Best Practice & Research Clinical Obstetrics and Gynaecology

Vol. 22, No. 6, pp. 1133–1148, 2008

doi:10.1016/j.bpobgyn.2008.08.003
available online at http://www.sciencedirect.com

10

Diagnosis and management of placenta

accreta

José Miguel Palacios-Jaraquemada * MD, PhD

Professor
CEMIC University Hospital, Department of Gynaecology and Obstetrics; J. J. Naón Morphological Institute,
School of Medicine, University of Buenos Aires; and Fundación Cientı́fica del Sur,
Lomas de Zamora, Buenos Aires, Argentina

The diagnosis of placenta accreta begins with clinical suspicion in patients at risk. Ultrasound and
Doppler are first-choice diagnostic methods because of their accessibility and high sensitivity.
Placental MRI is an accurate method of topographic stratification that makes it possible to define
anatomy, to plan the surgical approach and to consider other therapeutic possibilities. Manage-
ment of placenta percreta involves great technical dexterity and significant clinical support. The
main challenges include controlling the haemorrhage and dissection of the invaded tissues. Now-
adays, there are two treatment options: caesarean hysterectomy or a conservative approach.
With the latter, there is a choice between leaving the placenta in situ and waiting for its later
resolution, and a one-step surgery that addresses the problems of invasion, vascular control
and myometrial damage in a single surgical act.

Key words: conservative treatment; diagnosis; one-step surgery; placenta accreta; therapeutic
approach.

INTRODUCTION

Placenta accreta is a disorder characterized by abnormal placental penetration into the

uterine wall. It is currently one of the main causes of maternal morbidity and mortality.
This entity has been historically classified according to the degree of pathological pen-
etration and includes superficial invasions (placenta accreta), middle-layer invasions
(placenta increta), and deep invasions (placenta percreta). This chapter refers to all
these varieties as placenta accreta.
As a result of its close relation to caesarean section1,2, the incidence of placenta
accreta has grown in the last few decades. Myometrial damage secondary to repeated

* Av. Corrientes 5087 4 a C14141 AJD Ciudad Autónoma de Buenos Aires, Argentina. Tel./Fax: þ54 11
4857 1331.
E-mail address: jpalacios@fmed.uba.ar
1521-6934/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved.
1134 J. M. Palacios-Jaraquemada

caesarean sections, and other myometrial injuries associated with dilatation and curet-
tage (D&C) and corrective surgeries, among others, are the main predisposing factors.
Ultrasound (US) and Doppler3,4 are two first-line methods for the diagnosis of pla-
centa accreta; both have a high degree of diagnostic sensitivity and both methods
have made it possible to establish diagnostic signs that allow the suspicion of an abnor-
mally implanted placenta in a high percentage of cases.
In addition, placental nuclear magnetic resonance imaging (pMRI) has proved to be
a noteworthy auxiliary when it comes to plan the surgery of placenta accreta.5 Placen-
tal MRI (pMRI) makes it possible to have total acquisition of images; its multiplane char-
acteristic allows a correct three-dimensional (3D) reconstruction, necessary for
surgical planning.
Placenta accreta causes morbidity and mortality due to haemorrhage, coagulopathy
and its inherent surgical difficulty; these facts make this disorder the first cause of
obstetric hysterectomy.6
Traditionally, the treatment of placenta accreta has consisted of puerperal hysterec-
tomy. This is a high-risk procedure, especially when haemorrhage and coagulation dis-
orders coexist. To minimize damage and conserve the reproductive potential in
women, a series of procedures that aim to preserve the uterus affected by placenta
accreta have been incorporated.7,8 These conservative tactics have proved to be effec-
tive and safe under controlled conditions.
Below, we provide a synthesis of the current knowledge about placenta accreta, in-
cluding practical data for obstetricians and surgeons. We emphasize early detection of
risk factors, diagnostic guidelines and treatment alternatives in accordance with the
human and technical resources available.

