Farah Amro, MD, discusses leaving the placenta in situ for patients with placenta accreta spectrum

A single-center retrospective cohort study presented by Farah Amro, MD, at the 2025 ACOG Annual Clinical and Scientific Meeting evaluated maternal outcomes when the placenta was left in situ for patients with placenta accreta spectrum (PAS). The study examined outcomes by both planned and final surgical management strategies, including uterine preservation and delayed hysterectomy.

Farah Amro, MD

Study overview and methodology

The study included patients with antenatal PAS diagnoses who were managed by leaving the placenta in situ between January 2015 and October 2024. At the presenting institution, patients were offered options beyond cesarean hysterectomy, including planned uterine preservation or delayed hysterectomy. Maternal outcomes assessed included infection, hemorrhage requiring hysterectomy, blood transfusion rates, and other serious maternal complications.

Out of 180 patients with PAS, 50 were initially planned for conservative management. Of those, 43 (86%) successfully underwent management by leaving the placenta in situ. Seven patients required immediate cesarean hysterectomy due to antepartum or intraoperative hemorrhage.

Clinical outcomes and final procedures

Among the 43 patients managed with the placenta left in situ, 5 (12%) experienced bleeding that necessitated hysterectomy, and 4 (9%) developed endometritis. There were no reported cases of venous thromboembolism or maternal death. Twenty-nine patients had been planned for uterine preservation, while 14 were scheduled for delayed hysterectomy.

Of the 29 patients planned for uterine preservation, 13 (45%) successfully retained their uterus. “Thirteen moms were able to preserve their uterus through this approach, and five of those 13 moms have gone on to get pregnant again, and all of the subsequent pregnancies have not had a placenta accreta,” said Amro.

In patients with successful uterine preservation, the median time to placental expulsion or resorption was 17 weeks. Sixteen patients (55%) ultimately required interval hysterectomy—9 due to clinical indications and 7 at the patient’s request.

Patients who underwent successful uterine preservation had better outcomes compared with those who eventually underwent interval hysterectomy, with lower estimated median blood loss (700 mL vs 1,950 mL, P<.01), lower transfusion rates (31% vs 73%, P<.01), and fewer cases of transfusion exceeding 4 units (8% vs 47%, P=.01).

However, when analyzed by the original surgical plan (planned uterine preservation vs planned delayed hysterectomy), there were no significant differences in blood loss or transfusion needs.

Patient selection and program criteria

Amro emphasized that these outcomes are contingent on careful patient selection. “Our criteria for selecting the appropriate patient to leave the placenta in is pretty strict, and it's for a good reason,” she said. Criteria include proximity to the hospital (within an hour), the ability to attend follow-up visits, reliable transportation, insurance coverage, and a strong support system.

“This can’t necessarily be translated and done everywhere in the United States,” Amro noted, highlighting the need for institutional infrastructure and multidisciplinary support. “We're a very large accreta program. We have a big infrastructure. We have very strict criteria for these patients that we manage this way.”

Implications and future directions

The study’s findings suggest that leaving the placenta in situ may be a viable alternative to cesarean hysterectomy for selected patients with PAS, particularly those desiring uterine preservation. “It is going to be definitely a conversation starter, hopefully into looking at other approaches to managing placenta accreta, other than performing a cesarean hysterectomy,” Amro said.

She added that future research, including national prospective trials, may further inform the safety and feasibility of conservative management strategies in PAS: “Maybe the goal would be to do a prospective trial nationally looking at these approaches for managing placenta accreta, other than just doing a cesarean hysterectomy.”

References:

1. Amro FH, et al. Leaving placenta in situ for management of placenta accreta spectrum disorder. Abstract. Presented at: ACOG Annual Clinical & Scientific Meeting; May 16-18, 2025; Minneapolis, Minnesota.

2. Amro FH, Hernandez-Andrade EA, Papanna R, et al. Leaving Placenta In Situ for Management of Placenta Accreta Spectrum Disorder. Obstetrics & Gynecology. April 24, 2025. doi:10.1097/AOG.0000000000005926.

Disclosure:

Amro reports no relevant disclosures.