Journal of Obstetrics and Gynaecology, January 2011; 31(1): 1–6

Ó 2011 Informa UK, Ltd.

ISSN 0144-3615 print/ISSN 1364-6893 online
DOI: 10.3109/01443615.2010.532248

REVIEW

Management of placenta praevia and accreta

S. ALLAHDIN1, S. VOIGT2 & T. T. HTWE1

Departments of 1Obstetrics and Gynaecology and 2Radiology, St Mary’s Hospital, Newport, Isle of Wight, UK

Summary
With the rising incidence of caesarean sections, the numbers of cases of placenta praevia accreta and its complications is
continuing to increase. There is a paucity of information about the management of placenta praevia accreta. An Embase and
MEDLINE search was performed using the keywords ‘placenta praevia’, ‘placenta accreta’, and ‘placenta praevia and accreta’,
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from 1978 to 2010. Further articles were identified by cross-referencing. In addition to the above information from the Royal
College of Obstetricians and Gynaecologists Guideline on placenta praevia and placenta praevia accreta, RCOG Guideline No.
27 and the Confidential Enquiry into Maternal Deaths in the UK were searched. The review discusses the incidence,
predisposing factors, pathogenesis, diagnosis, clinical implications and management options of this condition. It is concluded
that a multidisciplinary team approach is essential to reduce neonatal and maternal morbidity and mortality. The mainstay of
treatment is by caesarean hysterectomy, however in carefully selected cases, conservative options may be considered with
caution.

Keywords: Diagnosis, placenta praevia accreta, treatment

For personal use only.

Introduction Incidence of placenta praevia accreta

The term placenta praevia refers to a placenta that lies in close
proximity to the internal cervical os or may partially or
completely cover it (Clark et al. 1985). Placenta accreta refers
to a placenta that is abnormally adherent to the uterus in which
the placental villi embed directly onto myometrium in the
absence of decidua (Clark et al. 1985). Maternal and fetal
morbidity and mortality from placenta praevia is considerable
(Ferrazzani et al. 2009). With the rising incidence of caesarean
section operations, combined with increasing maternal age, the
number of cases of placenta praevia accreta and its complica-
tions is continuing to increase (Clark et al. 1985). Early
diagnosis and a multidisciplinary team approach is essential to
manage this challenging condition. For this review paper,
Embase and Medline were searched for systematic reviews
relating to placenta praevia and accreta from 1978 to 2010. The
majority of publications on placenta praevia and accreta are
retrospective studies, case reports and reviews, with a paucity of
prospective studies. These represent wide international ex-
perience and concern of this condition. In addition to the above
information from the Royal College of Obstetricians and
Gynaecologists guideline on placenta praevia and placenta
praevia accreta (Guideline No. 27, RCOG 2005) and the
Confidential Enquiry into Maternal Deaths in the UK (Hall
2004) have been included. This paper will discuss the
predisposing factors, pathogenesis, incidence, diagnosis and
management options of placenta praevia accreta. The optimal
management regimen has yet to be defined because of the
paucity of outcome data in the present literature.
With the rising incidence of caesarean section operations
combined with increasing maternal age, the number of cases
of placenta praevia accreta and its complications is continuing
to increase (Clark et al. 1985).The risk of placenta praevia in a
first pregnancy is 1 in 400, but it rises to 1 in 160 after one
caesarean section; 1 in 60 after two; 1 in 30 after three; and 1
in 10 after four caesarean sections (Clark et al. 1985). If the
placenta is over the lower segment scar, then there is an
attendant risk that the placenta will invade into or occasionally
through the myometrium. This risk is about 1 in 50 if there
has been one caesarean section; 1 in 6 after two; 1 in 4 after
three; 1 in 3 after four; and 1 in 2 after five caesarean sections
(Usta et al. 2005).
Predisposing factors and pathogenesis
It is unclear why some placentae implant in the lower uterine
segment rather than in the fundus. Advanced maternal age,
multiparity, multiple gestation and smoking are commonly
associated with placenta praevia (Miller et al. 1997). This may
be because there is a greater amount of placental tissue
present in these gestations or due to a hypoxaemia-related
mechanism, which may result in compensatory placental
hypertrophy and increased likelihood of placental encroach-
ment on the cervical os (Miller et al. 1997). Placenta praevia is
also commonly associated with myometrial damage from one
or more prior caesarean deliveries (Usta et al. 2005), uterine
curettage, manual removal of the placenta and myomectomies
(Breen et al. 1977). In these circumstances, the uterine