TERMINOLOGY

From a histopathological perspective, there are marked differences among placenta ac-
creta, increta and percreta. However, from a clinical–surgical point of view, sectors
that show a different degree of invasion can coexist in the same patient. This phenom-
enon leads to discrepancies between what is observed during surgery and the final
pathological diagnosis. This difference is not only semantic; it makes comparisons of
surgical techniques and clinical results from different authors virtually impossible.
Unlike other illnesses, the histopathological study of invasive placenta does not al-
ways constitute a diagnostic ‘‘gold standard’’. This phenomenon occurs when biopsy is
obtained in an area without invasion or with a degree of minor penetration. In these
cases, there is a mismatch between histology and the surgical finding. We prefer to
define placenta accreta according to its clinical–surgical characteristics.9,10

RISK FACTORS

Patients with myometrial damage secondary to repeated caesarean sections in associ-

ation with placenta praevia constitute the main risk factor for placenta accreta.11,12
Multiple uterine D&C, particularly those performed in patients who have had previous
caesarean section(s)13, are closely associated with adherent placentation.
Myometrial tissue damage, whether surgical, instrumental or physical14, followed by
a secondary collagen repair, is closely related to the appearance of placenta accreta.
The challenge of confirming or discarding the diagnosis of invasive placenta is greatest
when the topography of the uterine lesion coincides with the placentation zone.
 Diagnosis and management of placenta accreta 1135

DIAGNOSTIC METHODS

Ultrasound

Transabdominal ultrasound (US) is the simplest, most widespread and cost-effective

method for the initial diagnosis of placenta accreta. However, US does not allow ad-
equate visualization of a low-segment cervix or common areas of placental invasions
after multiple caesareans.
Transvaginal ultrasound (TVUS) enables a more accurate examination of the distal
uterine sector (Figure 1). However, the posterior wall cannot be assessed correctly by
this method. It is worth highlighting that this is a safe imaging method for patients with
placenta praevia. Detailed visualization of the cervix and low segment with TVUS
increases diagnostic accuracy in low-insertion placentas.15,16

Figure 1. Transvaginal ultrasound: anterior placenta percreta in patient with twin pregnancy. LMVL, loss of
myometrial-vesical layer; NFV, newly-formed vessels.
1136 J. M. Palacios-Jaraquemada

Ultrasound signs
Certain patterns have been associated with placenta accreta. One such sign is the
presence of placental lagoons, which, unlike those seen in the second trimester, are
large, irregular and multiple. The aetiology of these placental lagoons is unknown.
Their presence, characteristics and number are not directly related to the gravity of
placenta accreta. The sensitivity of this ultrasound sign is 79%, with a positive predic-
tive value of 92%, when identified between weeks 15 and 40.16
The loss of the retroplacental hypoecogenic zone, represented by the absence of
the retroplacental vascular bed, basal decidua and placental advancement over the my-
ometrium is another ultrasound sign associated with the presence of placenta accreta.
This sign does not have great significance when found in isolation. Certain authors
question its importance due to its low diagnostic and predictive sensitivity and
a false-positive rate of nearly 50%.
Progressive thinning of the retroplacental myometrium indicates the extreme prox-
imity of the placental tissue to the peritoneal serosa or to the neighbouring organs,
another sign of placenta accreta. Segmental myometrial thinning of less than 1 mm
is suggestive of abnormal placental adherence, with sensitivity of 93%, specificity of
79% and predictive value of 73%.17
Thinning or disruption of the uterine–vesical serosa occurs due to the lack of my-
ometrial tissue, leaving the visceral serosa exposed. It is not easy to make a differential
diagnosis between placenta accreta and the irregularities of the vesical wall. Disruption
of the serosa indicates a higher degree of compromise; the presence of extrauterine
placental parenchyma confirms placenta percreta.
US grey-scale general capacity is enough to diagnose placenta accreta with sensitiv-
ity 87%, specificity 98%, a positive predictive value 93% and a negative predictive value
98%.18
The presence of vessels perpendicular to the uterine axis indicates the presence of pla-
cental vessels from and towards the myometrium or other neighbouring tissues17–19; this
pattern is associated with the presence of different degrees of placenta accreta.

Magnetic resonance imaging of the placenta

Initially, the aim was to determine whether placental magnetic resonance imaging (pMRI)
can improve the diagnostic sensitivity of ultrasound in the detection of placenta ac-
creta.20–22 The first prospective study was performed in 1997. The report included 18
patients and did not find any diagnostic differences between the techniques, although it
did identify a higher diagnostic sensitivity in pMRI in the case of posterior placenta accreta.
In 2005, a prospective series comprising 300 cases showed that pMRI adequately
outlined the topographic anatomy of the invasion, relating it to the regional anasto-
motic vascular distribution. The characteristics of the invasion confirmed the possibil-
ity of bleeding, the occurrence of complications, and the inherent technical difficulty in
certain cases. It is the only published study to date that has been able to confirm the
presence of parametrial invasion (axial slices)5; an important factor associated with the
possibility of urethral damage during surgery.

Diagnostic practice points

 Clinical risk factors for placenta accreta: repeated caesarean sections þ placenta
praevia, multiple D&C, caesarean and D&C, placenta inserted in the site of previous
uterine surgeries, pelvic radiation, endometrial thermoablation.
 Diagnosis and management of placenta accreta 1137

 US signs of morbidly adherent placentae: loss or thinning of the retroplacental

hypoecogenic zone, multiple intraplacental lagoons, thinning or disruption of the
uterine–vesical serosa, extrauterine placental tissue mass.
 Signs of morbidly adherent placentae: absence of Doppler signal in the hypoecogenic
zone, diffuse lacunar colour flow pattern, turbulent flow with pericervical vascular di-
lation, arterial vessels emanating from the placenta towards neighbouring organs or
tissues

Technical aspects
Like other diagnostic methods, pMRI has certain technical details that can enhance or
emphasize its diagnostic accuracy. The main aim of the imaging study is to obtain the
best definition of the uterine–placental interphase and its relation to the bladder
(Figure 2).

Figure 2. pMRI (sagital slice): isodense placental tissue is present inside the bladder, a characteristic sign of
placenta percreta.
1138 J. M. Palacios-Jaraquemada

Newly formed vessels (NFV) secondary to the development of placenta accreta are
underdeveloped in the middle layer. This particularity requires the pMRI study to be
performed with a semi-full bladder, to avoid false negatives as a result of overdisten-
sion and/or collapse of the NFV, as well as false negatives due to an empty bladder. It is
important that the bladder is only partially full; an empty bladder next to the pubic
bone would prevent an adequate sign of the uterine–vesical interphase, resulting in
diagnostic error.
The use of ultrafast techniques that minimize artefacts produced by fetal movement
is recommended.23 T2-weighted imaging highlights urine as a naturally white contrast,
thus allowing better delineation of the vesical muscle in relation to the placenta and
the underlying myometrium.24
In the presence of risk factors (multiple D&C, myomectomies or corrective sur-
gery), if there are clinical antecedents for the T2 mode allowing a naturally white con-
trast and a suspicion of posterior placenta accreta, the use of gadolinium is
recommended to improve diagnostic accuracy. Without this, a combination of pla-
centa, myometrium, abdominal viscera and the vertebrae form a complex image, which
makes an adequate diagnosis of posterior myometrial placental invasion virtually
impossible.
So far, gadolinium has not shown any side effects during pregnancy, and there are no
toxicity reports. However, and as a precaution, its use is generally recommended for
cases in which diagnosis by other techniques is not possible.25,26
It is prudent to use pMRI in all cases with a resulting non-conclusive ultrasound or
Doppler examination, when it is important to rule out or confirm the presence of par-
ametrial invasion. Therapeutic options depend on the size of the invasions and exact
anatomy of the lesion.5,27,28

THERAPEUTIC MANAGEMENT OF PLACENTA ACCRETA

Preoperative evaluation

The objective of preoperative evaluation is to gather and analyse diagnostic informa-

tion, with the aim of determining the best procedure for each case. Imaging diagnostic
studies, ultrasound and pMRI will allow us to establish the degree, extension and lo-
cation of the placental invasion. The level of penetration will determine the timing of
the caesarean (Figure 3). As a rule, we perform surgery at 37 weeks for superficial in-
vasions (accreta), and at 35 weeks for deep invasions.5–27
In cases of lateral–inferior placental invasion, uretheral catheterization is recom-
mended to avoid inadverted lesions during surgery. In those cases with extensive para-
metrial invasion, cervical pregnancies or pregnancies after hysterotomy, identifying and
isolating the urether at its crossing with the iliac artery before surgery noticeably
reduces the possibility of lesions.8

Surgical strategy

The primary objective is to perform the caesarean section in the safest conditions pos-
sible, according to the resources available. Placental removal is s not an essential step
and can be postponed. However, initiation of the removal manoeuvre is usually the
point of no return. If placental detachment, dissection or proximal vascular control
is ineffective, serious complications are generally immediate.
 Diagnosis and management of placenta accreta 1139

Figure 3. Characteristic deformity of anterior placenta percreta. The invaded surface is cribbed by newly
formed vessels among the placenta, uterus and bladder. This patient underwent a one-step surgery.

3D imaging of the invasion5–24, together with the corresponding anatomical profile

will facilitate the planning and performance of the surgical procedure. Nevertheless,
3D anatomical mapping acquisition of the lower pelvis is usually available only after
hours of training in an anatomy laboratory, which limits its practical application and
adds an inherent difficulty to this procedure. Correct dissection of the interfascial sur-
gical planes8 will make it easier to recognize the anatomical elements adjacent to the
invasion and will increase the safety of the procedure.

PROXIMAL VASCULAR CONTROL

Regional irrigation

The pelvic vascular system widely interconnects the internal iliac, external iliac and
femoral systems.17–29 External and internal compression of the abdominal aorta
1140 J. M. Palacios-Jaraquemada

reduces distal flow significantly.30,31 This haemostatic manoeuvre, whether external or

internal, is essential when there is active and uncontrolled bleeding due to adherent
placenta, and allows control of the haemorrhage quickly and effectively.
Ligature, occlusion or embolization of the internal iliac artery (IIA) is a procedure
with a high number of failures in placenta accreta.32,33 Anastomotic compensation
following IIA ligature or occlusion is almost immediate.34 This, added to the fact
that the procedure should be bilateral, makes it unsuitable for low-insertion placenta
accreta. Paradoxically, several authors recommend the use of occlusion of the iliac
artery in placenta accreta. This apparent contradiction arises from the use of incon-
sistent classifications of invasion, which do not take into account the invasion
topography.
The topographic features of the uterine body and of the lower segment and cervix
differ in that the arterial pedicles supplying the uterine body are irrigated by the uter-
ine artery and the upper vesical artery, whereas the lower segment is irrigated by the
cervical artery, the inferior vesical artery and by the upper, middle and lower vaginal
arteries.5 These differences imply a deep dissection for lower segment surgical haemo-
stasis, and inherent difficulties for the endovascular procedures in this area.35 Using
a uniform haemostasis for all types of placental invasions has resulted in vascular
complications.36,37
The presence of a highly vascularized structure, such as placenta accreta, a cervical
myoma or a cervical ectopic pregnancy, predisposes to the opening of anastomotic
channels that are usually closed. There are two main supplementary irrigation systems,
one from the bladder and the other from the vagina. Both systems must be recognized
when performing a hysterectomy or a one-step surgery. These anastomotic networks
are connected to the lower segment and are usually the most common cause of post-
operative bleeding.35–38
Ligature or occlusion of the uterine arteries can be an insufficient or useless in
lower-segment invasions. However, if the lower anastomotic system needs to be oc-
cluded, there is high risk of uterine necrosis, as well as undesired devascularization.
Arterial embolization followed by haemostatic procedures involving ligature or com-
pression has a high possibility of ischaemic complications in conservative treatments
due to the massive occlusion of the anastomotic components.

Obstetric hysterectomy

With the exception of upper-segment invasions, hysterectomy for placenta accreta

must be total; otherwise there is a high percentage of rebleeding in subtotal resections
within the lower-segment invasions.38,39 If it is necessary to perform a subtotal hyster-
ectomy, it is not recommended to close the peritoneum over the cervical stump, as
rebleeding in these circumstances usually goes unnoticed.17 If a subtotal hysterectomy
has been performed, diagnosis of rebleeding should be suspected whenever there is
haemodynamic deterioration after an effective replacement. Exploration by ultrasound
is often inefficient, because it examines only the pelvis, and a retroperitoneal haema-
toma might be hidden, unnoticed, behind the colon. Computerized tomography (CT)
has a high diagnostic sensitivity in these cases; however, it is not usually available. An-
giography might be recommended, although it can be ineffective due to shock vessel
spasm or venous bleeding. All of the above result in a recommendation for early sur-
gical re-exploration in patients with haemodynamic deterioration and a history of sub-
total hysterectomy for placenta accreta.
 Diagnosis and management of placenta accreta 1141

