Clinical Expert Series

Abnormal Placentation
Placenta Previa, Vasa Previa, and Placenta Accreta
Robert M. Silver, MD

Placental disorders such as placenta previa, placenta accreta, and vasa previa are all associated
with vaginal bleeding in the second half of pregnancy. They are also important causes of serious
fetal and maternal morbidity and even mortality. Moreover, the rates of previa and accreta are
increasing, probably as a result of increasing rates of cesarean delivery, maternal age, and
assisted reproductive technology. The routine use of obstetric ultrasonography as well as
improving ultrasonographic technology allows for the antenatal diagnosis of these conditions. In
turn, antenatal diagnosis facilitates optimal obstetric management. This review emphasizes an
evidence-based approach to the clinical management of pregnancies with these conditions as
well as highlights important knowledge gaps.
(Obstet Gynecol 2015;126:654–68)
DOI: 10.1097/AOG.0000000000001005

PLACENTA PREVIA (eg, 3.2 cm over the os or 1.3 cm away from the
Background os) should be reported for low-lying placentas.
Placenta previa is defined as the placenta overlying The incidence is estimated to be 1 in 200
the endocervical os. In the past, previas were pregnancies at term and varies throughout the
characterized as complete, partial, and marginal world.2,3 The incidence appears to have increased in
depending on how much of the internal endocervical relationship to the increasing rate of cesarean deliver-
os was covered by the placenta. However, the use of ies. Indeed, there is a dose–response relationship
transvaginal ultrasonography allows for precise between the number of previous cesarean deliveries
localization of the placental edge and the cervical and subsequent placenta previa.4 Other risk factors
os. Accordingly, the nomenclature has been modi- include previous spontaneous and elective pregnancy
fied so as to eliminate the terms “partial” and “mar- terminations and previous uterine surgery.5 As with
ginal.”1 Instead, all placentas overlying the os (to any cesarean delivery, the risk of previa increases with
degree) are termed previas and those near to but not increasing numbers of prior pregnancy losses. Thus,
overlying the os are termed low-lying.1 The precise although the pathophysiology of placenta previa re-
relationship of the placenta and the os and the mains uncertain, there appears to be an association
distance that it overlies or is away from the os between endometrial damage and uterine scarring
and subsequent previa. Other risk factors for previa
From the University of Utah School of Medicine, Salt Lake City, Utah.
include increasing maternal parity, increasing mater-
The author thanks Susan Fox for assistance in the technical preparation of the
nal age, smoking, cocaine use, multiple gestations, and
manuscript and Anne Kennedy, MD, and Paula Woodward, MD, for assistance prior previa.6–8
with the figures.
Continuing medical education for this article is available at http://links.lww.
com/AOG/A672. Clinical Implications
Correspondence: Robert M. Silver, MD, Department of Obstetrics and Gynecol- Placenta previa is associated with numerous adverse
ogy, University of Utah School of Medicine, 30 North 1900 East, Room 2B308, maternal and fetal–neonatal complications. Many of
Salt Lake City, UT 84132; e-mail: bsilver@hsc.utah.edu.
these are direct consequences of maternal hemor-
Financial Disclosure
The author did not report any potential conflicts of interest. rhage. Indeed, women with placenta previa are at an
approximately 10-fold increased risk of antepartum
© 2015 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved. vaginal bleeding.9 The mechanism of bleeding is
ISSN: 0029-7844/15 uncertain but appears to be attributable to separation

