SURGICAL technique

Unrecognized placenta accreta spectrum: Intraoperative management

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Assembling a multidisciplinary team and preparing for massive bleeding are essential components of the surgical plan for managing PAS



CASE Concerning finding on repeat CD

A 30-year-old woman with a history of 1 prior cesarean delivery (CD) presents to labor and delivery at 38 weeks of gestation with symptoms of mild cramping. Her prenatal care was uncomplicated. The covering team made a decision to proceed with a repeat CD. A Pfannenstiel incision is made to enter the abdomen, and inspection of the lower uterine segment is concerning for a placenta accreta spectrum (PAS) (FIGURE).

What would be your next steps?

Placenta accreta spectrum describes the range of disorders of placental implantation, including placenta accreta, increta, and percreta. PAS is a significant cause of severe maternal morbidity and mortality, primarily due to massive hemorrhage at the time of delivery. The incidence of PAS continues to rise along with the CD rate. The authors of a recent meta-analysis reported a pooled prevalence rate of 1 in 588 women.1 Notably, in women with PAS, the rate of hysterectomy is 52.2%, and the transfusion-dependent hemorrhage rate is 46.9%.1

Ideally, PAS should be diagnosed or at least suspected antenatally during prenatal ultrasonography, leading to delivery planning by a multidisciplinary team.2 The presence of a multidisciplinary team—in addition to the primary obstetric and surgical teams—composed of experienced anesthesiologists, a blood bank able to respond to massive transfusion needs, critical care specialists, and interventional radiologists is associated with improved outcomes.3-5

Occasionally, a patient is found to have an advanced PAS (increta or percreta) at the time of delivery. In these situations, it is paramount that the appropriate resources be assembled as expeditiously as possible to optimize maternal outcomes. Surgical management can be challenging even for experienced pelvic surgeons, and appropriate resuscitation cannot be provided by a single anesthesiologist working alone. A cavalier attitude of proceeding with the delivery “as usual” in the face of an unexpected PAS situation can lead to disastrous consequences, including maternal death.

In this article, we review the important steps to take when faced with the unexpected situation of a PAS at the time of CD.

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