Placenta Accreta Spectrum (acreta/increta/percreta)
Admission & discharge
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Bleeding, labour, membrane rupture, maternal deterioration or fetal concern requires hospital assessment. Planned birth should be in an appropriately resourced multidisciplinary centre.
When clinic, day care or home care may be suitable
- Stable antenatal PAS may be followed by a specialist team until the planned admission; outpatient care needs a documented emergency-access plan.
Before going home
- After surgery, no recurrent bleeding, sepsis or unresolved organ-support need; bowel, bladder, pain, mobility and nutrition are satisfactory.
- Document any urinary tract injury, hysterectomy, retained placenta/conservative management, drains or planned further procedures. Conservative PAS management needs an explicit prolonged follow-up pathway.
Discharge medicines and treatment changes
- Provide the actual anaemia, analgesia and VTE-prevention prescription with stop/review dates; antimicrobial treatment is indication-specific.
Tests, pending results and their reviewer
- Assign review of pathology, Hb/renal findings and outstanding imaging or specialist results.
Home care and counselling
- Teach wound/drain/catheter care when applicable; discuss fertility consequences, future-pregnancy planning and emotional recovery.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
Before discharge | Name the lead obstetric/surgical team and dates for wound, blood, urinary and pathology reviews. |
If placenta retained/conservative treatment | Provide a specialist monitoring schedule and rapid-return access; ordinary post-caesarean discharge advice alone is insufficient. |
Return urgently
- Heavy bleeding, fever, worsening pain, urinary problems, breathlessness or collapse require immediate assessment.
Treatment
① Immediate stabilization — first minutes
- Unsuspected finding at caesarean: DO NOT pull the placenta — call senior help, close over placenta in situ (conservative bridge) and transfer to capable centre OR convert to caesarean hysterectomy if team assembled
- Never piecemeal-remove an accreta
③ First-line treatment & drug regimens
- PLANNED MULTIDISCIPLINARY CAESAREAN HYSTERECTOMY (standard recommended management) at 35+0–36+6 weeks (earlier 34+0–35+0 for bleeding episodes/extreme invasion)
- Conservative management (leaving placenta in situ/methotrexate-assisted resorption) = SELECTED EXPERT-CENTRE ALTERNATIVE only — high risks: infection, haemorrhage, late hysterectomy, GTN-confounding follow-up
- Cell salvage + rapid infuser prepared; 4–6 units crossmatched minimum (complex: 10+)
- Prophylactic internal iliac balloon occlusion/pre-operative embolisation: institution-dependent evidence — use per local protocol
Definitive treatment
- THEATRE SEQUENCE (planned case):
- 1. Regional±GA strategy per anaesthetics (long case; GA conversion readiness)
- 2. Midline/transverse access chosen for exposure; bladder flap HIGH
- 3. Fetus delivered via incision AVOIDING placenta (transverse fundal where anterior percreta)
- 4. Cord clamped; NO placental traction
- 5. Hysterectomy performed WITH placenta in situ (total hysterectomy ± parametrial dissection per grade)
- 6. Bladder cystotomy repair/ureteric stenting as mapped pre-op by urology
- 7. Haemostasis layer-wise; packing option; IR embolisation on standby
Monitoring
| Phase | Watch |
|---|---|
Intra-op | Cumulative blood loss >2 L → activate MTP formally |
HDU/ICU 24–48 h | Ongoing ooze, urine output, coags, bladder drain contents (haematuria) |
Day 2–5 | Ileus, infection, VTE prophylaxis timing, wound |
Response assessment
- Stable counts/coags
- Drains dry/declining
- Ambulating; bowel function returning
Treatment failure
- Re-look laparotomy for bleeding → IR embolisation → packing + damage-control closure
- Urine leak → urology re-imaging (CT urogram) + stent revision
Second-line treatment
- Delayed-interval approach complications managed jointly (sepsis → antibiotics ± completion hysterectomy; secondary haemorrhage → embolisation)
Rescue treatment
Catastrophic haemorrhage: aortic compression/clamp, massive transfusion ratios, damage-control surgery with packing + transfer to ICU, re-look in 24–48 h.
Procedure / surgery
Detailed operative pages: see procedures-caesarean-hysterectomy (linked).