Therapeutic practice points

 The primary objective of surgery for placenta accreta consists of applying the sim-
plest and most efficient procedure that minimizes the risk of haemorrhage.
 The presence of pericervical or lower-segment varicose veins proper of placenta
praevia can be confused with the neovascularization of placenta accreta. In these
cases, surgical exploration will make a differential diagnosis, thus avoiding unneces-
sary hysterectomies.
 Surgical difficulties and possibility of complications in placenta accreta are directly
related to the invaded anatomical area, its specific circulation and to the dissection
of the organs involved.
 When total hysterectomy must be performed in the presence of non-dissectable
lower-segment invasion, it is useful to apply some kind of aortic vascular control
(internal compression, endoluminal balloon or loop) before performing dissection
of the invaded tissues.
 Indications for hysterectomy in placenta accreta include: (1) anticipated technical
problems with the technical impossibility of repair; (2) the technical impossibility
of performing a safe haemostasis; and (3) when, after performing conservative tech-
niques, complications such as infection or untreatable haemorrhage arise.
 Neoformation vessels should not be electrocoagulated because of poor develop-
ment of the middle layer. This procedure can be the cause of bleeding difficult to
control, or of a postsurgical haemorrhage.

Table 1. Placenta accreta: general evaluation of two conservative techniques.

Conservative Placenta in situ with or without One-step surgery:
approach methotrexate: 1985e2006 (n ¼ 60) 1989e2004 (n ¼ 300) 2004e2006
(n ¼ 94, unpublished)
Advantages Less bleeding Less bleeding
Primary uterine conservation Primary uterine conservation
(selected patients) s1:95e100%; s2: 27e60% (consecutive
and unselected patients)
Medium-complexity technique Evaluation of early fibrinolysis
Lower hospital costs
Damaged area removed
No evidence of recurrence of accreta in
a next pregnancy
Disadvantages Damaged area not removed Secondary haemorrhage
High possibility of High-complexity technique
accreta recurrence
Secondary infection
Secondary DIC Possibility of ureteral or bladder damaged
Secondary haemorrhage
Secondary hysterectomy Additional pain following uterine reconstruction
High hospital costs and pelvic dissection in the first 24 h
Retained placenta

DIC, disseminated intravascular coagulation.

1142 J. M. Palacios-Jaraquemada

CONSERVATIVE TREATMENT

The first successful conservative treatment of placenta accreta was performed in

193340; the decision was taken because it was not possible to perform a puerperal hys-
terectomy. Nowadays, conserving the uterus, avoiding the possibility of haemorrhage
and making future pregnancies possible are the main objectives of conservative treat-
ments in placenta accreta. There are two main options. One consists of leaving the
placenta in situ41,42 and waiting for its later reabsorption, the other involves resecting
the invaded area together with the placenta and performing the reconstruction as
a one-stop procedure.43 Table 1 shows an overall comparative analysis of these two
conservative procedures.
When the placenta is left in situ, the baby is delivered through the incision that
should avoid placental implantation. Following delivery of the baby, the uterus is closed

Figure 4. Control MRI (sagittal slice) from the patient seen in Figure 2. Note the homogeneous thickness of
the reconstructed anterior wall.
 Diagnosis and management of placenta accreta 1143

and the placenta is expected to be reabsorbed or expelled. During the period of

placental involution, haemorrhage, infection44,45 and disseminated intravascular
coagulation (DIC) can occur. Methrotrexate has been used by several authors as an
auxiliary treatment to reduce placental mass and its vascularization. However, there
is no evidence to shows conclusive advantages from its use. From 1985 to 2006, 60
cases of conservative treatment, in which the placenta was left in situ, were published,
and eight subsequent pregnancies were reported. The recurrence of placenta accreta
in this group was over 60%.
With a one-step surgery, anatomical and vascular separation of the invaded organs,
usually uterus and bladder, is achieved through Pfannenstiel or median incision. Metic-
ulous dissection allows an accurate haemostasis, which makes it possible to resect the
invaded tissue and have adequate tissue repair (Figures 4 and 5).8 Since 1989, 45

Figure 5. Post-reconstruction segment caesarean performed 2 years after the surgery for anterior placenta
percreta (patient in Figure 2). The uterine segment can be observed, in perfect condition, opening up to the
fetal head.
1144 J. M. Palacios-Jaraquemada

pregnancies have been reported in patients who underwent a one-step surgery; 43 had
posterior of fundal placenta, and in 2 cases, anterior placenta. Only one recurrence
was reported, in a patient who became pregnant a few months after the repair
(Palacios-Jaraquemada, unpublished data).
As mentioned above, there is no unique approach to the management of placenta
accreta. Surgical team expertise, availability of resources and local conditions are de-
termining factors when choosing the safest procedure. Table 2 shows the choice of
procedures according to the technical and material resources available; these actions
have proved to be the safest procedures that make it possible to solve the problem
delivery with an acceptable maternal risk.