Correspondence: S. Allahdin, Department of Obstetrics and Gynaecology, St Mary’s Hospital, Newport, Isle of Wight, PO30 9TZ, UK.
E-mail: drallahdin@hotmail.co.uk
 2 S. Allahdin et al.
scarring may predispose to placental implantation in the lower
segment (Breen et al. 1977).
Placenta praevia is more commonly associated with
placenta accreta as the lower segment is an area of relatively
poorer decidualisation and is associated with a thin or absent
decidua basalis (Bencaiova et al. 2007). Damage to the
endometrium and uterine scarring are strongly implicated
with placenta praevia accreta (Oyelese and Smulian 2006). It
has been proposed that the primary deficiency of decidualisa-
tion in the lower uterine segment compounded by poor
decidualisation from the repair process may allow chorionic
villi to implant directly into the myometrium (Oyelese and
Smulian 2006).
Over invasiveness of the trophoblast may also result in a
morbidly adherent placenta. In cases of placenta accreta the
extra villous trophoblast at the materno–placental interface is
reported to be cytotrophoblast, as opposed to the usual
placental bed syncytial giant cells. These are invasive in the
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early stages of pregnancy in the development of the placental
bed (Pijnenborg et al. 1981). It is likely that a balance between
the two hypotheses can vary in different cases of placenta
praevia accreta.
Diagnosis of placenta praevia accreta
Prenatal diagnosis of placenta accreta allows effective manage-
ment planning to minimise morbidity. The diagnosis of
placenta praevia accreta would likely benefit from the
advances made in both radiological and biological techniques.
For personal use only.
Radiological techniques
This diagnosis is usually made by ultrasonography or
magnetic resonance imaging (MRI) techniques.
Pelvic ultrasound is regarded as the most commonly used
imaging modality for the diagnosis of placenta praevia accreta
(Chou et al. 2000). Ultrasound findings include loss of the
normal hypoechoic retroplacental myometrium zone, thinning
or disruption of the hyperechoic uterine serosa – bladder
interface, presence of focal exophytic mass lesions and the
presence of lacunae in the placenta (Masselli et al. 2008).
Further criteria have been successfully introduced, such as
obliteration of retroplacental clear space, a myometrial
thickness of 51 mm, presence of vessels bridging the placenta
and uterine margin, and vessels crossing the sites of interface
disruption (Wong et al. 2008).
On grey-scale ultrasound imaging, Shih and colleagues
(2009) have considered the presence of at least one of the
following characteristics to indicate placenta accreta (includ-
ing its variants, placenta increta and placenta percreta): (1)
complete loss of the retroplacental sonolucent zone; (2)
irregular retroplacental sonolucent zone; (3) thinning or
disruption of the hyperechoic uterine serosa – bladder
interface; (4) the presence of focal exophytic masses invading
the urinary bladder and (5) the presence of abnormal
placental lacunae. Similarly, the diagnosis of placenta accreta
was regarded as positive when any one of these colour
Doppler criteria were present: (1) diffuse or focal lacunar
flow; (2) sonolucent vascular lakes with turbulent flow typified
by high velocity (peak systolic velocity 415 cm/s) and low
resistance waveform; (3) hypervascularity of the uterine –
bladder interface with abnormal blood vessels linking the
placenta to the bladder and (4) markedly dilated vessels over
the peripheral subplacental region (Shih et al. 2009).
Conversely, the diagnosis of placenta accreta and its variants
was regarded as positive by Shih and colleagues (2009), if at
least one of the following 3D power Doppler criteria was
illustrated in the lateral view: (1) intraplacental hypervascu-
larity, (2) inseparable cotyledonal and intervillous circulations
and (3) tortuous vascularity with ‘chaotic branching’. ‘Chaotic
branching’ was defined as vessels growing in an irregular
manner, with tortuous courses, varying calibres and complex
vessel arrangement (Shih et al. 2009). Based on receiver
operating characteristics analysis, ‘numerous coherent vessels’
visualised using 3D power Doppler in the basal view was the
best single criterion for the diagnosis of placenta accreta, with
a sensitivity of 97% and a specificity of 92%. If the presence of
at least one criterion was considered to be diagnostic when
using each ultrasound technique, then 3D power Doppler
would have the best positive predictive value (76%), followed
by grey-scale (51%) and colour Doppler (47%) (Shih et al.
2009).
There are some known pitfalls in the ultrasound detection
of placental adhesive disorders, for example ultrasound might
not be reliable in cases where the placenta is located
posteriorly (Levine et al. 1999b). There is also no evidence
published so far of a precise ultrasound estimation of the
depth of placental invasion through the myometrium (Com-
stock 2005). A rather general problem is the inability of
ultrasound to report the precise topography of invasion of the
placenta through the myometrium (Masselli et al. 2008).
With the development of the newest generation of MRI
scanners and with technological advances such as powerful
gradients, parallel imaging capabilities, three-dimensional
imaging and real-time sequences, MRI has been confirmed
as a useful tool for staging and anatomical evaluation of
placental adhesive disorders. A commonly used MRI protocol
consists of axial, sagittal and coronal half-Fourier acquisition
single-shot turbo spin echo (HASTE) and true fast-imaging
with steady-state precession (True-FISP) sequences in breath
hold technique to minimise motion artefacts. Finally, a sagittal
T1-weighted three-dimensional (3D) breath hold sequence
will be acquired. The entire examination time varies usually
between 20 and 25 min (Masselli et al. 2008).
The advantage of high resolution, high soft tissue contrast
and a large field of view of MRI images compared with
ultrasound can be used in all sequences for a better
anatomical correlation of MRI findings (Dwyer et al. 2008).
The MRI finding of focal thinning and irregularity or
disruption of the myometrium represents a placenta praevia
accreta (Masselli et al. 2008). Further findings are an outer
bulge, heterogeneous signal intensity within the placenta itself
and dark intraplacental bands best seen on T2-weighted
images (Dwyer et al. 2008). The presence of nodular foci of
increased signal intensity within the myometrium represents a
placenta increta. Transmural extension of abnormal signal
intensity through the full myometrium and additional
irregularity of the bladder wall are suggestive of a placenta
percreta (Masselli et al. 2008).
Although ultrasound is the mainstay in imaging placenta
accreta, MRI has been used as an adjunct in diagnosis when
the ultrasound results are equivocal and/or clinical suspicion is
high. MRI has the potential benefit in that it provides greater
soft tissue contrast and a larger field of view as compared with
sonography. Several studies have evaluated the utility of MRI
in the diagnosis of placenta accreta. Mixed results have been
found but advantages have been described over ultrasound
due to the patient’s body habitus or due to posterior location
of the placenta. Lax et al. (2007) found that pelvic ultrasound
is highly reliable to diagnose or exclude the presence of

