CONTINUING MEDICAL EDUCATION

169

Placenta AccretaAn Updated

Approach to Diagnosis
and Management
5 SKP

Charleen Sze-Yan Cheung, MBBS(HK), MRCOG, FHKAM(O&G); Ben Chong-Pun Chan, MBBS(HK), FRCOG, FHKAM(O&G), FHKCOG, Cert RCOG (Maternal and Fetal Med)

INTRODUCTION
Morbidly adherent placenta involves
a spectrum of abnormal placental implantation. Placenta accreta occurs
when chorionic villi attach to the myometrium. Placenta increta refers to the
invasion of villi into the myometrium.
Placenta percreta is defined by invasion extending deep beyond the uterine serosa. It may also involve adjacent
organs, commonly the urinary bladder.
Placenta accreta and its associated
spectrum are often collectively described in the literature.1,2
Placenta accreta is associated with
substantial maternal risks, including
life-threatening obstetric haemorrhage,
dilution or consumptive coagulopathy,
massive

transfusion

and

reactions,

injuries to surrounding organs, prolonged

A previous caesarean delivery is a major risk factor for placenta accreta.

hospitalization, and increased risks of

intensive care admission.35 It accounts

Repeated dilatation and curettage and

caesarean

for 3850% of emergency peripartum

other corrective uterine surgeries may

especially in developed countries. In the

caesarean hysterectomies.68 It is a

result in myometrial trauma and scarring,

US, the incidence of placenta accreta

leading cause of maternal morbidity and

contributing to the risk of developing

was reported to be 8.3 per 10,000

mortality. Inevitably, there is high demand

abnormal

adherence.

deliveries and had doubled over a 12-

for health resources as well as concerns

Advanced maternal age has been

year period.15 It is anticipated to continue

about adverse obstetric outcomes.

identified as an independent risk factor.

as a growing health problem.

The

two

most

important

placental

section

rates

worldwide,

risk

Other risk factors include smoking,

Women at risk for placenta accreta at

factors of placenta accreta are previous

uterine anomalies, grand multiparity,

term are also at risk in earlier gestations.

caesarean section and placenta praevia.

and recurrent miscarriages.4,13,14

Placenta accreta has been reported

The risk increases with the number

of previous caesarean sections.

5,1012

The incidence of placenta accreta

but occurs less frequently in the first

continues to rise with increases in

trimester. This is usually a retrospective

CONTINUING MEDICAL EDUCATION

170

diagnosis, when massive bleeding is

7197%, and positive predictive value of

Magnetic Resonance Imaging

noted during dilatation and curettage

6588%.1,20,21

Magnetic resonance imaging (MRI) and

procedures and placental invasion of the

Sonographic features suggestive of

ultrasonography are comparable in diag-

myometrium is found.16 At any gestation,

placenta accreta include the following:

nosing placenta accreta. Magnetic reso-

prior scarring from uterine incision can

obliteration of the retroplacental sono-

nance imaging carries additional value in

result in myometrial thinning. Women

lucent

vascular

detecting the depth of placental invasion

may present with uterine rupture, acute

lacunae (large, irregular Swiss cheese

and depicting posterior placenta accre-

abdomen, and shock.17,18

appearance), myometrial thinning (less

ta, and in cases where ultrasonography

of

than 1 mm), interruption of bladder line,

is inconclusive.9 Uterine bulging, het-

placenta accreta is needed as unexpected

and presence of extrauterine placental

erogeneous signal intensity within the

encounter of morbidly adherent placenta

parenchyma

cases.3,5,9,22

placenta, dark intraplacental bands on

can lead to catastrophic outcomes as

While

retroplacental

T2-weighted images, tenting of the blad-

described above. It is also essential in

sonolucent zone in isolation has a

der, and direct visualization of placental

allowing both patients and physicians to

high false-positive rate-up to 50% is

invasion into pelvic structures have been

prepare for the potential complications of

reported23-the combination of vascular

reported as the MRI features of placenta

pregnancy and delivery.

lacunae and myometrial thinning is rather

accreta.29,30 Nonetheless, the use of MRI

predictive of morbidly adherent placenta,

does not seem to improve the manage-

DIAGNOSTIC APPROACH

with sensitivity reaching 100%, specificity

ment and obstetric outcome. There is

A careful review of history and a high

7279%, and positive predictive value

insufficient evidence to support its rou-

index of suspicion are necessary in

73%.3,9,24 Given that none of these

tine use in sonographically suspected

alerting health care providers to the

sonographic signs is pathognomonic,

placenta accreta.9,20,31,32

possibility of placenta accreta. Various

they should be interpreted with caution

types of imaging modalities have been

in a clinical setting.

