The quintessential high-risk profile: advanced management strategies for placenta accreta spectrum in patients with...

The convergence of Advanced Maternal Age (AMA ≥ 35), In Vitro Fertilization (IVF) conception, and Placenta Accreta Spectrum (PAS) represents a clinical nexus of potentially elevated obstetric risk, hypothetically associated with a high probability of massive peripartum hemorrhage (MPH). Based on limited observational evidence, this case-based narrative review hypothesizes that this risk profile warrants protocol-driven management considerations, which are presented as hypothesis-generating rather than definitive.

A 54-year-old gravida 4, para 2 (2 living children) with an IVF-conceived twin pregnancy and two prior cesarean deliveries presented at 34 1/7 weeks with catastrophic hemorrhage. Prenatal MRI confirmed placenta percreta. During a planned, coordinated admission for delivery, the patient experienced acute hemorrhage, prompting an emergency classical cesarean hysterectomy with partial cystectomy. This was performed by a multidisciplinary team employing a comprehensive hemostatic strategy including prophylactic arterial balloon occlusion, tranexamic acid, intraoperative cell salvage, and a massive transfusion protocol. Estimated blood loss was 4,500 mL. Both neonates required NICU admission but were discharged in stable condition.

Based on this single case and the available observational literature (summarized in Supplementary Tables S1-S7), we hypothesize that this case exemplifies a potential the compounded pathophysiology that may amplify morbidity in the AMA/IVF/prior uterine scar risk profile. While the management principles discussed are derived from limited evidence and should be considered hypothesis-generating, they may inform care for similar high-risk patients. We suggest that effective management may include: 1)Aggressive prenatal diagnosis with early MRI where available; 2) Consideration of delivery at a Level IV center with a multidisciplinary team; and 3) Implementation of a proactive Patient Blood Management plan. These suggestions derive from limited evidence and require prospective validation.