placental adhesive disorders. They also found MRI to be an
excellent tool for staging and topographic evaluation of
adhesive disorders. For the detection of placenta accreta
(Warshak et al. 2006), have described a sensitivity of 0.77 and
specificity of 0.96 for ultrasound. The sensitivity for MRI has
been published as 0.88 with a specificity of 1.0. The authors
concluded, that a two-stage protocol for evaluating women at
high risk for placenta accreta, which uses ultrasonography
first, and then MRI for cases with inconclusive ultrasound
features, will optimise diagnostic accuracy.
In addition to standard sequences, new MRI techniques
have been tested regarding their capabilities to help to
improve the diagnostic accuracy in the detection of placental
adhesive disorder. Diffusion-weighted imaging (DWI) has
been shown to help to define the interface between placenta
and myometrium as only the placenta itself shows very high
signal intensity. Therefore, image fusion can be used to
improve the detection of focal thinning of the myometrium as
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found in placenta increta, which has been difficult to diagnose
on conventional MRI sequences without contrast enhance-
ment. However, fetal safety for of the use of DWI sequences
has not been established yet (Masselli et al. 2008).
It has also been shown that dynamic contrast MRI can
differentiate chorionic villi and decidua basalis. This techni-
que can provide excellent contrast between placenta and
myometrium anywhere within the uterus; it may be a
promising technique for antepartum diagnosis of the placenta
accreta (Morita et al. 2009). However, the use of gadolinium
intravenous contrast in fetal MRI is not recommended, as its
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safety in the human fetus has not been established. Gadoli-
nium crosses the placenta, is excreted by the fetus into the
amniotic fluid, is subsequently swallowed by the fetus
and may be resorbed by the fetal gastrointestinal tract (Lax
et al. 2007).
Biological techniques for diagnosis of placenta praevia
accreta
It is intuitively appealing to hypothesise that maternal blood
analysis might yield information on abnormal placental
development. Several biological factors such as creatine kinase
levels or elevated levels of alpha-fetoprotein (Tanaka et al.
2001; Oppenheimer and SOGC 2007; Ophir et al. 1999) have
been described in the past to reflect placental dysfunction, but
these hypotheses have not been confirmed. Three biological
markers or techniques have recently been described as
potential tools for the diagnosis of placental abnormalities:
cell-free fetal DNA, placental mRNA, and DNA microarray
(Kupferminc et al. 1993). The identification of biological
markers in maternal blood could also serve to monitor these
patients in cases where conservative treatment has been
implemented (Sekizawa et al. 2002).
Clinical implications of placenta praevia accreta
Maternal and fetal morbidity and mortality from placenta
praevia are considerable (Sekizawa et al. 2002; Jimbo et al.
2003). Placenta praevia accreta may lead to considerable
emotional distress from recurrent antepartum haemorrhage
and hospitalisation (Ferrazzani et al. 2009). It can be
complicated by massive postpartum haemorrhage, dissemi-
nated intravascular coagulopathy, caesarean hysterectomy,
surgical injury to the ureter, bladder, and other viscera, adult
respiratory distress syndrome, blood transfusion associated
complications, renal failure, septicaemia and even maternal
death (Oyelese and Smulian 2006). This condition is also
Management of placenta praevia and accreta 3
associated with an increased incidence of pre-term birth and
perinatal mortality and morbidity (O’Brien 2007; Crane et al.
1999, 2000).
Management options
Placenta praevia accreta is among the greatest treatment
challenges in modern obstetrics. It is a major cause of
maternal mortality and morbidity. The optimal management
of this condition necessitates a multidisciplinary team
approach headed by the obstetrician involving the anaesthe-
tist, diagnostic and interventional radiologist, haematologist,
urologists, gynaecological oncologists, vascular surgeons, and
neonatologists. Early diagnosis and advance planning is the
key to minimising complications (Crane et al. 1999).
Antepartum haemorrhage may occur with this condition and
potentially necessitate early delivery along with its concurrent
risks for the premature neonate (Crane et al. 1999). Prenatal
management of placenta praevia accreta remains controver-
sial. Most authors agree that patients can be expectantly
managed as outpatients until the first bleeding episode.
Subsequent management should be individualised to the
circumstances, including gestational age, severity of haemor-
rhage, and patient’s proximity to the hospital (Oyelese and
Smulian 2006). Antepartum anaemia may occur and this
should be investigated and corrected at the earliest. In cases of
placenta praevia accreta, if a patient has no antepartum
bleeding, an elective caesarean delivery at 38 weeks is usually
advocated. If there has been evidence of antepartum vaginal
bleeding, then an elective caesarean section at 36 weeks’
gestation may be considered to reduce the risk of emergency
out of hours delivery (Crane et al. 1999). This has been no
associated increased neonatal morbidity (Miller et al. 1997;
Oyelese and Smulian 2006). The options for placenta praevia
accreta are surgical and conservative.
Surgical options
Patients presenting with placenta praevia accreta have a high
risk of undergoing caesarean hysterectomy due to severe
haemorrhage (Crane et al. 1999). Confirmed antepartum
diagnosis is not possible in many of the cases, thus the most
important component of successful management of invasive
placental conditions remains preparation. This provides the
opportunity to counsel the patient in advance and plan
management (Crane et al. 1999; Chou et al. 2003; Read et al.
1980).
In all cases of placenta praevia accreta, preparations for the
massive postpartum haemorrhage should be made. The
required blood products should be available in theatre and
the use of the cell saver can be considered for intraoperative
blood cell salvage. Cell salvage is a mode of autologous blood
transfusion. It has advantages over homologous transfusion by
reducing disease transmission, less acidosis, less potassium,
higher levels of 2,3 diphosphoglycerate and is acceptable to
some patients who are Jehovah’s Witnesses (Waters et al.
2000). Blood salvaged from a cell saver has a haematocrit of
40–60, and when given back to the patient its volume is
equivalent to twice as much as whole blood. Fear of amniotic
fluid embolism has limited its use in obstetrics until the
addition of a leukocyte depleting filter (Palls Medical,
Portsmouth, UK), which is shown to reduce significantly
particulate contaminants to a concentration equivalent to
maternal venous blood at caesarean section (Waters et al.
2000). There have been no reports in the literature of any
 4 S. Allahdin et al.
amniotic fluid embolism and this now remains only a
theoretical risk (Catling et al. 2002). The other main concern
is Rhesus immunisation of the mother by transfusing fetal
incompatible blood. A calculated dose of anti-D should be
used when there is Rhesus incompatibility.
When the surgical approach is decided upon, balloon
catheter occlusion or embolisation of the pelvic vessels may be
a useful adjunct to surgery, as it decreases blood flow to the
uterus and makes it possible to perform surgery under more
controlled circumstances, with less profuse haemorrhage
(Clark et al. 1985). In balloon catheter occlusion, the occlusive
balloon catheters are sited in the internal iliac arteries
preoperatively. These catheters are inflated after delivery of
the fetus, allowing surgery under controlled circumstances,
and are deflated after the surgery (Clark et al. 1985).
Alternatively, internal iliac arteries embolisation can be
performed (Kidney et al. 2001; Levine et al. 1999a).
When there is an anterior placenta praevia accreta it is not
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unusual for the lower uterine segment to be markedly
enlarged and vascular, with distortion of normal anatomy
and tissue planes (Levine et al. 1999a). There is a consider-
able likelihood of incising through the placenta during
delivery. This could lead to significant maternal and fetal
blood loss and also to difficulty with delivery (Chou et al.
2003). Before making a uterine incision, a careful inspection
of the lower segment is recommended to rule out placenta
praevia percreta (Hudon et al. 1998).
In patients with placenta percreta involving the urinary
bladder, it is often impossible to separate the bladder from the
For personal use only.
lower uterine segment. The involved portion of the urinary
bladder is often resected with the hysterectomy specimen. The
extent and type of reconstruction needed are determined by
the potential for salvage of the bladder, trigone and distal
ureters. All devitalised tissues must be completely excised
before urinary reconstruction. If the distal ureters and trigone
are intact, the bladder defect can usually be closed in routine
two-layer fashion. An attempt should be made to separate the
suture line on the posterior bladder from the vaginal cuff by
interposing an omental pedicle graft. If the distal ureter and/or
trigone have been resected, ureteroneocystostomy followed by
bladder repair is the usual practice. Other options are
ureteroureterostomy, transureteroureterostomy, and cuta-