Reliable

antenatal

diagnosis

zone,

presence

in

of

extreme

obliteration

of

further improves the diagnostic accuracy.

OBSTETRIC MANAGEMENT
STRATEGIES
Antenatal Management

Features include preD, turbulent high-

Treating placenta accreta is a real ob-

Ultrasonography

velocity

extending

stetric challenge. Anticipation and iden-

Ultrasonography is a non-invasive, widely

from the placenta into the surrounding

tification of risk factors form the corner-

available, and cost-effective modality for

tissues was found to be sDDensitive

stones of safe management strategies

diagnosis of placenta accreta in clinical

in identifying individuals with placenta

in placenta accreta. It has been recom-

practice. Transvaginal ultrasonography

accreta.16,19,25,26 Hypervascularity of the

mended that women with previous cae-

overcomes the limitations of transab-

vesicouterine serosa interphase also

sarean section should have placental

dominal approach due to maternal body

increases the possibility of placenta

localization to exclude placenta prae-

habitus and suboptimal view of the lower

accreta, although bladder varicosities

via and further investigation to identify

uterine cervix or placental invasion. Its

from previous caesarean sections can

accreta, if necessary.33,34 Women who

use and safety in placenta praevia have

give rise to false positives. Using three-

have had previous caesarean section

been well accepted.19 Over the years, nu-

dimensional power Doppler, visualization

and placenta praevia, especially ante-

merous ultrasound imaging techniques,

of numerous coherent vessels in the

rior placenta, should be managed as if

including greyscale, colour, and three-di-

basal view was the best single criterion

they have placenta accreta until proven

mensional power Doppler sonography,

for the diagnosis of placenta accreta, with

otherwise.28

have been developed to assist in diag-

sensitivity of 97% and specificity of 92%.

nosing morbidly adherent placenta an-

Inseparable cotyledonal and intervillous

for

tenatally. Nowadays, ultrasonography is

circulations, chaotic branching, and

advocated. Elements of good care

the recommended first-line investigation

detour vessels may also be observed on

consist of preoperative planning by a

with a sensitivity of 7793%, specificity of

lateral view.

multidisciplinary team, involvement of the

utilized in an attempt to predict placenta accreta.

Application

flow

of

colour

(> 15 cm/s)

Doppler

26

27,28

A multidisciplinary care bundle

placenta

accreta

has

been

CONTINUING MEDICAL EDUCATION

171

consultant obstetrician and consultant

anaesthetist for planned and directly
supervised delivery, possible input from
urology, gynaecological oncologist, and
vascular surgeons, availability of blood
bank and blood products, intensive care,
and discussion and consent including
possible interventions.28
While maternal haemorrhage is
likely and blood product transfusion
is

anticipated,

prevent

it

anaemia

is

beneficial

to

and

optimize

the

haemoglobin level antenatally. Oral iron

supplementation should be considered
to improve the iron stores and oxygencarrying capacity.5
Delivery should ideally be planned
under elective and controlled conditions,
with adequate ancillary support. Optimal
timing of scheduled delivery depends
on various clinical factors. Emergency
preterm delivery may be necessary
because of obstetric complications, for
instance,

antepartum

haemorrhage.

The maternal benefits of earlier elective

delivery must be balanced against the
neonatal

morbidity

associated

with

premature birth. In the absence of

antepartum hemorrhage or pregnancy
complications,

elective

late

preterm

delivery at around 3637 weeks of

Management of placenta accreta requires a multidisciplinary team approach.

gestation (with potential corticosteroid

cover) is an acceptable compromise

interventional radiological procedures),

contact persons in case perioperative

to reduce the likelihood of emergency

should be discussed as well. Fertility

assistance is required.9

delivery at term.9,28

wish and acceptance of the extent

Detailed preoperative counselling

of procedures should be explored.