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Unauthorized reproduction of this article is prohibited.
of the placenta from the underlying decidua resulting approach greatly reduces the need for follow-up
from contractions, cervical effacement, cervical dila- ultrasonograms to “exclude” placenta previa.15 Al-
tion, and advancing gestational age. In turn, bleeding though there are theoretical concerns about increas-
is associated with an increased risk of need for blood ing the risk of bleeding, the procedure is quite
transfusion, hysterectomy, maternal intensive care safe.16,18 Transabdominal ultrasonography serves as
unit admission, septicemia, thrombophlebitis, and an excellent screen for placenta previa, and it is not
even maternal death.2,9–12 necessary to perform transvaginal ultrasonography
Fetal complications are primarily those associated on all women.19 For example, using a cutoff of 4.2
with prematurity. A population-based U.S. cohort cm between the placental edge and the os had 93.3%
noted 55.6% of women with previas delivered after sensitivity, 76.7% specificity, and a 99.8% negative
37 weeks of gestation, 27.5% delivered between 34 predictive value for previa.19 Translabial ultrasonog-
and 37 weeks of gestation, and 16.9% delivered before raphy is another more accurate alternative to trans-
34 weeks of gestation.8 In turn, perinatal mortality abdominal ultrasonography.20
rates are increased by threefold to fourfold.13 Perinatal It is noteworthy that many placenta previas noted
morbidity also is substantial. at midpregnancy during routine screening ultrasono-
grams will no longer be present by the time of
Diagnosis delivery. The relationship between the cervix and
The “classic” presentation used to be painless vaginal the placenta changes over time with the placenta
bleeding in the third trimester. Of course, bleeding typically “moving away” from the cervix. Accord-
may be associated with abdominal pain, contrac- ingly, only approximately 10–20% of previas at 20
tions, or both. Now, most previas are diagnosed by weeks of gestation will remain previas in the late third
antenatal ultrasonography, which is considered diag- trimester.21 The placenta does not truly “migrate.”
nostic. Almost all women receiving prenatal care in Instead, it is thought that the placenta undergoes a pro-
high-income countries undergo routine screening cess termed trophotropism, growing toward the area
using transabdominal ultrasonography. At that time, of the uterus with the best blood supply (typically the
the placental location is systematically evaluated. In fundus). In turn, the portion of the placenta closest to
cases of suspected placenta previa on transabdomi- the cervix regresses and atrophies. The result is that
nal ultrasonography, the patient should undergo only a small proportion of previas noted early in preg-
transvaginal ultrasonography to more accurately nancy remains at term. The earlier in gestation a pre-
delineate the relationship between the placenta and via is noted, the higher the probability that it will
the endocervical os, which is considerably more “resolve” by the late third trimester.22
accurate than transabdominal ultrasonography. For There is no evidence to guide the optimal time of
example, transvaginal ultrasonography will “reclassi- subsequent imaging in pregnancies thought to have
fy” a diagnosis of low-lying placenta noted on trans- placenta previa. In stable patients it is reasonable to
abdominal ultrasonography in the second trimester perform a follow-up ultrasonogram at approximately
26–60% of the time (Fig. 1).14,15 Transvaginal ultra- 32 weeks of gestation. This allows adequate time for
sonography also improves the accuracy of the diag- “resolution” of low-lying placentas and avoids poten-
nosis in the third trimester (Fig. 2).16,17 Such an tially unnecessary studies. It may be worthwhile to

Fig. 1. A. Apparent placenta previa

on transabdominal ultrasonogram.
Arrow shows placenta apparently
overlying the endocervical opening.
B. The same patient with no previa
on transabdominal ultrasonogram
after resolution of focal uterine con-
traction. Arrow shows the endocer-
vical opening with no placenta.
Silver. Placenta Previa, Vasa Previa, and
Placenta Accreta. Obstet Gynecol 2015.

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 operators should be experienced owing to increased
risks and difficulty of the procedure.23
There is an increased risk of postpartum hemor-
rhage in the setting of previa, even without accreta.
This often is attributable to diffuse bleeding at the
placental implantation site in the lower uterine
segment. In addition to uterotonics, measures such
as “oversewing” of the placental bed, intrauterine bal-
loon tamponade, and B-Lynch or other compression
sutures may be helpful. Cesarean delivery for placenta
previa can usually safely be performed using regional
anesthesia, and general anesthesia is reserved for
unstable patients, the need for hysterectomy, and
other nonobstetric indications. In fact, general anes-
thesia may increase blood loss without improving
safety in cases of placenta previa.24
Although cesarean delivery is universally accepted
as the optimal approach if the placenta overlies the
endocervical os, if the placenta is 2 cm or greater from
Fig. 2. True placenta previa on transvaginal ultrasonogram. the os, a trial of labor is appropriate and the risk of
Silver. Placenta Previa, Vasa Previa, and Placenta Accreta. Obstet bleeding is acceptable.25,26 Conversely, if there is less
Gynecol 2015. than 1 cm between the edge of the placenta and the os,
the chances of hemorrhage are so high as to warrant
planned cesarean delivery.26,27 The optimal manage-
perform an additional study at 36 weeks of gestation ment of patients with between 1.0 and 2.0 cm between
(if the previa persists) to determine the optimal route the os and the placenta is uncertain (Fig. 3). Success
and timing of delivery. There is no clear benefit from rates of vaginal delivery range between 76.5% and
more frequent ultrasonograms (eg, every 4 weeks) in 92.9% in small series.27–29 It is reasonable to individu-
stable cases. Numerous factors influence the chances alize the management of such patients.
of the previa persisting until delivery such as prior The optimal timing of delivery in “stable” cases
cesarean delivery, the distance the placental edge of placenta previa also is controversial. The benefits
overlies the os, and the thickness of the placenta of a planned delivery under optimal circumstances
edge.15,22 In cases of prior cesarean delivery and and before labor or bleeding must be weighed
“resolved” previa or low-lying placenta, there is an against the risks of prematurity. There are no quality
increased risk for accreta and vasa previa, respec- data to guide management, and it is difficult to ana-
tively. These topics are addressed subsequently. lyze retrospective cohorts because many studies do
not differentiate between elective and emergent
Management delivery. The risk of bleeding, labor, or bleeding
The only safe and appropriate mode of delivery for and labor leading to the need for emergent delivery
placenta previa is by cesarean delivery. In the absence increases with increasing gestational age, and the
of accreta, this can usually be accomplished using risks of morbidity associated with prematurity
a lower segment uterine incision. It is important for decrease with advancing gestational age. A decision
the operator to move quickly but carefully, because analysis concluded that the optimal strategy was
cutting through the placenta often is associated with planned delivery at 36 weeks of gestation.30 This
increased maternal bleeding. When the placenta is issue is well-summarized in a review by Blackwell,
transected, the umbilical cord should be quickly who concluded that women with uncomplicated pla-
clamped after delivery to avoid excessive blood loss. centa previa should undergo scheduled late preterm
High vertical incisions are justified in some cases to birth by cesarean delivery between 36 0/7 and 37
avoid the placenta, especially if childbearing is 0/7 weeks of gestation.31,32 There is no need to assess
completed or in cases of preterm gestations or trans- fetal maturity with amniocentesis. Earlier delivery
verse lie. Preoperative ultrasonography to precisely may be warranted for those with meaningful vaginal
determine placental location is often useful in deter- bleeding, labor, or other comorbidities such as obe-
mining the optimal place for the uterine incision. The sity or multiple prior cesarean deliveries.31

