Navigating the complexities of managing placenta accreta spectrum: A case series and literature review

Placenta accreta spectrum (PAS) poses a significant risk for maternal morbidity and mortality. There is a global rise in incidence of PAS in tandem with an increase in rates of cesarian section. Previous cesarian section and presence of placenta previa are two independent risk factors for development of PAS. Other risk factors are dilatation and curettage, endometrial ablation, and hysteroscopy. Ultrasound and magnetic resonance imaging are useful in prenatal diagnosis, antenatal follow-up, and pre-operative planning. Patient care is individualized to optimize outcomes with appropriate preoperative counseling. However, a significant number of cases remain undiagnosed and are incidentally discovered during cesarian section or management for retained placenta. Patients may suffer significant morbidity such as postpartum hemorrhage, massive blood transfusion, injury to pelvic viscera, hysterectomy, acute kidney infection, and even death. Cesarean hysterectomy is the mainstay of treatment. In selected cases, conservative management may be offered. This includes leaving the placenta in situ with interval resolution, manual removal, application of compression sutures and balloon tamponade, myometrial resection with repair, and the triple P procedure. In this series, we present seven patients with PAS managed at a tertiary teaching and referral hospital in Kenya. We highlight and discuss their antenatal presentation, intraoperative findings, management and the postoperative course. Early diagnosis, involvement of multidisciplinary team, and good preoperative planning are key to achieving a good outcome. Patients with PAS should be managed in facilities with sufficient resources, skilled personnel to manage complications arising from treatment such as need for massive transfusion, and intensive care.