Escalation
- ALL suspected/confirmed PAS births belong in centres with: 24/7 blood bank incl. massive supply, interventional radiology, urology, experienced obstetric surgeon, ICU, neonatal unit
- In-utero transfer BEFORE labour beats emergency retrieval
⑮ Complications & their management
Massive haemorrhage
MTP activation; ratio components; cell salvage; consider rFVIIa adjunct only after physiology corrected
Bladder/ureteric injury
Intra-op urology repair; stents 6 weeks; post-op cystogram/urogram
VTE
Extended prophylaxis post-discharge (28 days) balancing bleeding risk
Psychological trauma/fertility loss
Debrief; counselling referral; documented fertility discussion pre-operatively
Post-treatment care
- Histopathology confirmation
- 6-week pelvic review; urinary function check
- Contraception: permanent methods discussion appropriate
- Next pregnancy impossible without uterus — document counselling
Diagnosis & assessment
- Praevia + ≥1 prior caesarean → SCREEN EVERY CASE
- Loss of retroplacental clear zone
- Numerous placental lacunae (grade 2–3)
- Bladder wall interruption + subplacental hypervascularity
- Abnormal fetal-MRI findings where used
Definition: Accreta (attached to myometrium), increta (into myometrium), percreta (through serosa ± adjacent organs). FIGO/AIP classification grades 1–3 based on topography.
Risk factors
Presentation
- Usually ANTENATAL IMAGE DETECTION
- May present as APH/PFH at caesarean with placenta that will not separate
- Percreta: haematuria, bladder symptoms, rectal bleeding rarely
Initial assessment
- Screening ultrasound (greyscale + colour Doppler) for ALL praevia-with-scar cases at anomaly scan (~18–22 wks) AND again ~28 wks
- Suspicion → REFER to accredited centre (FIGO-endorsed multidisciplinary model) — do not manage operatively in unequipped facilities
- MRI adjunct where topographic mapping needed (posterior/parametrial invasion, ureteric involvement)
- Multidisciplinary board: obstetrics, anaesthesia, interventional radiology, urology, neonatology, haematology, intensive care
Investigations
| Test | Looking for |
|---|---|
TVS/TAS Doppler | Lacunae, clear-zone loss, bladder-line interruption, bridging vessels, subplacental vascularity |
MRI pelvis (selected) | Depth/topography; parametrial/posterior extension; ureteric proximity |
CBC, group&save, antibody screen | Transfusion planning; anaemia optimisation |
Renal function ± CT urogram (percreta with urinary symptoms) | Ureteric involvement mapping |
Algorithm
Sources (8)
2025-10 · checked 2026-10-17 · verified-summary
Open source ↗
Targeted recheck: WHO 2025 recognition/treatment trigger (≥500 mL or ≥300 mL with abnormal haemodynamics), concurrent first-response bundle and refractory-haemorrhage fibrinogen target ≥2 g/L if replacing a level <2 g/L. Primary recommendation chapter/table indexed at https://www.ncbi.nlm.nih.gov/bo…
· checked 2026-10-18 · verified-live
Open source ↗
Primary information read: individualised admission by bleeding/history/access, urgent attendance for bleeding/pain/contractions, specialist PAS/vasa praevia birth planning and postoperative/fertility counselling. No universal asymptomatic admission week is inferred.
31 March 2021 · updated 10 June 2025 · checked 2026-10-18 · verified-live
Open source ↗
Scope: additional clinical-detail explanation for lscs, vbac-tolac. Checked the assessment, management-decision and follow-up statements in that section against this source. This does not certify all pre-existing regimens, calculations or recommendations in the module. Additional admission/discharge…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary patient recovery page read: pain control, wounds, activity/VTE, urinary/bowel and infection warning signs, adult support and no driving/important decisions during the first 24 hours after general anaesthesia. Used as general recovery/handover principles, not operation-specific discharge…
· checked 2026-10-18 · verified-live
Open source ↗
Maternal/newborn transfer assessment, first void and effective feeding, handover, support/safeguarding, first midwife visit within 36 hours after transfer, postnatal danger symptoms. Full recommendations page read.
· checked 2026-10-18 · verified-live
Open source ↗
Normal-delivery discharge not less than 48 hours: full primary SOP PDF normal-delivery/discharge passages read. Corroborated by NHM CEmONC 2024 Part 1, chapter 8. This does not define a universal post-caesarean or complicated-case stay.
· checked 2026-10-18 · verified-live
Open source ↗
Official WHO summary read: at least 24-hour facility care after birth; additional contacts at 48–72 hours, 7–14 days and week 6; individual assessment/support. Summary facts only, not a claim that the full 242-page PDF was reviewed.
· checked 2026-10-18 · verified-live
Open source ↗
Full primary recommendations read, focusing on critical-care-to-ward transfer: structured written handover, shared plan, monitoring, rehabilitation and receiving-team capability. Step-down is distinct from home discharge; no universal organ-support discharge cutoff is asserted.