #2 Treatment of Placenta Previa & Placenta Accreta Spectrum

  https://www.iaso.gr/en/maternity-gynecology-clinic/services/maternity-clinic/center-of-excellence-for-placenta-accreta-spectrum

  The introduction of the Cell-Saver aims at restricting heterologous blood transfusion, meaning blood transfusion from a donor, and, therefore, any possible impact on the patient. […] In the event that the patient does not wish to receive heterologous blood transfusion, such as Jehovah’s witnesses. […] During a C-section in cases of Placenta Accreta, there is massive and rapid blood loss. Immediate transfusion is necessary. In many cases, more than 10 blood units are necessary, which must be transfused rapidly. The Intraoperative Autotransfusion System offers large quantities of blood immediately and allows surgeons to treat the case in the best possible manner and apply the conservative uterine preservation approach, wherever possible.

• #2 Optimal strategies for conservative management of placenta accreta: a review of the literature

  https://www.jstage.jst.go.jp/article/jsshp/3/1/3_19/_html/-char/en

  A conservative treatment of placenta accreta was first described in English literature in 1948. […] Recently, this approach has been frequently attempted in Europe and the United States, because conservative management is superior to the other two strategies in avoiding severe peripartum hemorrhage and adjacent organ damage as well as preserving fertility. […] The key prerequisites to success are meticulous advance preparations with appropriate resources and facilities. […] Close surveillance is recommended for patients in conservative management. […] The potential risks include: delayed massive hemorrhage, infection, sepsis, coagulopathy, persistent bleeding, and pelvic pain. […] Successful conservative treatment for placenta accreta can allow subsequent pregnancies. […] The decision on whether to opt for conservative management should be based on the degree of invasion, patients desire for future fertility, and the resources and facilities available for management of placenta accreta.

• #2 Placenta accreta spectrum – Wikipedia

  https://en.wikipedia.org/wiki/Placenta_accreta_spectrum

  Conservative management of PAS is an approach used to avoid a hysterectomy, total removal of the uterus. Leaving the placenta in situ and not removing it has been the main approach, specifically for those experiencing placenta percreta, as findings suggest that it can mitigate the high hemorrhage or tissue injury risk that can be caused by a hysterectomy. […] Although this approach has been successful, findings have shown that leaving the placenta in situ has posed some negative effects, including delayed hemorrhage, endomyometritis, and sepsis (a systemic infection that can lead to organ dysfunction). […] As mentioned earlier, methotrexate has been used to assist in placenta re-absorption in cases of placenta in situ. It has shown success in helping to decrease the vascularity of the uterus after pregnancy. However, women on methotrexate can not breastfeed, which can negatively impact maternal bonding, neonatal attachment, and postpartum depression. […] It is highly advised that those seeking conservative management (leaving the placenta in situ) are deeply knowledgeable in regards to the short and long term risks, as well as the need for close and lengthy monitoring and after delivery through appropriate counseling.

• #2 Treatment of Placenta Previa & Placenta Accreta Spectrum

  https://www.iaso.gr/en/maternity-gynecology-clinic/services/maternity-clinic/center-of-excellence-for-placenta-accreta-spectrum

  The international literature highlights the need to treat PAS cases in dedicated maternity clinics (Specialized Centers for Placenta Accreta Spectrum Cases) by a team of specialists in well-organized facilities, which are staffed with suitably trained personnel and have the necessary infrastructure. […] Having patients with PAS deliver in Specialized Center for Placenta Accreta Spectrum Cases leads to reduced maternal and neonatal morbidity rates, as well as a lower number of blood transfusion units, compared to non-dedicated maternity clinics. Additionally, mortality due to hemorrhaging in women treated in Specialized Center for Placenta Accreta Spectrum Cases is very low in international literature. […] In our case, conservative management was performed in 19 out of the 40 cases, and uterine preservation was possible, despite extending to the parametrium and urinary bladder.