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 and gestational age after cerclage placement.38 How-
ever, another slightly larger trial showed no benefit
to cerclage.39 Taken together, there is no clear ben-
efit from the procedure in women with previa and it
is not recommended.

VASA PREVIA
Background
Vasa previa is defined as fetal vessels that run through
the fetal membranes, over or near the endocervical os,
and unprotected by the placenta or umbilical cord
(Fig. 4). It is uncommon and occurs in 1 in 2,500 to 1
in 5,000 pregnancies.40–42 The pathophysiology is
uncertain, but there is some overlap with placenta
previa. Risk factors include succenturiate or bilobed
placenta, velamentous cord insertion, previa or low-
Fig. 3. “Low-lying” placenta on transvaginal ultrasono- lying placenta in the second trimester, and multiple
gram. The distance between the placental edge and the
cervix is clearly visualized despite the fetal head overlying gestation.41,43–45
the cervix. D, distance.
Silver. Placenta Previa, Vasa Previa, and Placenta Accreta. Obstet
Clinical Implications
Gynecol 2015. Undiagnosed vasa previa is associated with up to
a 60% rate of perinatal mortality.41 This is the result of
fetal–neonatal hemorrhage and exsanguination if fetal
The mainstay of antepartum care is “expectant
management.” Most women with asymptomatic pre-
via (no bleeding or contractions) are managed as out-
patients. Several,33,34 but not all,35 retrospective
studies show similar outcomes with outpatient man-
agement at lower cost. In contrast, hospitalization is
advised in most cases of vaginal bleeding or uterine
contractions. One small, randomized controlled trial
noted no difference in outcomes between patients
with outpatient compared with inpatient care after
an initial period of hospitalization and stabilization
after a single episode of bleeding.36 It is difficult to
standardize an approach to hospitalization for symp-
tomatic previas given the potentially episodic nature
of vaginal bleeding. Nonetheless, most experts advise
hospitalization in women with multiple episodes of
bleeding or in cases in which the patient has limited
access to appropriate medical care.37 It is appropriate
to consider corticosteroids to enhance fetal pulmo-
nary lung maturity in all cases of previa; they should
always be given in cases of expectant management
after vaginal bleeding before 34 weeks of gestation.
The use of tocolysis in women with previa is a matter
of debate and the potential benefit of tocolysis in
women with previa remains uncertain.
Although often prescribed, the benefits of bed
rest, pelvic rest, or reduced activity remain Fig. 4. Vasa previa. Fetal vessels traverse the fetal mem-
unproven. Cerclage was proposed to potentially branes unsupported by Wharton’s jelly.
stabilize the cervix and decrease bleeding. One small Silver. Placenta Previa, Vasa Previa, and Placenta Accreta. Obstet
prospective trial noted an increase in birth weight Gynecol 2015.

