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Placenta previa percreta with surrounding organ involvement: a proposal for management
  1. Koji Matsuo1,
  2. Rauvynne N Sangara2,
  3. Shinya Matsuzaki3,
  4. Joseph G Ouzounian2,
  5. Sue E Hanks4,
  6. Kazuhide Matsushima5,
  7. Rodolfo Amaya6,
  8. Lynda D Roman1 and
  9. Jason D Wright7
  1. 1 Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
  2. 2 Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
  3. 3 Department of Gynecology, Osaka International Cancer Institute, Osaka, Japan
  4. 4 Department of Radiology, University of Southern California, Los Angeles, California, USA
  5. 5 Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California, USA
  6. 6 Department of Anesthesiology, University of Southern California, Los Angeles, California, USA
  7. 7 Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
  1. Correspondence to Dr Koji Matsuo, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90033, USA; koji.matsuo{at}


Placenta accreta spectrum encompasses cases where the placenta is morbidly adherent to the myometrium. Placenta percreta, the most severe form of placenta accreta spectrum (grade 3E), occurs when the placenta invades through the myometrium and possibly into surrounding structures next to the uterine corpus. Maternal morbidity of placenta percreta is high, including severe maternal morbidity in 82.1% and mortality in 1.4% in the recent nationwide U.S. statistics. Although cesarean hysterectomy is commonly performed for patients with placenta accreta spectrum, conservative management is becoming more popular because of reduced morbidity in select cases. Treatment of grade 3E disease involving the urinary bladder, uterine cervix, or parametria is surgically complicated due to the location of the invasive placenta deep in the maternal pelvis. Cesarean hysterectomy in this setting has the potential for catastrophic hemorrhage and significant damage to surrounding organs. We propose a step-by-step schema to evaluate cases of grade 3E disease and determine whether immediate hysterectomy or conservative management, including planned delayed hysterectomy, is the most appropriate treatment option. The approach includes evaluation in the antenatal period with ultrasound and magnetic resonance imaging to determine suspicion for placenta previa percreta with surrounding organ involvement, planned cesarean delivery with a multidisciplinary team including experienced pelvic surgeons such as a gynecologic oncologist, intra-operative assessment including gross surgical field exposure and examination, cystoscopy, and consideration of careful intra-operative transvaginal ultrasound to determine the extent of placental invasion into surrounding organs. This evaluation helps decide the safety of primary cesarean hysterectomy. If safely resectable, additional considerations include intra-operative use of uterine artery embolization combined with tranexamic acid injection in cases at high risk for pelvic hemorrhage and ureteral stent placement. Availability of resuscitative endovascular balloon occlusion of the aorta is ideal. If safe resection is concerned, conservative management including planned delayed hysterectomy at around 4 weeks from cesarean delivery in stable patients is recommended.

  • Surgery
  • Surgical Procedures, Operative

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  • KM, RNS and SM contributed equally.

  • Correction notice This article has been corrected since it was first published. A typographical error in the abstract has been corrected.

  • Contributors Conceptualization: KM, JDW. Data curation: KM, SM. Formal analysis: KM. Funding acquisition: LDR, KM. Investigation: all authors. Methodology: KM, JDW. Project administration: KM. Resources: KM, LDR. Supervision: KM, RA, SEH, JGO, LDR, JDW. Visualization: KM, SM. Writing - original draft: KM, RNS. Writing - review and editing: all authors.

  • Funding This study was funded by Ensign Endowment for Gynecologic Cancer Research (KM).

  • Competing interests JDW: research funding, Merck; royalty, UpToDate. SM: research funding, Merck. LDR: consulting, Cardiff Oncology, Nutcracker Therapeutics and AXDEV; participation in the Steering Committee for the Global Coalition of Adaptive Research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.