AutorInformation
Shila Chakre*, Himangi Warke**, N M Mayadeo ***, Sachin
Pardeshi*
(* Assistant Professor, ** Associate Professor, ***
Professor. Department of Obstetrics and Gynecology, Seth
G.S. Medical
College and K.E.M
Hospital , Mumbai , India
Abstract
Placenta
accreta is due to abnormal invasion of placenta.[1] It may lead to
morbidity and mortality following severe obstetrical hemorrhage. Its diagnosis
in the antenatal period and management is very important to prevent maternal
morbidity and mortality. The diagnosis is suspected after delivery if there is
no expulsion of the placenta. We report a case of clinically presumed placenta
accreta in a 29 years multiparous patient with previous cesarean delivery following
failed manual removal placenta. Conservative management with methotrexate was
done in a clinically stable patient desiring future fertility. However, ongoing
close observation is required to identify complications.
Introduction
Placenta accreta is an uncommon disorder of placentation due to invasion of chorionic villi into the myometrium. Histologically, it is due to poorly developed or absent decidua basalis. Placenta accreta is commonly
seen after cesarean delivery.[2] It is also associated with placenta
previa.[2] Antenatal diagnosis
can be made in patient with previous cesarean deliveries, placenta previa and
by doing ultrasonography (USG).[3] This could allow for predelivery
planning to reduce complications. But, diagnosis of placenta accreta is made
mostly postdelivery when there is failure of manual removal of the placenta.[4]
It results in severe postpartum hemorrhage and complications such as need
for transfusion of blood and blood products, DIC, acute renal failure,
infectious morbidities, adult respiratory distress syndrome, and compromised fertility.[3]
Mortality may be upto 7%.[5] In the past, hysterectomy was the mainstay of
treatment for placenta accreta. But with this, there is significant
perioperative risks and compromised future fertility.[5] For those
who wish to conserve their reproductive function, placenta can be left in situ
as an alternative strategy.[6] Adjuvant therapy with methotrexate
has also been used to expedite resorption of placental tissue.[4]
Though infective morbidity, hemorrhage and need for hysterectomy are there with
conservative management, it can be applied with case discretion.
Case
report
A 29
years old gravida three, para one, living one, abortion one with previous lower
segment cesarean section 4 years back
for meconium stained amniotic fluid was admitted at 37 weeks of gestation in
active labor. Her pelvis was adequate. Her antenatal profile was normal. On antenatal
USG, there was no placenta accreta or percreta. She delivered vaginally a 2.7
kg male baby with Apgar score of 9/10. After 1 hour of baby delivery, there
were no signs of placental separation. So manual removal of placenta was tried
but there was no cleavage plane between placenta and uterus. Hence the procedure
was abandoned. On USG there was no evidence of adherent placenta but clinical diagnosis
was adherent placenta. Umbilical cord was ligated and cut close to the cervical
os and placenta was left in situ.
MRI was
done on day 2. It was suggestive of retained product of conception, fundal
focal adherent placenta with rest of the placenta showing distinct plane with
uterine myometrium.
On day
2, Hb was 8.2 gm%. CBC was 8400/cmm. She was given 2 units of blood. A single
dose of 50 mg of methotrexate was given intramuscularly on day 2. She was
monitored in the ward for any signs of separation of placenta, fever, bleeding
and foul smelling discharge per vaginum. Serial ultrasounds for placental volume
and β-HCG were done. While in the ward, she gave history of passage of
placental bits per vaginum. She was discharged on day 22 and advised USG for
placental volume and after β HCG one month. Placenta was not seen on USG at 8
weeks with β-HCG report of <2.
Days after
delivery
|
USG for placental volume in ml
|
β HCG
(mIU/ml)
|
Day 2 to 4
|
280 to 300
|
6543
|
Day 7
|
270
|
3499
|
Day 14
|
250
|
1188
|
Day 21
|
215
|
763
|
After 8 weeks
|
Nil
|
<2
|
Discussion
Placenta
accreta occurs 1 in 533 deliveries and has been increasing largely due to the
global increase in caesarean deliveries and MTP’s.[7] Those are at high risk of developing placenta
accreta should be screened antenatally by USG and if required magnetic resonance
imaging.[1] Optimal management of placenta accreta remains unclear. Caesarean
hysterectomy is usually done if the diagnosis of placenta accreta is made antenatally.[8] Maternal morbidity such as loss of fertility, gastrointestinal or urinary tracts injuries,
infection, massive obstetrical
hemorrhage and its sequelae occurs with emergency postpartum hysterectomy.[4]
Several reports have described the conservative strategies. These include leaving the placenta in situ in hemodynamically
stable patients, replacing the blood loss by using blood and blood products, selective
arterial embolization and/or balloon occlusion, and uterine and/or hypopgastric
artery ligation and use of mehotrexate.[3]
Mehotrexate leads to necrosis and rapid removal of the
placenta.[9] But, there is a lack of consensus regarding optimal dosing,
frequency, or route of administration. In this particular case, a single dose
of 50 mg per m2 of body surface area was used. Some reports described
a half- life of serum β-HCG of 5.8 days in cases of retained placenta managed with
methotrexate.[10] Fever is a commonly reported complication.
Prophylactic use of broad-spectrum antibiotic therapy may reduce infectious
morbidity.[4] Vaginal bleeding may also occur for several months
following delivery. Though conservative management of placenta accreta can
successfully avoid hysterectomy in most cases, there is still risk of serious morbidity.
Intensive monitoring for complications is required in patients with retained
placenta.
References
1.
Hundley AF, Lee-Parritz A. Managing placenta
accreta. OBGY Management 2002;8:18-33.
2.
Miller DA, Chollet JA, Goodwin TM. Clinical risk
factors for placenta previa - placenta
accreta. Am J Obstet and Gynecol 1997;177(1):210-214.
3.
Oyelese Y, Smulian JC. Placenta previa,
placenta accreta, and vasa previa. Obstet Gynecol 2006;107(4):927-941.
4.
Timmermans S, Van Hof AC, Duvekot JJ. Conservative management of
abnormally invasive placentation. Obstet Gynecol Survey. 2007;62(8):529–539.
5.
Kayem G, Davy C, Goffinet F, Thomas C,
Clément D, Cabrol D. Conservative versus extirpative management in cases of
placenta accreta. Obstet
Gynecol 2004;104(3):531–536.
6.
Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after
conservative treatment of placenta accreta. Obstet Gynecol 2010;115(3):526–534.
7.
Wu S, Kocherginsky M, Hibbard JU.
Abnormal placentation: twenty-year analysis. Am JObstet Gynecol 2005;192(5):1458–1461.
8.
Rossi AC, Lee RH, Chmait RH. Emergency postpartum hysterectomy for
uncontrolled postpartum bleeding: a systematic review. Obstet Gynecol 2010;115(3):637–644..
9.
Arulkumaran S, Ng CSA, Ingemarsson I, Ratnam SS. Medical treatment
of placenta accreta with methotrexate. Acta Obstet Gynecol Scandinavica.
1986;65(3):285–286.
10. Silver LE, Hobel CJ, Lagasse
L, Luttrull JW, Platt LD. Placenta previa percreta with bladder
involvement: new considerations and review of the literature. Ultrasound in Obstetrics and Gynecology.
1997;9(2):131–138.
Citation
Chakre S, Warke H, Mayadeo
NM