• #2 National Accreta Foundation — What Do Accreta Patients Need to Know? | Placenta Accreta Patient FAQ | National Accreta Foundation

  https://www.preventaccreta.org/faq

  The use of a consistent multidisciplinary team improves maternal outcomes and can drive internal continuous quality improvement as progressive experience is gained by that same group. […] National Accreta Foundation cannot stress enough the importance of delivering at a hospital that is experienced and capable in treating accreta.

• #2 Alternative Placenta Accreta Spectrum Treatment Can Improve Outcomes | Duke Health Referring Physicians

  https://physicians.dukehealth.org/articles/alternative-placenta-accreta-spectrum-treatment-can-improve-outcomes

  The Duke MFM and Gynecologic Oncology teams demonstrated that patients who had hysterectomies some six weeks after their cesarean deliveries had significantly less blood loss and decreased need for transfusion compared with patients who had the percreta removed at the time of childbirth. […] Secord says its been a multi-year effort to develop an algorithm for management of these patients and to refine the treatment so that therapy is always individualized based on patient factors such as the degree of placental involvement. […] Our distinctive care at Duke for placenta accreta spectrum patients begins with the diagnostic help of a world-class obstetric ultrasound unit with providers highly skilled in interpretation of abnormal placentation by ultrasound, says MFM specialist Jennifer B. Gilner, MD, PhD.

• #2

  https://link.springer.com/article/10.1007/s13669-024-00395-w

  We provide recommendations for patient-centered care planning, resource requirements, and conservative management techniques. Conservative management of PAS is a feasible alternative to cesarean-hysterectomy, and options for management should be discussed with all pregnant individuals with PAS. […] This study highlights that conservative management with PAS in situ poses a risk of coagulopathy. Keeping the placenta in situ after delivery prolongs the risk factors that are integral to PAS. […] This systematic review and meta-analysis shows favorable pregnancy outcomes are possible following successful conservation of the uterus in a placenta accreta spectrum disorder pregnancy. Specifically, approximately 1 out of 4 subsequent pregnancies following conservative management of placenta accreta spectrum disorder had considerable adverse maternal outcomes.

• #2

  https://journals.lww.com/md-journal/fulltext/2017/03100/management_of_patients_with_placenta_accreta_in.52.aspx

  This study aims to analyze the clinical characteristics and to manage patients with retained placenta left in situ accompanied by fever following vaginal delivery. […] All patients were managed with a multidisciplinary approach. Mifepristone was administrated to 16 patients. Fourteen patients received uterine artery embolization. Eleven patients were treated with ultrasound-guided curettage within 24 hours following delivery. Seven patients needed delayed-hysterectomy due to development of complications. […] Antibiotic treatment, interventional therapy, and ultrasound-guided curettage within 24 hours following vaginal delivery are the recommended conservative management strategies. […] The optimum management strategies include either conservative management of the placenta left in situ, or surgical management which mainly includes hysterectomy.

• #2 Alternative Placenta Accreta Spectrum Treatment Can Improve Outcomes | Duke Health Referring Physicians

  https://physicians.dukehealth.org/articles/alternative-placenta-accreta-spectrum-treatment-can-improve-outcomes

  We have developed a standardized hemorrhage management protocol and offer comprehensive transfusion services, maternal critical care, and a neonatal unit with the highest level of care for critically ill infants, which is particularly important for unscheduled or necessary preterm deliveries caused by complications of placenta accreta spectrum, Gilner says. […] Our multidisciplinary approach with a consistent and therefore increasingly experienced core team of specialty physicians, nurses, surgical staff, and transfusion services allows us to lead innovations such as the delayed interval hysterectomy described in the consensus statement and fulfill criteria to make us a center for excellence for care of this highly morbid condition, Gilner says.

• #3 Placenta Accreta | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/27260

  Placenta accreta spectrum is best managed when it has been diagnosed antenatally. Many steps can be undertaken to minimize risks. The American College of Obstetricians and Gynecologists (ACOG) has recommended delivery between 34 0/7 and 35 6/7 weeks of gestation via cesarean hysterectomy to optimize neonatal maturity and minimize the risk of maternal bleeding. […] Before delivery, there should be a consideration for transfer to a Placenta Accreta Center of Excellence (PACE) or a level 3 or 4 center for delivery. Outcomes have been improved by delivery at these facilities due to the availability of a large, interprofessional team. […] Cesarean sections are typically performed in a manner that allows for easy conversion to hysterectomy. This includes dorsal lithotomy positioning and a vertical skin incision. The uterine incision should be made in a manner that would avoid the placenta. After the delivery of the neonate, if the placenta does not deliver spontaneously, the current recommendation is to leave the placenta, close the hysterotomy, and perform a hysterectomy. This approach minimizes the risk of hemorrhage.

