Placenta accreta spectrum (including accreta, increta, and percreta) is one of the most dangerous diagnoses of pregnancy. The depth of chorionic villi invasion characterizes the severity of the placental abnormality, accrete denotes no chorionic invasion, increta is partially invading, and percreta is full-thickness invasion of the myometrium beyond the serosa. In placenta percreta, the abnormal placenta may adhere to the surrounding abdominopelvic organs and musculature. The most common site of attachment is the bladder, but attachment can occur to the rectum and occasionally to the bowel, although this is rare.

After delivery, when the abnormal placenta does not separate from the uterus, postpartum hemorrhage may occur, potentially leading to hemorrhagic shock, coagulopathy, hysterectomy, and death. Average blood loss is between 3000 and 5000 mL and can be much more. Approximately 90% of these patients need a transfusion. Ideally, the delivery of a patient with placenta accreta should be planned and controlled,¹,² but every obstetrician must be prepared if an unexpected patient with placenta accreta comes into triage.

While placenta accreta spectrum can be one of the most life-threatening pregnancy complications, being prepared with a multidisciplinary plan in place can improve outcomes and decrease provider anxiety. All members of the team should be included in planning and all staff should be aware of protocols. Planning will not only improve management of scheduled deliveries of patients with placenta accreta spectrum, but will also improve management of unexpected deliveries.

As soon as a patient is identified as having placenta accreta, a multidisciplinary patient conference should be scheduled to formulate a delivery plan. Ideally, members of the team should include the primary obstetrician, a maternal fetal medicine specialist (if not acting as the primary obstetrician), the obstetrical nursing team, obstetrical anesthesia team, a gynecologic oncologist, interventional radiology team, the pediatric/neonatal intensive care unit (NICU) team, the blood bank, the cell saver team, the laboratory, and the ICU team. Urology, trauma/general surgery, and vascular surgery should be aware and available. A contact person should be identified for each of the services. If the hospital has an accreta team, the team should be notified.¹,²

The following include descriptions of the role of each member of the multidisciplinary team.

Primary obstetrician: The primary obstetrician is the head of the team, is primarily responsible for the patient, and leads the patient conference. The obstetrician schedules the cesarean hysterectomy and assures that all members of the team are in place.

Maternal fetal medicine specialist: This specialist diagnoses the placenta accreta and documents location and any possible involved structures. The maternal fetal medicine specialist decides the optimal delivery time and guides the obstetrician in timing of steroids or other interventions.

Obstetrical nursing team: The charge nurse or designated head of the nursing team is responsible for notifying all team members of the delivery and assuring all equipment is available. The nursing team assists in obtaining supplies including blood and labs. One nurse will be responsible for inflating the balloon catheters, if needed.

Gynecologic oncologist: If the primary obstetrician is not experienced in performing high blood loss cesarean hysterectomies, a gynecologic oncologist should be present and responsible for taking charge of the hysterectomy after delivery of the fetus.

Interventional radiology team: The interventional radiology team can place balloon catheters prior to the planned procedure. If it is decided not to use the balloon catheters, the interventional radiologist should be available for embolization of continued bleeding.

Pediatric/NICU team: The NICU team is responsible for the fetus after delivery and is responsible for assuring that all equipment is available, especially if the delivery is performed out of the usual obstetric operating room.

Blood bank: The blood bank should be alerted and prepared for the massive transfusion protocol to be activated.

Cell saver team: If the cell saver is to be used, they will remind the surgeons that all amniotic fluid needs to be cleared prior to using the cell saver. They will operate the machine.

Laboratory: The laboratory should be prepared to run stat samples as needed.

ICU team: A bed needs to be arranged and the ICU team should be expecting to receive the patient after surgery.