Intrapartum Period

essential.

Adoption

versus

Rapid mobilization of trained operating

partner is advisable. They should be

early resort to radical treatment is an

team and assistant staff is essential, espe-

counselled on the risks of operation,

important decision to be made during

cially in the event of emergency. In many

including life-threatening haemorrhage

the planning process. A standardized

institutions, surgeries are performed in

and

information

is

Involvement

of

the

of

conservative

preoperative

the main operating room as opposed to

perioperative interventions, such as

check list would be helpful in the

labour and delivery wards. Proper equip-

hysterectomy,

visceral

injuries.

Possible

sheet

and

management, confirmation of necessary

ment should be in place before the com-

stenting, and conservative measures

communication

mencement of an operation.35

(cell salvage, leaving placenta in situ,

preparation, and identification of the

cystotomy,

ureteric

and

understanding,

Dorsal

lithotomy

positioning

CONTINUING MEDICAL EDUCATION

172

Cystoscopy and prophylactic retrograde

stenting may be considered.35 Midline
skin incision is often preferred, in
preparation for possible exploration
of

the

upper

abdomen.

Careful

inspection of the abdominal cavity

allows identification of the site and
extent of placental invasion (Figure 1).
Anatomical distortion and the difficulty
in subsequent surgical dissection of the
bladder plane and in the isolation of the
ureters or pelvic vasculature should be
anticipated. Uterine incision should be
made away from the placenta during
entry into the uterine cavity. One should
avoid incision through the placenta
and subsequent haemorrhage. It is
also unwise to attempt to remove the
placenta at this juncture, as it can lead
to disruption of the highly vascular
lower uterine segment and the infiltrated
placental bed, and increase maternal
morbidity.9
Traditionally, caesarean hysterectomy is the gold standard for treating
placenta accreta. In women who have
completed their family, a lower threshold
for hysterectomy is desirable. It is

Figure 1. Thin and very vascular uterine lower segment at the time of caesarean section.
the rich vascularity usually correlates with the position of placentation

sensible to complete the delivery of the

infant and proceed to the closure of the
hysterotomy and planned hysterectomy

with hip abduction but limited flexion

is of foetal advantage but limits the

with placenta in situ expeditiously to

enables direct evaluation of vaginal

manipulation of abdominal contents.

control ongoing blood loss.34 Total, rather

bleeding during the operation and

General anaesthesia may be appropriate

than subtotal, hysterectomy is advocated

allows placement of the uterine balloon,

in most cases because of the likelihood

because of risks of haemorrhage from

if necessary.

of prolonged operating duration and

lower-segment invasions. There is also

severe haemorrhage.5,35

the concern of carcinoma developing

Anaesthetic considerations include

have

in the cervical stump and the need for

of high flow rate infusion and suction

preoperative ultrasound mapping of the

continuation of cervical screening after

devices,

peripheral

placental location to guide the surgical

subtotal hysterectomy. In cases in which

haemodynamic monitoring capabilities,

avoidance

large-bore venous access, availability

central
of

and

It

is

good

practice

to

decisions. When placental invasion to

subtotal hysterectomy is performed,

hypothermia,

and

the parametrium is suspected, major

peritoneal closure over the cervical

prophylaxis.

The

obstetric

to

stump should be avoided as further

decision of anaesthetic technique is

further increase struggle in ureteric

haemorrhage may be concealed and go

individualized.

identification, and risk of injury is high.

unnoticed.1

thromboembolic

Regional

5,36

anaesthesia

haemorrhage

is

likely

CONTINUING MEDICAL EDUCATION

173

With advancements in obstetric

care and interventional modalities, it
is now feasible to offer conservative
management

to

women

who

wish

to retain fertility rather than to adopt

an

aggressive

Conservative

surgical

approach.37

management

aims

to

avoid hysterectomy by leaving a part

or the whole placenta in situ, with or
without additional measures, such as
application of compression sutures,
arterial embolization, and segmental
resection of the myometrial tissues,
followed by repair of the defect or
uterine reconstruction. This lowers the
risk of subsequent hysterectomy from
85% to 15%.1 Prerequisites include
haemodynamic

stability

without

significant blood loss, wish to preserve

fertility,

possibility

of

preoperative

With advancements in obstetric care and interventional modalities, it is now feasible to

offer conservative management to women who wish to retain fertility.

consultation, and the availability of

resources and expertise to follow up and

the internal iliac or uterine arteries, with

pressure to prevent continual bleeding.

manage late postpartum complications.

or without balloon inflation at the time of

Of the balloon tamponade devices, the

Careful

delivery, or embolization after caesarean

Bakri balloon was specifically designed

selection

and

preoperative

section can be performed. A recent

for postpartum haemorrhage and was

methods

systematic review of uterus-preserving

first described in the management

can be applied to control postpartum

treatment modalities reveals that uterine

of placenta praevia accreta during

haemorrhage. Placement of compression

artery embolization for placenta accreta

caesarean section. It is least invasive,

sutures and pelvic devascularization

could achieve a subsequent menstruation

relatively easy to apply, effective, and

can be used accordingly. Compression

rate of 62%, pregnancy rate of 15%, and

rapid in action. It carries the advantage

sutures, such as B-Lynch38 or Cho

secondary hysterectomy rate of 18%.41

of having a large-bore drainage channel,

counselling are essential.

Various

haemostatic

are particularly effective in

Most of these studies are limited by their

which is less likely to be blocked by

dealing with uterine atony in general.

small series, and so larger prospective

fibrin

Hwu et al described two parallel vertical

series are awaited.

Sengstaken-Blakemore tube and Rusch

square,

39

40

formation.

Substitutes

include

sutures, which were placed in the lower

It is worth noting that, in placenta

segment to compress the anterior and

praevia accreta, there are additional

tamponade

posterior walls, that may be more effective

arterial supplies by the cervical, vaginal,

resource-limited settings.42,43

in targeting the source of bleeding in

and inferior vesical arteries to the

In contrast to leaving the placenta in

placenta accreta.

balloon,

uterine
can

Foley
be

or

condom

considered

in

lower uterine segment. Internal iliac

situ, resection of the invaded myometrium

Interventional radiology serves an

artery ligation alone or embolization

together with the placenta and repair

important role in managing placenta

is associated with significant risks of

or reconstruction of the non-invaded

praevia accreta. It offers prophylactic

failure.1

myometrial defect can be practically

by

performed. Lack of comparative studies

haemorrhage.

exerting an inward-to-outward pressure

also resulted in wide variation in the

Preoperative placement of a catheter in

that is greater than systemic arterial

surgical approaches adopted.1

measures
and

to

prevent

reduce
ongoing

uterine

flow

Balloon

tamponade

acts

CONTINUING MEDICAL EDUCATION

174

Transfusion is unavoidable and

hage, and disseminated intravascular

constitutes a key step in managing

coagulopathy.15

major obstetric haemorrhage. Although

spectrum

cell

agents

Prophylactic

uterotonic

if the operation is not the only delivery

option. Identification of risk factors,

infuse fetal debris and possibly result

although a consensual guideline has

accurate antenatal and preoperative

in alloimmunization, its use and safety

yet to be established. Ready access to

diagnostic imaging, dedicated multi-

in obstetrics have been supported.

medical assessment and resuscitation

disciplinary team management, and

Use of other tissue sealants or even

are

conservative

appropriate counselling will all aid in

mesh has been reported; but to date,

management, as women are still at risk for

the overall management of women with

there is insufficient evidence on their

interval hysterectomy should conservative

placenta accreta, and their importance

effectiveness and safety.1 Recombinant

management fail and complications arise.

cannot be emphasized enough. Elective

factor VIIa has been approved for use

It is controversial whether the placenta

caesarean delivery at near-term should

in patients with haemophilia A and with

should be removed postpartum, left to

be arranged in an institute with ade-

inhibitors of coagulation. It induces

absorb, or be expelled spontaneously.