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vessels tear in the process of spontaneous or artificial multilobed placenta, succenturiate lobed placenta,
rupture of membranes and labor. Because the entire or velamentous cord insertion are noted, targeted
fetal blood volume is usually less than 100 mL/kg, screening for vasa previa should be performed using
clinically important bleeding can be rapid. Also, there transvaginal ultrasonography and color Doppler.
is a theoretical risk of compromised blood flow to the Typical findings include a linear tubular echolu-
fetus from compression and occlusion of fetal vessels cent body overlying the os on gray scale ultrasonog-
by the presenting fetal part. Vasa previa also is asso- raphy. Color Doppler demonstrates flow through the
ciated with an increased risk of preterm birth and structure and pulsed Doppler shows fetal vascular
associated complications of prematurity. In most waveforms (Fig. 5). It is noteworthy that a “free loop”
cases, this is the result of iatrogenic preterm birth in of cord can overlie the os and mimic a vasa previa.
an effort to avoid stillbirth. Accordingly, it is important to trace the insertion of
The most important variable influencing fetal–neo- the vessels and to demonstrate that they do not
natal outcome is prenatal diagnosis. Oyelese and col- “move” with changing maternal position. Also, it
leagues40 noted a 97% survival rate in cases of prenatal may be helpful to use the Trendelenburg position to
diagnosis compared with only 44% when the diagnosis remove the fetal presenting part out of the pelvis. In
was made intrapartum in a cohort of 155 women with addition to assessing if the vessel moves, this may
vasa previa. Gestational age at delivery is the only allow better visualization of the vessels on ultrasonog-
other variable associated with perinatal outcomes.41 raphy without compression by the presenting part.46 It
is likely that a combination of both transabdominal
Diagnosis and transvaginal ultrasonography provides the best
Rarely, diagnosis may occur by palpation of fetal diagnostic accuracy.23
vessels or fetal tachycardia and sinusoidal pattern The performance characteristics of ultrasonogra-
on fetal heart rate tracing. Because these approaches phy for the detection of vasa previa have been
are unreliable and are associated with unacceptably reported to be excellent.42,43,47,48 However, these stud-
high death rates, morbidity resulting from vasa ies may overestimate accuracy because they were con-
previa was thought to be unavoidable. However, ducted in specialty centers, the number of vasa previas
the condition is now frequently diagnosed by was small, and the cohorts assessed were subject to
antenatal ultrasonography. It is standard to assess bias. Power Doppler, three-dimensional ultrasonogra-
placental location, cord insertion, and number of phy, and magnetic resonance imaging all have been
placental lobes as part of a midpregnancy obstetric reported as beneficial modalities to diagnose vasa pre-
ultrasonography. When cases of low-lying placenta, via.49,50 However, it is unclear that they are superior to

Fig. 5. Vasa previa. Color Doppler

demonstrating fetal vessels over the
cervix. Pulse wave Doppler showing
pulsatile flow in the vessels.
Silver. Placenta Previa, Vasa Previa, and
Placenta Accreta. Obstet Gynecol 2015.

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two-dimensional ultrasonography alone. It is notewor- decidua. If the trophoblast invades the myometrium,
thy that although it is possible to diagnose vasa previa it is termed placenta increta, and if it invades through
antenatally, some cases will be missed by competent the myometrium beyond the serosa and into sur-
centers.37 rounding structures such as the bladder, it is termed
a percreta. Often the term placenta accreta is used to
Management refer to the entire spectrum of conditions including
The optimal management of vasa previa remains accreta, increta, and percreta as well as to cases of
controversial owing to a lack of quality data. It is clinically apparent morbidly adherent placenta. In
generally accepted that delivery should occur by this article, placenta accreta refers to the spectrum
cesarean before the onset of labor of rupture of unless specifically noted.
membranes. As with previa and accreta, the risk of In normal circumstances, trophoblast stops
perinatal death increases (as a result of increasing invading the uterus when Nitabuch’s (spongiosus)
chances of labor, bleeding, and ruptured membranes), layer is reached in the decidua. In cases of accrete,
whereas risks of prematurity decrease with advancing this fails to occur, possibly as a result of damaged or
gestational age. A decision analysis noted that sched- deficient Nitabuch’s layer. The incidence appears to
uled delivery between 34 and 35 weeks of gestation is be dramatically rising in high-income countries and
optimal with no need to assess fetal pulmonary is thought to be the result of a similar increase in the
maturity.51 Others also recommend 35–36 weeks of rate of cesarean delivery. In the United States, the
gestation.49 Urgent cesarean delivery should be incidence increased from 1 in 30,000 pregnancies in
accomplished in cases of vaginal bleeding with sus- the 1960s to approximately 1 in 2,500 pregnancies in
pected vasa previa.23,52 a cohort from 1985 to 1994.57 This further increased
Another area of uncertainty is the need for to 1 in 533 pregnancies in a cohort from 1982 to
hospitalization. Inpatient management theoretically 2002.58 Other more recent reports note a rate as high
allows for timely delivery in cases of bleeding, rupture as 1 in 300 pregnancies, though precise data are
of membranes, or labor and could be lifesaving. Many lacking.59,60
authorities advise hospitalization at 30–32 weeks of Regardless of the incidence of accreta, it is clear
gestation.53 Conversely, benefit remains unproven that prior cesarean delivery and especially multiple
and outpatient care has been associated with excellent cesarean deliveries are major risk factors.60–63 An Irish
outcomes.53 The probability of bleeding in women study noted an increasing rate of accretas specifically
with previas is less if the cervix is greater than 2.5 in women with prior cesarean deliveries.63 A large
cm in length.54 Based on this observation as well as multicenter U.S. cohort study noted an increasing risk
a lower probability of labor, women with normal cer- of placenta accreta with increasing numbers of cesar-
vical length are the best candidates for outpatient ean deliveries.62 This was especially true for women
management. with placenta previa and prior cesarean deliveries; in
With suspected vasa previa, it is worthwhile to cases of placenta previa, the risk of accreta was 3%,
repeat the ultrasonography in the third trimester, 11%, 40%, 61%, and 67% for first, second, third,
because approximately 15% of apparent vasa previas fourth, and fifth or more cesarean deliveries, respec-
will resolve by the late third trimester.55 As with pre- tively.62 It is noteworthy that the rate of accreta in-
via, the optimal frequency of ultrasonograms for cases creases with increasing cesarean deliveries, even
of suspected vasa previa is uncertain. If vasa previa is without placenta previa.62
suspected at 20 weeks of gestation, follow-up ultraso- Any surgery that damages or transects the endo-
nograms at 28–30 and 32–34 weeks of gestation are metrium increases the rate of subsequent accreta.
reasonable to confirm the persistence of the diagnosis These include uterine curettage, myomectomy, pelvic
before indicated preterm birth through cesarean deliv- radiation, and endometrial ablation.64–66 Women with
ery. There have been case reports of fetoscopic laser prior endometrial ablation are at particularly high risk
ablation of vasa previas.56 However, there are too few of accreta. Other risk factors include smoking, in vitro
published cases to assess the risk-to-benefit ratio for fertilization, advanced maternal age, multiparity, pre-
this procedure. via, and a short interval between a prior cesarean
delivery and subsequent pregnancy.58,67,68 It is likely
PLACENTA ACCRETA that surgical technique plays a role in the pathophys-
Background iology of accreta, because rates vary throughout the
Placenta accreta is defined as trophoblastic attach- world, and some but not all women with risk factors
ment to the myometrium without intervening develop the condition.

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Clinical Implications zone also have been reported.79,80 In the second and
Accreta is associated with considerable maternal and third trimesters (gray scale ultrasonography) accretas
fetal morbidity and even mortality. Maternal compli- are associated with the presence of placenta previa, loss
cations are primarily the result of massive hemorrhage. of the normal hypoechoic retroplacental–myometrial
Indeed, many cases are associated with “audible hem- zone, multiple vascular lacunae (Fig. 7), extension of
orrhage.” In turn, this leads to disseminated intravas- the villi into the myometrium or beyond, interruption
cular coagulation, multiorgan failure, the need for of the uterine serosa–bladder interface, and decreased
additional surgery including hysterectomy, thrombo- retroplacental space (less than 1 mm).79 Doppler find-
embolism, and even death. ings associated with accreta include turbulent lacunar
Median estimated blood loss in cohorts of accre- blood flow, increased subplacental vascularity
tas ranges from 2,000 to 7,800 mL.69 Similarly, the (Fig. 8), vessels bridging the placenta to the uterine
median number of units of blood transfused is five69 margin, and gaps in myometrial blood flow.79,80 Pla-
and many women require multiple units of blood and cental lacuna and turbulent flow are the findings
other blood products.69–73 In a series of 76 cases from most consistently linked to accreta.79–81 Three-
Utah, 28% had disseminated intravascular coagula- dimensional power Doppler may improve accuracy
tion.70 Maternal morbidity is common and 25–50% but data are preliminary and the technique should be
of patients are admitted to an intensive care unit.70,71 considered experimental.82
There is an increased risk of thromboembolism,
pyelonephritis, pneumonia, adult respiratory distress
syndrome, and renal failure.70,74 Infection also is com- Box 1. Ultrasound Findings Suggesting Placenta
mon and may occur in the wound, abdomen, or vag- Accreta Spectrum
inal cuff.70,75,76 Vesicovaginal fistula is rare but is
First trimester
a serious cause of morbidity.77 Finally, maternal death  Gestational sac that is located in the lower
has been reported in up to 7% of cases.74 Most recent uterine segment
large series have lower rates of maternal death.69–73  Multiple irregular vascular spaces noted within
However, maternal deaths are likely underreported. the placental bed
 Implantation of the gestational sac imbedded
Surgical complications also are common, owing
into the uterine window at the site of the prior
to the frequent need for hysterectomy, which can be cesarean delivery (“cesarean scar ectopic”)
technically difficult. The most frequent problem is
injury to the bladder. However, it is difficult to assess Second trimester
the true rate of incidental cystotomy, because it is  Multiple vascular lacunae within the placenta
often performed intentionally to facilitate the surgery
and to avoid worse injury. Ureteral injury has been Third trimester
 Loss of the normal hypoechoic retroplacental
reported in 10–15% of patients.75,76 Other less com-
zone
mon complications include injury to the bowel, large  The presence of multiple vascular lacunae
vessels, and pelvic nerves. These morbidities are all within placenta (Swiss cheese appearance)
more likely in cases of percreta. Finally, many  Abnormalities of the uterine serosa–bladder
women need repeat operations to control hemor- interface (interruption of the line, thickening
of the line, irregularity of the line, and
rhage, treat infection, or address an injury to a pelvic
increased vascularity)
structure.  Extension of the villi into the myometrium,
Neonatal complications are primarily the result of serosa, or bladder
preterm birth. The average gestational age of delivery of  Retroplacental myometrial thickness of less
accretas is typically 34–36 weeks of gestation, typically than 1 mm
 Turbulent blood flow through the lacunae on
as a result of medically indicated preterm birth.70,71,73,78
Doppler ultrasonography
Diagnosis  Increased subplacental vascularity
 Vessels bridging from the placenta to the uter-
The mainstay of antenatal diagnosis is obstetric ine margin
ultrasonography (Box 1). In some cases diagnosis is  Gaps in myometrial blood flow
possible in the first trimester. Abnormalities include
a cesarean scar ectopic pregnancy or a gestational sac
Reprinted from Silver RM, Fox KA, Barton JR, Abuhamad AZ,
that is implanted in the lower uterine segment Simhan H, Huls CK, et al. Center of excellence for placenta
(Fig. 6).79,80 Irregular vascular spaces within the pla- accrete. Am J Obstet Gynecol 2015;212:561–8, with
cental bed and loss of the retroplacental–myometrial permission from Elsevier.

