Managing a morbidly adherent placenta (MAP), which includes conditions like placenta accreta, increta, and percreta, is challenging and requires a multidisciplinary approach. Below are the key steps in the management process:
1. Antenatal Diagnosis
Suspect MAP in all patients with previous cesarean or uterine surgery and if the placenta is anteriorly located.
• Ultrasound with Doppler is the primary tool for diagnosing MAP.
• MRI may be used in uncertain cases or to assess the extent of invasion.
• Early diagnosis allows for better planning, including scheduling delivery in a tertiary care center.
2. Multidisciplinary Planning
Involves a team of:
• Obstetricians (Maternal-Fetal Medicine specialists if available)
• Anesthesiologists
• Interventional radiologists
• Neonatologists
• Urologists or general surgeons (if bladder or bowel involvement is suspected)
• Blood bank team
Planning includes:
• Counseling the patient about risks, delivery timing, and possible hysterectomy.
• Ensuring adequate blood products are available.
3. Timing and Mode of Delivery
• Elective cesarean section is typically scheduled around 34-36 weeks, after steroid administration for fetal lung maturity.
• Vaginal delivery is contraindicated due to the risk of severe hemorrhage.
4. Intraoperative Management
• Cesarean hysterectomy (CH) is the definitive treatment in most cases: Subtotal hysterectomy with minimise bleeding & injuries to the bladder in my opinion . Based on personal experience.
• Deliver the baby via a classical uterine incision (avoiding the placenta).
• Leave the placenta in situ to minimize hemorrhage, before proceeding with CH
• Proceed with a planned Cesarean hysterectomy on step wise manner.
• Uterine artery embolization or balloon occlusion catheters can be used to reduce blood loss prior to CH
• Massive hemorrhage protocol should be in place, with cross-matched blood, platelets, and coagulation factors ready at the time of CH
If hysterectomy is not performed:
• Consider leaving the placenta in situ with close follow-up, but this is reserved for selected cases and carries risks like infection or delayed hemorrhage.
5. Postoperative Care: HDU/ ICU
• Monitor for complications such as:
• Infection
• Secondary hemorrhage
• Coagulopathy
• Administer thromboprophylaxis as per risk assessment.
Key Challenges
• Massive hemorrhage is the leading cause of maternal morbidity and mortality in MAP.
• Bladder injury is common in placenta percreta cases.
• Emotional support and psychological counseling may be necessary, especially if hysterectomy affects future fertility.