quate intrapartum anaesthetic, haema-

coagulation at sites of active bleeding in

Serum human chorionic gonadotrophin

tological, and interventional radiological

the presence of tissue factor. However,

and Doppler ultrasound may be utilized

support. Early resort to hysterectomy

it is associated with high cost and

to assess the cessation of placental

may help to avoid further haemody-

significant thrombotic risk, and should

vascularity for consideration of interval

namic deterioration while combating a

therefore be reserved as a last resort.

removal,

but

remains

undetermined.

could

theoretically

re-

are

and

about this complication risk, especially

recommended,

salvage

antibiotics

sarean section should be well informed

broad-

often

prerequisites

correlation

major maternal haemorrhage. Conserv-

Hysteroscopic

ative management may be considered

Postpartum Period

retrieval of retained trophoblastic tissues

for women who desire to retain fertility.

Patients with placenta accreta and ma-

has been described. It achieves similar

Women should ideally be closely moni-

jor postpartum haemorrhage are at risk

surgical and reproductive outcomes, but

tored in intensive care or high-depend-

for intrapartum hypotension and persis-

carries the advantage of direct visualization

ency unit postoperatively and followed

tent coagulopathy. Close monitoring of

and reduces the risk of uterine perforation

up for late complications. A designated

vital signs and organ functions postop-

compared with blind curettage.44,45

care bundle and local protocol would

35

the

to

clinical

eratively is of utmost importance. Input

Methotrexate, a folate antagonist,

from intensive care physicians is inval-

has been proposed as a conservative

uable. Further imaging by computed

medical measure for retained placenta

Last but not least, psychological

tomography or MRI is necessary should

with morbid adherence. It is effective

assessment and appropriate support

there be alteration in haemodynamics or

against proliferating trophoblasts, but

after major obstetric events are often

signs of haemoperitoneum. Exploratory

its action on degenerative placenta

overlooked in busy clinical settings.

re-laparotomy must not be delayed if

after delivery remains questionable.

Debriefing sessions with the patient and

clinically indicated. Physicians should be

In general, outcomes do not differ

family at appropriate intervals, provision

alerted of possible unrecognized urinary

significantly with or without the use

of adequate explanation, and effective

tract injury, which may present as per-

of

communication would help to reduce

sistent haematuria or anuria. Sheehan

contraindicated in breastfeeding and is

patient

syndrome, transient or permanent, is a

not routinely recommended for use.

medical litigation.

tum haemorrhage. Hyponatraemia may

CONCLUSION

About the Authors

be an early sign for this.

Placenta accreta is an evolving chal-

methotrexate.

Methotrexate

is

be beneficial for management of this

high-risk obstetric condition.

dissatisfaction

and

risks

of

known complication of massive postpar9,34

While the placenta is left in situ,

patients

should

be

monitored

lenge in modern obstetrics. It is an iatro-

and

genic consequence of change in obstet-

followed up for possible secondary

ric practice and increasing caesarean

infection, sepsis, postpartum haemorr-

section rates. Patients undergoing cae-

Dr Cheung is Resident in the Department of Obstetrics and

Gynaecology, Queen Mary Hospital; and Honorary Clinical
Assistant Professor in the Department of Obstetrics and Gynaecology, University of Hong Kong, Hong Kong. Dr Chan is
Specialist in Obstetrics and Gynaecology in the Hong Kong
Maternal and Fetal Medicine Clinic; Part-time Consultant in
the Department of Obstetrics and Gynaecology, Queen Mary
Hospital; and Honorary Clinical Associate Professor in the
Department of Obstetrics and Gynaecology, University of
Hong Kong, Hong Kong.

