Conservative Management of Placenta Accreta

Explanation

A placenta that will not separate and cannot be removed manually indicates placenta accreta spectrum, in which trophoblast invades through a deficient decidua basalis into the myometrium. Definitive treatment is cesarean or peripartum hysterectomy, but when fertility preservation is the priority the placenta may be left in situ with the cord ligated, sometimes with adjuvant methotrexate, and followed with serial beta-hCG and ultrasound while the tissue resorbs. Retained devitalised placental tissue in a uterus that communicates with the vaginal flora is an excellent culture medium, so endometritis and pelvic sepsis are the most frequent complication of this conservative approach, reported in a substantial minority of cases and occasionally progressing to septic shock requiring emergency hysterectomy. Delayed secondary hemorrhage is the other major hazard, sometimes weeks later as the placenta separates. Patients therefore need close surveillance, prompt antibiotics for fever or foul lochia, and a clear plan for urgent hysterectomy if sepsis or hemorrhage supervenes. Amniotic fluid embolism is an acute intrapartum or immediate postpartum catastrophe unrelated to retained placenta management. Uterine inversion is caused by traction on the cord with a fundal placenta and presents immediately. Methotrexate at these doses rarely causes hepatic failure, and its efficacy in accreta is itself doubtful because the postpartum placenta has little dividing trophoblast.

Why each option

A.

Correct. Retained necrotic placental tissue in a uterus open to vaginal flora predisposes strongly to endometritis and pelvic sepsis.

B.

Amniotic fluid embolism is an abrupt intrapartum or immediate postpartum event and is unrelated to leaving the placenta in situ.

C.

Uterine inversion follows cord traction on a fundal placenta and appears immediately at delivery, not during expectant management.

D.

Single-agent methotrexate at obstetric doses rarely causes hepatic failure, and its benefit in accreta is unproven.

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