• #3 Management strategies for patients with placenta accreta spectrum disorders who underwent pregnancy termination in the second trimester: a retrospective study | BMC Pregnancy and Childbirth | Full Text

  https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1935-6

  To promote the passing of the implanted placenta and reduce the risk of heavy hemorrhaging and infection, we prescribed certain adjuvant treatments, including UAE, methotrexate (MTX) chemotherapy, traditional Chinese medicine and mifepristone, followed by curettage under ultrasound guidance. […] Prophylactic intravenous or oral antibiotics were administered to prevent infection-related complications. […] In our series, UAE, MTX chemotherapy, traditional Chinese medicine, and/or mifepristone followed by curettage under ultrasound guidance were viable adjuvant treatments in the fertility-preserving approach. […] The role of MTX in treating PAS disorders remains controversial because of its uncertain function and possible side effects, and additional evidence of its efficacy and safety is required. […] In the present study, curettage was performed in 42.3% of patients, and all operations went smoothly with little bleeding. […] The management strategies for patients with PAS disorders who undergo pregnancy termination in the second trimester should be comprehensive and individualized.

• #3 National Accreta Foundation — How to Choose a Hospital for your Placenta Accreta Delivery | Placenta Accreta Center of Excellence

  https://www.preventaccreta.org/hospital

  As a result of preterm delivery, many accreta babies require admission to a neonatal intensive care unit. […] ACOG recommends women with suspected placenta accreta spectrum diagnosed in the antenatal period based on imaging or clinical acumen should be delivered at a level III or IV center with considerable experience whenever possible to improve outcomes. […] Both efforts have helped pave the way for improvements in caring for accreta moms, and more will be done over the coming years.

• #3

  https://journals.lww.com/md-journal/fulltext/2017/03100/management_of_patients_with_placenta_accreta_in.52.aspx

  The treatment modalities of conservative approach include use of methotrexate, uterine artery embolization, dilation and curettage, and hysteroscopic loop resection. […] We recommend utilization of imaging modalities such as ultrasound or MRI for the diagnosis and follow-up of women with abnormally invasive placentation. […] We recommend using MRI in patients with high risk factors in case ultrasound fails to detect abnormal placenta plantation antenatally. […] We performed curettage in 11 patients within 24 hours after delivery. Our study has shown that curettage is an effective conservative management strategy. It reduces hemorrhage and also helps to preserve the uterus and fertility. […] Patients with serious complications such as septic shock need delayed hysterectomy, which can be performed 4 to 6 weeks after cesarean delivery. […] A conservative and multidisciplinary approach helped to preserve uterus in 14 patients, whereas 7 patients needed hysterectomy due to development of infections and other complications.

• #3 National Accreta Foundation — What Do Accreta Patients Need to Know? | Placenta Accreta Patient FAQ | National Accreta Foundation

  https://www.preventaccreta.org/faq

  Placenta accreta spectrum is becoming increasingly common and is associated with significant morbidity and mortality. It is worth noting that even in the most optimal setting, substantial maternal morbidity and, occasionally, mortality occur. This is part of why it is so important to deliver at a hospital that is capable of managing accreta. […] Accreta literature has previously indicated that better outcomes are achieved at a placenta accreta center of excellence, or at facilities with experience and expertise in treating accreta. […] The ACOG SMFM Accreta Care Consensus states: Conservative management or expectant management should be considered only for carefully selected cases of placenta accreta spectrum after detailed counseling about the risks, uncertain benefits, and efficacy and should be considered investigational. If you are going down this path, do know that current literature DOES NOT recommend use of methotrexate for placental reabsorption due to the possibility of maternal harm.

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