CONTINUING MEDICAL EDUCATION

175

REFERENCES
1. Doumouchtsis SK, Arulkumaran S. The
morbidly adherent placenta: an overview of
management options. Acta Obstet Gynecol
Scand 2010;89:11261133.
2. Palacios-Jaraquemada JM. Diagnosis and
management of placenta accreta. Best Pract
Res Clin Obstet Gynaecol 2008;22:1133
1148.
3. Comstock CH. Re: Morbidly adherent placenta: evaluation of ultrasound diagnostic
criteria and differentiation of placenta accreta from percreta. G. Cali, L. Giambanco, G.
Puccio and F. Forlani. Ultrasound Obstet Gynecol 2013;41:406412. Ultrasound Obstet
Gynecol 2013;41:365.
4. Usta IM, Hobeika EM, Musa AA, Gabriel
GE, Nassar AH.. Placenta previa-accreta:
risk factors and complications. Am J Obstet
Gynecol 2005;193:10451049.
5. Publications Committee, Society for
Maternal-Fetal Medicine; Belfort MA.
Placenta accreta. Am J Obstet Gynecol
2010;203:430439.
6. Demirci O, Tu rul AS, Yilmaz E, Tosun ,
Demirci E, Eren YS. Emergency peripartum
hysterectomy in a tertiary obstetric center:
nine years evaluation. J Obstet Gynaecol
Res 2011;37:10541060.
7. Kwee A, Bots ML, Visser GH, Bruinse HW.
Emergency peripartum hysterectomy: a prospective study in The Netherlands. Eur J Obstet Gynecol Reprod Biol 2006;124:187192.
8. Knight M, UKOSS. Peripartum hysterectomy in the UK: management and outcomes
of the associated haemorrhage. BJOG
2007;114:13801387.
9. Cheung CS, Chan BC. The sonographic appearance and obstetric management
of placenta accreta. Int J Womens Health
2012;4:587594.
10. Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol 1985;66:8992.
11. Silver RM, Landon MB, Rouse DJ, et al;
National Institute of Child Health and Human
Development Maternal-Fetal Medicine Units
Network. Maternal morbidity associated with
multiple repeat cesarean deliveries. Obstet
Gynecol 2006;107:12261232.
12. Hull AD, Moore TR. Multiple repeat ce-

sareans and the threat of placenta accreta:

incidence, diagnosis, management. Clin Perinatol 2011;38:285296.
13. Miller DA, Chollet JA, Goodwin TM.
Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol
1997;177:210214.
14. Gielchinsky Y, Rojansky N, Fasouliotis
SJ, Ezra Y. Placenta accretasummary of
10 years: a survey of 310 cases. Placenta
2002;23:210214.
15. Eller AG, Porter TF, Soisson P, Silver RM.
Optimal management strategies for placenta
accreta. BJOG 2009;116:648654.
16. Comstock CH. Antenatal diagnosis of
placenta accreta: a review. Ultrasound Obstet Gynecol 2005;26:8996.
17. Dahiya P, Nayar KD, Gulati AJ, Dahiya K.
Placenta accreta causing uterine rupture in
second trimester of pregnancy after in vitro
fertilization: a case report. J Reprod Infertil
2012;13:6163.
18. Roca LE 2nd, Hoffman MC, Gaitan LF,
Burkett G. Placenta percreta masquerading as an acute abdomen. Obstet Gynecol
2009;113:512514.
19. Lerner JP, Deane S, Timor-Tritsch IE.
Characterization of placenta accreta using
transvaginal sonography and color Doppler imaging. Ultrasound Obstet Gynecol
1995;5:198201.
20. Warshak CR, Eskander R, Hull AD,
et al. Accuracy of ultrasonography and
magnetic resonance imaging in the diagnosis of placenta accreta. Obstet Gynecol
2006;108:573581.
21. Hayes E, Ayida G, Crocker A. The morbidly adherent placenta: diagnosis and management options. Curr Opin Obstet Gynecol
2011;23:448453.
22. Comstock CH, Love JJ Jr, Bronsteen
RA, et al. Sonographic detection of placenta accreta in the second and third trimesters of pregnancy. Am J Obstet Gynecol
2004;190:11351140.
23. Kerr de Mendona L. Sonographic diagnosis of placenta accreta: presentation of six
cases. J Ultrasound Med 1988;7:211215.
24. Twickler DM, Lucas MJ, Balis AB, et al.
Color flow mapping for myometrial invasion

