Overview Snapshot A 28-year-old G3P2 female at 39 weeks of gestation is on the labor and delivery floor in active labor. The cervix is 10 centimeters dilated and preparations are made for delivery of the newborn. A male neonate is born with appropriate Apgar scores and without any perinatal complications. During placental delivery there is a lot of resistance when traction is placed on the umbilical cord. After an attempt at manual placental separation, there is profuse bleeding. Obstetric history is significant for previous cesarean delivery. She has missed a number of prenatal visits during this pregnancy. Introduction Overview abnormal implantation of the placenta chorionic villi of the placenta attach to the surface of the myometrium rather than the decidua Epidemiology incidence login to view 3 more bullets risk factors login to view 6 more bullets Pathogenesis theory of defective decidualization login to view 2 more bullets Prognosis 27% morbidity login to view 1 more bullet risk of death from sequelae of massive hemorrhage Classification Placenta accreta spectrum placenta accreta placental villi attach to myometrium (instead of decidua) placenta increta placental villi penetrate into the myometrium placenta percreta placental villi penetrate through the myometrium and attach to the uterine serosa or adjacent organs Presentation Symptoms often asymptomatic profuse life-threatening hemorrhage during attempted manual placental separation Physical Exam inability to fully separate placenta from uterus after delivery Imaging Transvaginal or transabdominal ultrasonography indications routine prenatal care a history of cesarean delivery or other uterine surgeries used for diagnosis antenatally findings second and third trimester login to view 8 more bullets Studies Histology placental villi attached to the myometrium in the absence of a decidual plate used for diagnosis postnatally Maternal serum alpha-fetoprotein abnormally elevated in second trimester Differential Placenta increta Placenta percreta key distinguishing factors ultrasound findings login to view 2 more bullets Treatment Behavioral pre-delivery precautions avoidance of sexual intercourse avoidance of pelvic exams scheduled delivery preparation for potential hemorrhage during delivery Medical RhoGAM indications login to view 1 more bullet modalities login to view 1 more bullet blood products indications login to view 1 more bullet modalities login to view 4 more bullets Surgical cesarean hysterectomy indications login to view 2 more bullets Complications Massive hemorrhage Death