Frequently asked questions

No, placenta previa is not part of placenta accreta spectrum. In placenta previa, the placenta is low lying in the womb and covers the cervix. In placenta previa the placenta is normally attached to the lining of the womb and will separate naturally following delivery of the baby. The term “previa” refers only to the location of the placenta inside the womb and there is no attachment of the placenta into the womb. However, most women who have placenta accreta spectrum also have placenta previa (approximately 9 in 10 women).

Not all cases of PAS will be diagnosed during pregnancy. For some women, the diagnosis is only made either at the time of caesarean section or following a vaginal delivery, when the placenta does not separate from the lining of the womb.

Where a diagnosis of placenta accreta spectrum has been made, delivery of the baby will be by caesarean section.

In most cases, the baby will be delivered a number of weeks before the due date. Usually the birth is planned for between 34-36 weeks. In some cases, where a diagnosis of placenta accreta spectrum is made very early in the pregnancy, a plan for the birth before 30 weeks may be necessary. Approximately 80% of patients will have an elective (planned) delivery if a pre-term birth is planned. In some cases, an emergency birth is necessary. This occurs in approximately 20% of patients. The most common reason for an emergency delivery is if you start bleeding or going into labour before your scheduled delivery date.

A planned plan is safer for mother and baby as it reduces the risk of bleeding and experiencing complications.

Some women will be advised to stay in hospital for close observation and monitoring. This most commonly happens where there has been bleeding in the pregnancy.

There is currently no evidence to recommend that bed rest is necessary. Any advice to reduce from normal activities will be discussed on an individual case basis with the team providing care. Sexual intercourse can cause bleeding from the placenta and is not recommended once a diagnosis of placenta accreta spectrum has been made.

The options for pain relief include either a spinal anaesthetic or a full anaesthetic.

Spinal: an injection is given into the lower back which numbs the nerves from the waist down. This is similar to a routine caesarean section, and women will be awake to witness the birth of their baby. A chosen support partner can also be there at the time of the birth. Most women with placenta accreta will be given a combined spinal-epidural, as described above.

General anaesthetic: during a full anaesthetic the person is fully asleep for both the birth and any other surgery being done, such as a hysterectomy.

Arterial line: before the surgery is started, an arterial line will be placed in the woman’s wrist, as well as a number of other drips in the arm.

Central line: A central line is a long, thin, flexible tube placed in the neck through which medicines, fluids, or blood products can be given as well as blood tests taken. A central line may stay in for number of days, if required, and avoids the need to repeatedly use new needles to give medication and take blood tests.

Urinary Catheter: A tube will be placed in the bladder before surgery is started. This usually stays in until the woman is able to walk comfortably, however where a balder injury has occurred the catheter will need to stay for a number of days.

In placenta accreta spectrum, once the baby has been born, the placenta stays firmly attached to the womb and there is a high risk of bleeding if attempts are made to remove the placenta.

Therefore, often the safest option for severe placenta accreta (grade 3) is to remove the womb (hysterectomy) with the placenta to minimise the risk of blood loss.

Approximately 50% of patients will require a hysterectomy.

In some select cases other treatment options are available. These are called “uterine conserving surgery”:

1. myometrial resection – The placenta may have grown deeply into the lining of womb only in one small area. The rest of the placenta may not be stuck and is attached normally to the lining of the womb. In these cases, this small area of the womb can be removed along with the placenta and the womb left inside. In cases where this approach has been planned during the pregnancy, sometimes during surgery it does become necessary to remove the womb. This may be because the placenta is grown more deeply into the womb than expected from ultrasound or due to heavy bleeding. 
2. If the placenta starts to separate by itself, a gentle attempt to remove the placenta can be made. However, this is often associated with heavy bleeding and will only be attempted if the placenta starts to separate naturally.

“Conservative management”

In a few cases, there may be very little blood loss and the placenta can be left inside the womb, where it may absorb over a few months. This is called conservative management. However, this is not always successful, and many women will need a hysterectomy at a later date or experience serious complications. There is also a risk of heavy bleeding or developing an infection.

No, the ovaries will not be removed. If women have a hysterectomy, or are having uterine conservation but are finished their family, the fallopian tubes can be removed at the time of the surgery.

• Most women will need to be admitted to the high-dependency unit for close monitoring and observation for at least 24 hours. During this time, the woman will have a catheter in the bladder and may have a number of drips in the arms and neck.
• Where the surgery has been uncomplicated and the blood loss minimal, they may only need to spend 3-4 nights in hospital after the delivery.
• However, if there was a complication or heavy bleeding, intensive care admission may be necessary for closer monitoring.

• The baby will usually need admission to the special care unit for support with breathing and feeding. This means that mother and baby will be separated following delivery.
• Steroids will be given to the mother which help to mature the baby’s lungs.
• How long the baby spends in the special care unit will depend on how early the baby is born.

Yes it is possible to breastfeed after a hysterectomy. Breastfeeding can be challenging with a premature baby after major surgery and lactation support is available if requested.

• Iron supplementation if your iron level was low when going home from hospital
• To minimise the risk of developing a blood clot, it is recommended to wear compression stockings for 6 weeks and to take blood thinning injections as prescribed, usually for between 10 days to 6 weeks
• Your wound will take approximately 3-6 weeks to heal
• Regular pain relief is recommended after surgery in order to reduce break through pain
• Physiotherapy for pelvic floor function

Recovery time is different for each person. It may take at least 6 weeks for the wound to heal and post-surgery pain to resolve. However, for some women this may take longer. During the first 6 weeks driving is not recommended. 

• Women may have spent a long time in the hospital before their surgery, and may go home before their baby has been discharged from the special care unit, so this can be a very challenging time for women and their families
• Some women may suffer from depression, anxiety and post-traumatic stress disorder
• Where a hysterectomy has been performed, it will not be possible to have further pregnancies and this can create additional anxiety around loss of fertility
• Follow up and support services are available in the hospital and through the patient support group to address any ongoing concerns.