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 the diagnosis of accreta was considerably less in
a recent study wherein clinicians were blinded to the
clinical status of the patients.81 Moreover, there was
considerable variation among “experts” in the predic-
tion of whether an accreta was present.83 Thus, the
high predictive values reported previously may not
be generalizable to the average medical center.
Magnetic resonance imaging (MRI) also has been
used to diagnose placenta accreta. It also is reported to
have good accuracy for the prediction of the condition
(Fig. 9).84–86 However, available studies are subject to
even more bias than those using ultrasonography,
because MRI is typically only used in patients at very
high risk for accreta. In addition, it is not clear that
MRI improves diagnostic prediction of accreta com-
Fig. 6. Cesarean delivery scar from ectopic pregnancy in pared with obstetric ultrasonography.79,86 Taken
first-trimester ultrasonogram. If untreated, this often pro- together with the cost, lack of widespread availability,
gresses to placenta accreta. Arrow shows gestational sac in and lack of radiologists with expertise in using MRI to
the cesarean delivery scar, outside and superior to the diagnose accreta, MRI is not recommended for rou-
uterine cavity. tine use in suspected accreta.1 It may have a role as an
Silver. Placenta Previa, Vasa Previa, and Placenta Accreta. Obstet
adjunctive tool in difficult cases such as if the placenta
Gynecol 2015.
is posterior or to assess invasion of adjacent organs in
suspected percreta.79,86
On balance, the sensitivity and specificity for It is unclear that serial ultrasonograms improve
second- and third-trimester ultrasonography for the diagnosis or outcome once accreta is suspected. As
identification of accreta are reported to be high and with previa and vasa previa, there are no data to guide
approximately 80–90%.79,80 However, these data may the optimal frequency of ultrasonograms. It is reason-
overestimate the accuracy of ultrasonography, because able to consider follow-up studies at 28–30 and 32–43
they are derived from referral centers with (often sin- weeks of gestation to confirm the diagnosis, precisely
gle) experts privy to the clinical history performing the locate the placenta (which may aid delivery), and to
ultrasonograms. The accuracy of ultrasonography for assess possible bladder invasion.

Fig. 8. Turbulent flow in the lacunae and increased vas-

Fig. 7. Placental lacunae (arrows) in a case of placenta cularity between the placenta and bladder in a case of
accreta. placenta percreta using color Doppler.
Silver. Placenta Previa, Vasa Previa, and Placenta Accreta. Obstet Silver. Placenta Previa, Vasa Previa, and Placenta Accreta. Obstet
Gynecol 2015. Gynecol 2015.

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 Fig. 9. Magnetic resonance image
demonstrating placenta percreta.
A. Vessels in bladder wall (ar-
rows). B. Percreta at bladder dome
(arrow).
Silver. Placenta Previa, Vasa Previa,
and Placenta Accreta. Obstet Gynecol
2015.

Several maternal serum biomarkers have been may be termed “centers of excellence” for placenta
proposed as being useful to predict accreta in women accreta.90 Features of such centers include multidisci-
at risk. Although of interest, none are accurate enough plinary teams that are experienced with accretas and
to recommend routine use in screening for placenta provide coordinated care. This may include specialists
accreta. in maternal–fetal medicine, gynecologic surgery,
gynecologic oncology, vascular trauma and urologic
Management surgery, transfusion medicine, intensive care, neona-
The optimal management of placenta accreta is tology, interventional radiology, and anesthesiology
unclear owing to a lack of randomized clinical trials. as well as specialized nursing staff and ancillary per-
A recent survey of health care providers noted widely sonnel. The specialty of the physicians is likely less
varied approaches to virtually every aspect of care for important than experience and expertise in accreta.
accretas.87 These included referral to subspecialists, Ideally, multidisciplinary preoperative consultation
timing of delivery, surgical techniques, the use of will occur along with the use of a checklist to reduce
radiographic embolization of pelvic vessels, blood errors (Box 2). A critical feature is a well-equipped
product replacement, and ureteral stents.87 In this sec- blood bank with ample blood products, activated fac-
tion, evidence-based guidelines are highlighted and tor VII, and other alternative blood products. Team
knowledge gaps and controversies outlined. training and simulation can further enhance the effec-
One of the most important modifiers of clinical tiveness of the multidisciplinary team.90
outcome is prenatal diagnosis of accreta. Several studies Women with clinical or ultrasonographic risk
confirm decreased hemorrhage and other maternal factors for accreta should be referred to a center of
complications in cases diagnosed antenatally rather than excellence or imaging expert for evaluation of possi-
intrapartum.70–73 Prenatal diagnosis allows for optimal ble accreta. Delivery in a center of excellence is
management, which typically includes planned cesarean advised if there continues to be suspicion for accreta
hysterectomy before the onset of labor or bleeding. The based on a combination of clinical and ultrasono-
hysterotomy (often fundal) is made with care to avoid graphic characteristics.90
transecting the placenta and no attempt is made to re- Occasionally placenta accreta will not be apparent
move the placenta. Simply avoiding an attempt at pla- until the time of laparotomy or cesarean delivery. It is
cental removal can dramatically reduce the amount of still often possible to safely transport patients to
bleeding as well as other complications.70–73 appropriate centers under such circumstances. First, if
In addition, prenatal diagnosis allows for delivery an accreta is suspected in a stable patient at the time of
to be arranged in a center that is best suited to care for laparotomy (as a result of placenta protruding through
women with accreta. Several recent studies demon- or hypervascularity noted in the lower uterine segment
strate improved outcomes and fewer complications in [Fig. 9]), it is appropriate to stop the procedure. At that
cases managed at such centers.73,78,88,89 Such centers time, additional preparations can be made (procuring

