The Quintessential High-Risk Triad: Advanced Management Strategies for Placenta Accreta Spectrum in Patients with Advanced Maternal Age and IVF Conception

Background: The convergence of Advanced Maternal Age (AMA ≥35), In Vitro Fertilization (IVF) conception, and Placenta Accreta Spectrum (PAS) disorders represents a clinical nexus of extreme obstetric risk, characterized by a high probability of massive peripartum hemorrhage (MPH). This triad necessitates a paradigm shift from reactive to proactive, protocol-driven management. Case presentation: A 54-year-old G4P2 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. An emergency classical cesarean hysterectomy with partial cystectomy 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. Conclusions: This case exemplifies the synergistic pathophysiology and amplified morbidity of the AMA/IVF/PAS triad. Effective management mandates: 1) Aggressive prenatal diagnosis with early MRI; 2) Mandatory delivery at a Level IV center with a pre-assembled, multidisciplinary team; and 3) Implementation of a proactive Patient Blood Management plan. We propose a structured clinical pathway and standardized referral algorithm to optimize outcomes for this uniquely high-risk population.