POSTSURGICAL CARE

The most frequent postsurgical complication of placenta accreta is haemorrhage, re-

gardless of the procedure used, and bleeding should be considered whenever there is
haemodynamic instability. With the possibility of rebleeding, clinical data are more rel-
evant at a higher level in hierarchy than imaging, especially ultrasound, as false nega-
tives are common. Conservative surgery in placenta in situ requires extensive
clinical follow-up looking for early signs of haemorrhage, infection or DIC (Figure 6).
One-step surgery involves wide mobilization of tissue, tissue resection, myometrial
and bladder sutures, which cause additional pain. Morphine administration, together
with non-steroid anti-inflammatory drugs (NSAIDs) from the beginning of the postop-
erative period, results in better management.

Table 2. Placenta accreta/percreta: current alternatives to surgical treatment.

Resources Patient, clinical and Decision Definitive treatment
anatomic features
Limited experience Possibility of percreta, Extraplacental Delayed hysterectomy
or expertise, poor lower segment invasion hysterotomy, or conservative procedure
resources or or vaginal bleeding delivery and delayed according clinical
no facilities with high suspicion placental and surgical status
for safe of accreta extraction followed
patient transfer by uterine closure
Qualified and No desire Resective surgery Subtotal hysterectomy
experienced for future pregnancy for upper segment lesions
team, adequate Tissue destruction Total hysterectomy
hospital resources more than 50% of uterine for lower segment
axial circumference and cervical involvement
Intractable haemorrhage
DIC
Qualified and Desire for future Conservative Placenta in situ with or
experienced pregnancy surgery without methotrexate
team, adequate Destruction less
hospital resources than 50% of uterine
axial circumference
Minor coagulation disorders One-step surgery

DIC, disseminated intravascular coagulation.

 Diagnosis and management of placenta accreta 1145

Figure 6. The placenta is gradually reduced in size, and no corrective measure in the invaded uterine or
vesical area is taken (sagittal slice).

Thromboprophylaxis is an unavoidable step in extensive pelvic surgery46, especially

in pregnancy and during the puerperium with bed rest. If available, it is advisable to use
an intermittent pneumatic compressor before beginning the surgery. Unless there are
contraindications, low-molecular-weight heparin should be started with a platelet
count over 100,000 mm and continued until there is full mobility.

SUMMARY

The identification of patients at clinical risk is an inescapable step in the diagnosis of

placenta accreta. Directed search will enable the echographer to look for direct and
indirect signs of placental invasion, and allow the choice of the most appropriate US
method to find them. pMRI allows the study of topographic stratification and helps
to resolve non-conclusive cases or posterior invasions. Therapeutic planning will
have to take into account the human and technical resources available for each
case. Haemostatic evaluation and clinical support are essential before, during and after
the surgical act, and their inadequate application often causes severe complications.
Surgery needs to enable the safe birth of the baby, while minimizing the risks of ma-
ternal haemorrhage. Proximal vascular control is essential when a puerperal hysterec-
tomy for placenta accreta is performed, or in the case of a one-step surgical
1146 J. M. Palacios-Jaraquemada

procedure. This measure, together with adequate dissection of the interfascial planes,
is the key to safe surgery. The two options for conservative treatments differ in their
complexity, complication rates and follow up. As caesarean rates are growing globally,
and with these the cases of placenta accreta, the best strategy for the future consists
of identifying the aetiological factors and avoiding them as much as possible.

Research agenda

 3D ultrasound47 has made it possible to describe the anatomy, topography and

the haemodynamics of the neovascular components. This information is vital
when haemostasis is planned, even though the actual value of 3D US will
only be established with the modification of the surgical tactics and techniques.
 No theory fully explains the biological behaviour of placenta accreta.48,49
Currently, a wholly different approach is being developed. It is proposed that
a morbidly adherent placenta is the result of the myometrial damage and the
underlying collagen exposure (Palacios-Jaraquemada, unpublished data). Confir-
mation of this theory would lead to the application of corrective measures
during caesarean section, which would eliminate the predisposing factor and
prevent recurrent (damaged myometrium).
 Therapeutic application of the diagnostic advances.
 Scheduled training in pelvic–subperitoneal pelvic anatomy.
 Correction of the aetiological cause of placenta accreta.

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