Conservative Management of Placenta Accreta

Shila Chakre*, Himangi Warke**, N M Mayadeo ***, Sachin Pardeshi*
(* Assistant Professor, ** Associate Professor, *** Professor. Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)


Placenta accreta is due to abnormal invasion of placenta.[1] It may lead to morbidity and mortality following severe obstetrical hemorrhage. Its diagnosis in the antenatal period and management is very important to prevent maternal morbidity and mortality. The diagnosis is suspected after delivery if there is no expulsion of the placenta. We report a case of clinically presumed placenta accreta in a 29 years multiparous patient with previous cesarean delivery following failed manual removal placenta. Conservative management with methotrexate was done in a clinically stable patient desiring future fertility. However, ongoing close observation is required to identify complications.


Placenta accreta is an uncommon disorder of placentation due to invasion of chorionic villi into the myometrium. Histologically, it is due to poorly developed or absent decidua basalis. Placenta accreta is commonly seen after cesarean delivery.[2] It is also associated with placenta previa.[2]  Antenatal diagnosis can be made in patient with previous cesarean deliveries, placenta previa and by doing ultrasonography (USG).[3] This could allow for predelivery planning to reduce complications. But, diagnosis of placenta accreta is made mostly postdelivery when there is failure of manual removal of the placenta.[4] It results in severe postpartum hemorrhage and complications such as need for transfusion of blood and blood products, DIC, acute renal failure, infectious morbidities, adult respiratory distress syndrome, and compromised fertility.[3] Mortality may be upto 7%.[5]  In the past, hysterectomy was the mainstay of treatment for placenta accreta. But with this, there is significant perioperative risks and compromised future fertility.[5] For those who wish to conserve their reproductive function, placenta can be left in situ as an alternative strategy.[6] Adjuvant therapy with methotrexate has also been used to expedite resorption of placental tissue.[4] Though infective morbidity, hemorrhage and need for hysterectomy are there with conservative management, it can be applied with case discretion.

Case report

A 29 years old gravida three, para one, living one, abortion one with previous lower segment cesarean section  4 years back for meconium stained amniotic fluid was admitted at 37 weeks of gestation in active labor. Her pelvis was adequate. Her antenatal profile was normal. On antenatal USG, there was no placenta accreta or percreta. She delivered vaginally a 2.7 kg male baby with Apgar score of 9/10. After 1 hour of baby delivery, there were no signs of placental separation. So manual removal of placenta was tried but there was no cleavage plane between placenta and uterus. Hence the procedure was abandoned. On USG there was no evidence of adherent placenta but clinical diagnosis was adherent placenta. Umbilical cord was ligated and cut close to the cervical os and placenta was left in situ.
MRI was done on day 2. It was suggestive of retained product of conception, fundal focal adherent placenta with rest of the placenta showing distinct plane with uterine myometrium.
On day 2, Hb was 8.2 gm%. CBC was 8400/cmm. She was given 2 units of blood. A single dose of 50 mg of methotrexate was given intramuscularly on day 2. She was monitored in the ward for any signs of separation of placenta, fever, bleeding and foul smelling discharge per vaginum. Serial ultrasounds for placental volume and β-HCG were done. While in the ward, she gave history of passage of placental bits per vaginum. She was discharged on day 22 and advised USG for placental volume and after β HCG one month. Placenta was not seen on USG at 8 weeks with β-HCG report of <2.

Days  after delivery
USG for placental volume in ml
Day 2 to 4
280  to 300
Day  7
Day  14
Day  21
After 8 weeks                     


Placenta accreta occurs 1 in 533 deliveries and has been increasing largely due to the global increase in caesarean deliveries and MTP’s.[7]  Those are at high risk of developing placenta accreta should be screened antenatally by USG and if required magnetic resonance imaging.[1] Optimal management of placenta accreta remains unclear. Caesarean hysterectomy is usually done if the diagnosis of placenta accreta is made antenatally.[8]  Maternal morbidity  such as loss of fertility,  gastrointestinal or urinary tracts injuries, infection,  massive obstetrical hemorrhage and its sequelae occurs with emergency postpartum hysterectomy.[4] Several reports have described the conservative strategies. These  include leaving the placenta in situ in hemodynamically stable patients, replacing the blood loss by using blood and blood products, selective arterial embolization and/or balloon occlusion, and uterine and/or hypopgastric artery ligation and use of mehotrexate.[3]
Mehotrexate leads to necrosis and rapid removal of the placenta.[9] But, there is a lack of consensus regarding optimal dosing, frequency, or route of administration. In this particular case, a single dose of 50 mg per m2 of body surface area was used. Some reports described a half- life of serum β-HCG of 5.8 days in cases of retained placenta managed with methotrexate.[10] Fever is a commonly reported complication. Prophylactic use of broad-spectrum antibiotic therapy may reduce infectious morbidity.[4] Vaginal bleeding may also occur for several months following delivery. Though conservative management of placenta accreta can successfully avoid hysterectomy in most cases, there is still risk of serious morbidity. Intensive monitoring for complications is required in patients with retained placenta.


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Chakre S, Warke H, Mayadeo NM, Pardeshi S. Conservative Management of Placenta Accreta. JPGO 2014 Volume 1 Number 5 Available from: