Controversies in the management of placenta accreta

Obstetric hemorrhage is one of the most common causes of maternal morbidity and mortality worldwide, and abnormal placentation, including placenta accreta, is currently the most common indication for peripartum hysterectomy. Prenatal identification of these cases and early referral to centers with the capability to manage them will likely result in improved outcomes. Interventions that may limit transfusion requirements include normovolemic hemodilution, selective embolization of pelvic vessels by interventional radiology, conservative management of accretism in a few selected cases, and the use of the cell saver intraoperatively. Current understanding of the mechanisms of acute coagulopathy has questioned the current transfusion guidelines, leading to a tendency to apply massive transfusion protocols based on hemostatic resuscitation. Prospective trials are required to validate the efficacy of this approach. Obstetricians should be familiar with current transfusion protocols, as the incidence of placental accretism is expected to increase in the future.