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 women with placenta accreta.91 However, timing of
Box 2. Preoperative Checklist for Patients With
delivery may be individualized based on the proba-
Placenta Accreta
bility of accreta, whether there is a percreta, prior
• Consents signed including cesarean delivery, hysterec- obstetric history (eg, preterm labor), uterine contrac-
tomy, cystoscopy, stent placement, anesthesia, arterial tions, vaginal bleeding, cervical length, patient com-
line, central line, blood transfusion, and repair or
removal of damaged organs pliance, and access to care. Preterm premature
• History and physical examination done rupture of membranes, bleeding, and contractions
• Case scheduled in the “main” operating room all are associated with unscheduled preterm delivery
• Anesthesia attending notified in women with accreta.92 It is noteworthy that most
• Interventional radiology attending notified women without bleeding or contractions can have
• Labor and delivery charge nurse notified
• Other subspecialty surgeons notified as needed a safe and planned delivery at 36 weeks of gestation.92
• Blood bank and transfusion medicine notified Accordingly, it may be reasonable to individualize
• Intensive care unit notified timing of delivery between 34 and 36 weeks of gesta-
• Neonatal intensive care unit team notified tion in stable patients without bleeding or labor.
• Blood typed and crossed (number of units: ____) Given the high probability of preterm birth,
• Recent complete blood cell count and prothrombin
time, partial thromboplastin time, and international corticosteroids should be administered to all women
normalized ratio available with suspected placenta accreta. This can be done
• Massive transfusion protocol available with the onset of bleeding or labor before 34 weeks of
• Cell saver available if needed gestation or before planned delivery; for example, at
• Ultrasonography available for placental mapping 33.5 weeks of gestation. As with stable previa, there is
• Pelvic balloon for pressure or compression available
• Sterile milk available for bladder instillation no consensus or data to support or refute the benefits
• Uterotonics available (Pitocin, Methergine, Hema- of antenatal hospitalization. Although of unproven
bate, Misoprostol) efficacy, it is reasonable to hospitalize preterm accre-
• Cystoscopy equipment and ureteral stents available tas with bleeding or labor, especially if the patient is
• Large-bore intravenous access remote from an appropriate medical center.
• Rapid infusion equipment
• Warmers for blood and patient The optimal surgical approach to accreta remains
• Venous thromboembolism prophylaxis controversial. Most authorities advise a planned
• Point-of-care testing for hematocrit, etc cesarean hysterectomy with fundal hysterotomy to
• Antibiotics available avoid compromising the placenta (Fig. 10). The sur-
gery should be performed in an appropriately equip-
Modified from protocols developed by Alfred Abuhamad, MD,
ped and staffed operating room with point-of-care
and Karin Fox, MD, with permission. testing (eg, hematocrit or lactate). The abdominal inci-
Data from Publications Committee, Society for Maternal-Fetal sion should allow for easy performance of a difficult
Medicine, Belfort MA. Placenta accreta. Am J Obstet
Gynecol 2010;203:430–9.
hysterectomy. This is typically a vertical incision,
although a Cherney incision affords excellent access.
Anesthesia is typically general with endotracheal intu-
blood, surgeons, equipment) before proceeding. Alter- bation because the patient may become unstable as
natively, it is reasonable to close the laparotomy and a result of hemorrhage. Large-bore intravenous
then safely transport the patient to a center of excel- access, pneumatic compression stockings, and possi-
lence for definitive management.90 If the patient is sta- ble access for hemodynamic monitoring are prudent.
ble, it also is reasonable to transport the patient after All of the measures pertinent to the optimal care of
a hysterotomy has been performed and closed. In the obstetric hemorrhage including a massive transfusion
setting of unanticipated hemorrhage, it is necessary to protocol, use of cell saver, and rapid infusion equip-
proceed with resuscitation and operative intervention. ment also are appropriate.90,93
If bleeding persists after hysterectomy, transport may The use of ureteral stents with accretas also varies
be possible after stabilization with pelvic and abdomi- among clinicians.87 The use of ureteral stents also is
nal packing. controversial in nonaccreta gynecologic surgery. One
The optimal timing of delivery for accretas study noted fewer ureteral injuries in cases using
remains controversial. As with previa and vasa previa, stents.70 However, the benefit of stents remains uncer-
the risks of prematurity must be balanced against the tain and use is best left to the preference of the surgeon.
risk of unscheduled delivery in the setting of labor or There also is debate about the routine use of
bleeding. A decision analysis indicated that 34 weeks pelvic devascularization. Advocates believe that using
of gestation is the optimal time for planned delivery of balloon catheters to occlude the uterine or internal

