Morbidly Adherent Placenta Program
Highly specialized, highly experienced care for the treatment of placenta accreta, increta and percreta
Morbidly adherent placenta (MAP) is a rare but serious pregnancy complication in which the placenta grows deeply into the wall of the uterus and is unable to detach after childbirth. Known as placenta “accreta”, “increta” or “percreta” depending on the depth of invasion, these conditions lead to complex pregnancies and deliveries with the potential for life-threatening hemorrhage.
About Morbidly Adherent Placenta Program (MAP)
When a woman becomes pregnant, the placenta develops in the uterus, attaches itself to the uterine wall and begins providing nutrients and oxygen to the growing fetus through the umbilical cord. Known as the “afterbirth”, normally immediately after childbirth the placenta afterbirth detaches from the uterine wall and is pushed out through the birth canal in vaginal deliveries or through the cesarean incision.
In cases of morbidly adherent placenta, the blood vessels and other parts of the placenta grow too deeply into the uterine wall and become inseparable. Known as morbidly adherent placenta, the condition can be life-threatening, causing vaginal bleeding during the third trimester of pregnancy and severe hemorrhage after delivery.
There are several types of morbidly adherent placenta, depending on the severity:
- Placenta accreta – the placenta grows into the uterine lining
- Placenta increta – the placenta grows into the muscular wall of the uterus
- Placenta percreta – the placenta grows through the wall of the uterus and in some cases into adjacent organs, such as the bladder, colon, or nearby vessels
Are You at Risk?
While the exact cause of morbidly adherent placenta is unknown, factors that can increase the risk of developing these conditions include:
- Placenta previa – a condition in which the placenta covers part or all of the cervix, or sits in the lower portion of the uterus; a reported 75% of women with morbidly adherent placental conditions have placenta previa
- Prior cesarean delivery – studies show an estimated 66% of women with morbidly adherent placenta have had prior cesarean deliveries; the risk increases with increasing numbers of cesareans
- Prior uterine surgery – including myomectomy (removal of uterine fibroids) or D&C (dilation and curettage)
- In vitro fertilization (IVF) – many women requiring IVF have had other intrauterine procedures
- Advanced maternal age – defined as 35 years or older
- Uterine conditions that cause abnormalities in the lining of the uterus, such as fibroids
Prenatal Care – What to Expect During Your Pregnancy
While your care will be individualized based on your unique needs and pregnancy, prenatal care for morbidly adherent placenta patients typically includes:
- Basic recommended prenatal care
- Oral and/or IV iron supplements, for treatment of anemia prior to any expected blood loss
- Steroids to promote lung function in preterm babies
- Frequent prenatal visits compared to routine pregnancy
- Regular ultrasounds, every 3-4 weeks
- Consultations with your care team, most of which take place after admission
- The need to be in close proximity to the hospital as your planned delivery date approaches
- Admission at 33 weeks and delivery by 34-35 weeks, earlier if bleeding or contractions occur during pregnancy
- Treatment of coexisting maternal or neonatal conditions by the multidisciplinary team of specialists, to reduce the risk to both mother and baby
Our Approach to Treatment
Delivery is carefully timed to minimize the risk of bleeding for you and to minimize the impact of prematurity for your baby. Our patients are typically delivered 4-5 weeks ahead of their due date through a planned cesarean delivery, followed immediately by a hysterectomy.
In general, the safest way to manage morbidly adherent placentation is to deliver the baby by cesarean delivery that leaves the placenta untouched, and then to remove the uterus and cervix (total abdominal hysterectomy). The patient's ovaries are both left in place unless one or both need to be removed for safety (which only occurs about 10% of the time). The surgery that we usually perform is called a modified radical hysterectomy because we remove the uterus and cervix along with a small amount of the tissue that attaches the uterus to the pelvis. This is to ensure that placental tissue is not disturbed. This method reduces the potential for blood loss and has been shown to be very effective with our patients (Shamshirsaz et al 2014).
Patients often ask whether there is a more conservative approach that allows them to avoid hysterectomy. In select cases where the placenta is not low-lying (previa), and when a patient would prefer to retain her uterus, it may be possible to remove the part of the uterus where the placenta is attached and repair the remaining uterus. However, this option is rare and must be determined on a case-by-case basis. We would only offer this option to a patient who understands the risks and consents to a hysterectomy if at the time of surgery that is the safest approach.
One other management alternative that has been offered is that of performing a cesarean section, leaving the placenta inside and waiting for the placental tissue to become reabsorbed. Unless this is the only safe option available to us, we usually do not do this because of the risks associated with this approach, which include:
- Delayed life-threatening hemorrhage
- Prolonged treatment that may involve multiple procedures to drain purulent material
- High risk of delayed emergency hysterectomy
- High risk of infection and need for ICU care due to sepsis (severe infection)
- Recurrent morbidly adherent placenta and other complications in subsequent pregnancies
Research by our physicians
- Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach
- Ultrasound predictors of placental invasion: the Placenta Accreta Index
- Conservative management of morbidly adherent placenta: expert review
- Center of excellence for placenta accreta
For more information or to schedule an appointment, call the Department of Obstetrics and Gynecology at Baylor College of Medicine at 832-826-7500 (select Option 2, then 2).