Leaving the Placenta In Situ in Placenta Accreta Spectrum Disorders: A Single-Center Case Series

Abstract

The most common treatment for placenta accreta spectrum disorders (PAS) is planned primary cesarean-hysterectomy. However, other management strategies may improve outcomes and/or allow fertility preservation. This is a series of 11 patients with PAS managed by leaving the placenta in situ at a single academic center in the U.S. from 2015-2022. The approach described involves delivery of the fetus via cesarean, no attempt at placental removal, closure of the hysterotomy, prophylactic intravenous antibiotics for up to one week, and close outpatient follow up until the uterus is empty. The uterus was successfully preserved in 6 (55%), minimally invasive hysterectomy was performed in 4 (36%), and abdominal hysterectomy was performed in 1 (9%). During cesarean delivery, the median estimated blood loss was 650mL (range 200 – 1,000 mL). The majority of patients had no vaginal discharge for several weeks after delivery, followed by brown or bloody discharge, and intermittent mild-moderate cramping. The median time to resolution of PAS was 18 weeks in patients with successful uterine preservation (range 5 – 25 weeks). Indications for hysterectomy included hemorrhage (n=1), coagulopathy (n=1), endomyometritis (n=2), and pain (n=1), and these occurred at a median of 5 weeks postpartum (range 1 – 25 weeks). Four patients had subsequent pregnancies, of whom three were live births at or near term, and one was a spontaneous abortion at 19 weeks.