neous ureterostomy. All anastomoses and suture lines should
be tension-free and watertight. Very rarely, a total or almost
total cystectomy may be required to control haemorrhage.
Management of the latter includes temporising with cuta-
neous ureterostomies or percutaneous nephrostomies, and
definitive procedures such as urinary diversion or bladder
augmentation.
A vertical incision in the uterus above the placental
insertion may allow expedient delivery of the infant while
avoiding the placenta leaving it undisturbed (Oyelese and
Smulian 2006). After delivery of the fetus when the diagnosis
is certain, there should be no attempt to detach the placenta
from the uterine wall. Detaching the placenta can frequently
result in massive haemorrhage often leading to caesarean
hysterectomy. The severity of this bleeding varies with the site
of placental implantation, depth of myometrial invasion, and
involvement of surrounding organs (Hudon et al. 1998). The
edges of the uterine incision may be oversewn for haemostasis,
after which a total abdominal hysterectomy should be
performed (Hudon et al. 1998), as the cervical region is often
the area of predominant bleeding (Lurie et al. 1996; Kitchen
1978).
Ligation of the internal iliac artery is a procedure associated
with a high rate of failure for controlling haemorrhage in
placenta praevia accreta (Usta et al. 2005), as anastomotic
compensation following ligation is almost immediate and the
arterial pedicles supplying the lower segment are irrigated by
the cervical artery, the inferior vesical artery and by the upper,
middle and lower vaginal arteries. For the same reason, the
ligation of the uterine arteries can be insufficient in cases of
placenta praevia accreta (Kitchen 1978).
Other methods that can be used to reduce the blood loss at
the time of hysterectomy can be uterine packing, oversewing
the placental bed, balloon catheterisation or argon laser
ablation (Breen et al. 1977). The use of vasopressin can also
reduce the bleeding while hysterectomy is being performed
(Breen et al. 1977).
Thus, pelvic artery embolisation is an effective alternative
to surgery in controlling obstetric haemorrhage and as a
fertility and life-saving procedure.
Vasopressin is well known as a potent vasoconstrictor of the
arterioles, its effect is mediated by V1receptors, which
apparently increase intracellular calcium ions (Kitchen 1978;
Scarantino et al. 1999). Meticulous haemostasis of the vaginal
cuff is essential and it may be useful to leave a large drain
through the vault into the vagina, to allow early identification
of persistent intra-abdominal bleeding (Lurie et al. 1996).
Conservative options
Hysterectomy removes any prospect of future fertility and is
associated with considerable morbidity and potential mortal-
ity. To minimise these complications and preserve fertility, the
approach to conserve the uterus and avoid hysterectomy has
been considered (Frederick et al. 1994). Conservative
management may have a limited role in carefully selected
patients who desire future fertility. Conservative options
should only be offered in centres where appropriate facilities
for radiological intervention are available (Lurie et al. 1996).
Women offered conservative management should be coun-
selled extensively that the outcomes are unpredictable and
that there is a significant risk of serious complications,
including death.
The principle behind conservative options is of leaving the
placenta in situ and waiting for its later reabsorption or
expulsion (Kayem et al. 2004). It is imperative that the
placenta is left undisturbed following delivery of the baby,
the cord is ligated and cut short, the uterus is closed and the
placenta is left to be reabsorbed or expelled.
There is a paucity of literature describing the conservative
options for the treatment of placenta praevia accreta. There
have been a number of case reports (Kayem et al. 2004), in
which the placenta has been left in situ after caesarean section.
Adjunctive procedures include: embolisation of the internal
iliac vessels (Kayem et al. 2004; Dunstone and Leibowitz
1998); combined external (B-Lynch suture) and internal
(Bakri balloon) uterine compression (Arduini et al. 2010;
Ferrazzani et al. 2009; Lam et al. 2004); prophylactic uterine
arteries ligation and uterine tamponade (Crane et al. 2000;
Chou et al. 2003; Nishijima et al. 2005). The use of
methotrexate has been suggested as an auxiliary treatment to
reduce placental mass and its vascularisation, and hasten the
resolution (Arduini et al. 2010). Methotrexate, a folate
antagonist, acts primarily against rapidly dividing cells and
therefore is effective against proliferating trophoblast. How-
ever, there is no evidence showing conclusive advantages from
its use (Ferrazzani et al. 2009), this may be because the effect