in women with a prior cesarean delivery. J

Matern Fet Med 2000;9:330335.
25. Cal G, Giambanco L, Puccio G, Forlani
F. Morbidly adherent placenta: evaluation of
ultrasound diagnostic criteria and differentiation of placenta accreta from percreta. Ultrasound Obstet Gynecol 2013;41:406412.
26. Comstock C, Bronsteen R. The antenatal diagnosis of placenta accreta. BJOG
2014;121:171182.
27. Shih JC, Palacios Jaraquemada JM, Su
YN, et al. Role of three-dimensional power
Doppler in the antenatal diagnosis of placenta accreta: comparison with gray-scale and
color Doppler techniques. Ultrasound Obstet
Gynecol 2009;33:193203.
28. Royal College of Obstetricians and Gynaecologists. Placenta praevia, placenta
praevia accreta and vasa praevia: diagnosis
and management. Green-top Guideline No.
27. January 2011.
29. Baughman WC, Corteville JE, Shah
RR. Placenta accreta: spectrum of US
and MR imaging findings. Radiographics
2008;28:19051916.
30. Lax A, Prince MR, Mennitt KW, Schwebach JR, Budorick NE. The value of specific
MRI features in the evaluation of suspected
placental invasion. Magn Reson Imaging
2007;25:8793.
31. Dwyer BK, Belogolovkin V, Tran L, et
al. Prenatal diagnosis of placenta accreta:
sonography or magnetic resonance imaging? J Ultrasound Med 2008;27:12751281.
32. Levine D, Hulka CA, Ludmir J, Li W, Edelman RR. Placenta accreta: evaluation with
color Doppler US, power Doppler US, and
MR imaging. Radiology 1997;205:773776.
33. Lewis G. The Confidential Enquiry into
Maternal and Child Health (CEMACH).
Saving Mothers Lives: Reviewing Maternal
Deaths to Make Motherhood Safer - 20032005. The Seventh Report of the Confidential
Enquiries into Maternal Deaths in the United
Kingdom. London: CEMACH; 2007.
34. ACOG Committee Opinion. Number 266,
January 2002: Placenta accreta. Obstet Gynecol 2002;99:169170.
35. Perez-Delboy A, Wright J. Surgical management of placenta accreta: to leave or

remove the placenta? BJOG 2014;121:163

170.
36. Snegovskikh D, Clebone A, Norwitz E.
Anesthetic management of patients with
placenta accreta and resuscitation strategies
for associated massive hemorrhage. Current
Opin Anaesthesiol 2011;24:274281.
37. Lo TK, Yung WK, Lau WL, Law B, Lau S,
Leung WC. Planned conservative management of placenta accreta experience of a
regional general hospital. J Matern Fetal Neonatal Med 2014;27:291296.
38. B-Lynch C, Coker A, Lawal AH, Abu J,
Cowen MJ. The B-Lynch surgical technique
for the control of massive postpartum haemorrhage: an alternative to hysterectomy?
Five cases reported. Br J Obstet Gynaecol
1997;104:372375.
39. Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding
during cesarean delivery. Obstet Gynecol
2000;96:129131.
40. Hwu YM, Chen CP, Chen HS, Su TH.
Parallel vertical compression sutures: a
technique to control bleeding from placenta
praevia or accreta during caesarean section.
BJOG 2005;112:14201423.
41. Steins Bisschop CN, Schaap TP, Vogelvang TE, Scholten PC. Invasive placentation
and uterus preserving treatment modalities:
a systematic review. Arch Gynecol Obstet
2011;284:491502.
42. Kumru P, Demirci O, Erdogdu E, et al. The
Bakri balloon for the management of postpartum hemorrhage in cases with placenta
previa. Eur J Obstet Gynecol Reprod Biol
2013;167:167170.
43. Georgiou C. Balloon tamponade in the
management of postpartum haemorrhage: a
review. BJOG 2009;116:748757.
44. Cohen SB, Kalter-Ferber A, Weisz BS,
et al. Hysteroscopy may be the method of
choice for management of residual trophoblastic tissue. J Am Assoc Gynecol Laparosc
2001;8:199202.
45. Golan A, Dishi M, Shalev A, Keidar R,
Ginath S, Sagiv R. Operative hysteroscopy
to remove retained products of conception:
novel treatment of an old problem. J Minim
Invasive Gynecol 2011;18:100103.