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 accretas that pose less risk than those reported in
other series. It is noteworthy that the French cohort
of accretas had fewer prior cesarean deliveries, pla-
centa previas, and ultrasonographic features of accre-
ta than other cohorts.98 Also, several cases of severe
morbidity have been noted with attempted conserva-
tive management.99 Others also have reported high
rates of complications with conservative manage-
ment100 and we are aware of several (unpublished)
cases of attempted conservative management in
which the patients experienced bleeding, infection,
or bleeding and infection at unpredictable times
remote from delivery. Accordingly, patients should
be counseled regarding potential risks of conserva-
Fig. 10. Placenta protruding through a prior cesarean tive management.
delivery scar in a case of accreta. It is not clear that methotrexate enhances the rate
Silver. Placenta Previa, Vasa Previa, and Placenta Accreta. Obstet of placental reabsorption. In theory, it may not be
Gynecol 2015. effective, because there are few actively dividing
trophoblast at term. Given the risks and a lack of
iliac arteries substantially decreases blood loss in cases proven efficacy, it is not recommended.
of accreta and especially percreta.94,95 Typically bal- The term “conservative management” also is used
loons are placed but not inflated before initiating the to describe planned delayed hysterectomy, typically in
surgery. They are then inflated after delivery of the cases of percreta. Hysterotomy is performed to deliver
neonate so as to not compromise fetal blood supply. the neonate and the placenta is left in situ. After a vari-
However, the procedure has considerable risks such able period of time, and with or without a radiographic
as arterial damage, occlusion, and infection.95–97 Also devascularization procedure, a hysterectomy is per-
efficacy is unclear, because hypogastric artery ligation formed. In theory, this allows for involution of the
has not been shown to be effective with accretas70 and uterus and placenta, decreased vascularity, and a less
there is considerable collateral circulation to the morbid surgery. Good outcomes have been reported in
uterus. Although prophylactic use of balloons is con- several cases using this approach.101 However, serious
troversial, radiographic embolization of the hypogas- complications also have been reported, and it is unclear
tric vessels remains an important strategy to reduce whether this strategy decreases or increases the risk of
residual hemorrhage posthysterectomy, especially in morbidity and mortality.
stable patients with slow oozing without a clearly iden- Finally, another strategy for conservative man-
tified source of bleeding. agement is to surgically remove a small portion of the
Conservative management of accreta is another uterus in the setting of focal accreta. This area can
unresolved controversy. This usually refers to a strat- then be repaired and the patient is treated as though
egy that intends to preserve the uterus. This is highly she had a classical cesarean delivery. Other strategies
desirable because it preserves fertility and avoids involve oversewing bleeding areas of the uterus or
a major and morbid operation. Typically this is lower uterine segment in hopes of preserving the
accomplished by performing a fundal hysterotomy uterus. An example is the Triple P procedure, which
with care to avoid the placenta, ligating the cord involves resection of a portion of the uterus along with
close to the placenta without disrupting it, closing the pelvic devascularization.102
hysterotomy, and allowing the placenta to resorb In a follow-up study of 96 women with successful
over time. Reasonably good outcomes have been conservative management, eight had Asherman’s syn-
reported using this approach.98 Despite these good drome.103 Twenty-four women had 34 subsequent
outcomes, concerns remain about conservative man- pregnancies, with 21 (62%) resulting in third-
agement. The largest concern is that patients who trimester deliveries.103 Recurrent accreta was noted
underwent conservative management may comprise in 6 of 21 (28.6%); of these, four of six were conser-
a different population than those who underwent vatively managed.103
planned cesarean hysterectomy. It is possible that There are many knowledge gaps regarding the
some women with successful expectant management pathophysiology and optimal management of pla-
did not truly have placenta accreta or had mild focal centa accreta. Given the relative infrequency of cases

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at individual centers, multicenter and multinational 8. Ananth CV, Demisse K, Smulian JC, Vintzileos AM. Placenta
previa in singleton and twin births in the United States, 1989
cooperation and properly designed trials are needed through 1998: a comparison of risk factor profiles and associ-
to address these gaps. Another focus should be ated conditions. Am J Obstet Gynecol 2003;188:275–81.
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