of methotrexate is on proliferating tissue and therefore a
significant effect on degenerating placental tissue is unlikely
(Dunstone and Leibowitz 1998; Nishijima et al. 2005). The
use of methotrexate also exposes the woman to the potential
for adverse problems, such as anaemia, neutropenia, alopecia,
nausea and vomiting, dermatitis, diarrhoea, hepatitis, and
pulmonary fibrosis. Additionally, it precludes breast-feeding
(Jaffe et al. 1994).
The use of uterotonics like oxytocics, mifepristone and
misoprostol have been suggested (Jaffe et al. 1994) for
placenta accreta, with a view to encourage uterine contraction
and expulsion of the placenta. However, in the case of
placenta praevia accreta situated in the lower segment, their
use can be questioned, as their effect on the thin residual
myometrium may be minimal. Furthermore, as the myome-
trium in this area is often very thin, the newly formed vessels
can bleed profusely (Buckshee and Dadhwal 1997).
There are some potential complications of conservative
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options, such as uterine necrosis, uterine lacerations, or
endomyometritis (Morgan and Atalla 2009) and there is a
20% failure rate with the antecedent risk of caesarean
hysterectomy from unpredictable massive postpartum hae-
morrhage and its associated complications (Morgan and
Atalla 2009).
Conclusion
Placenta praevia accreta is among the greatest treatment
challenges in modern obstetrics. Its incidence is rising in
For personal use only.
association with the rising rate of caesarean sections. Prenatal
diagnosis of this condition is difficult and often cannot be
confirmed. A multidisciplinary team approach and prepara-
tion is essential to manage this challenging condition which
can lead to neonatal and maternal morbidity and mortality.
The anticipation and planning for preoperative, intrao-
perative and postoperative management of suspected cases of
placenta praevia accreta enable logical and timely decision-
making. Referral to tertiary referral centres where facilities are
available for radiological intervention, blood products and cell
savers should be considered in suspected cases of placenta
praevia accreta, especially in women who refuse blood
transfusions. The mainstay of treatment is by caesarean
hysterectomy, however in carefully selected cases, conserva-
tive options may be considered.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the paper.
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