Conservative management of placenta praevia with accreta

It has been advocated that placenta accreta/percreta should be managed conservatively to avoid massive pelvic bleeding and preserve fertility. Diagnosis of this condition with high-resolution imaging investigations performed during the antenatal period facilitates discussion of management plans with other clinical disciplines (eg interventional radiologists), the patient, and her family. Three cases of placenta praevia with accreta are presented. The three cases were managed by leaving the placenta in-utero after caesarean section, using uterine arterial embolisation to control postpartum haemorrhage only when needed. In all these cases, we succeeded in conserving the uterus without major complications. With improved imaging techniques, accurate antenatal diagnosis of placenta praevia with accreta is now possible. This new approach to conservative management can be considered in order to not only conserve the uterus but also to avoid uncontrolled pelvic haemorrhaging.

[Treatment of pregnancy in a previous caesarean section scar with uterine artery embolization: analysis of 60 cases]

OBJECTIVE

To evaluate the security and effectiveness of uterine artery embolization (UAE) in treatment of pregnancy in uterine caesarean scar compared with medicine treatment.

METHODS

Sixty patients with pregnancies in uterine caesarean scar were divided into medicine group (n = 31) that received intravenous injection of methotrexate (MTX) 100 mg once or MTX 20 mg once a day for 5 days as the first course, received the second course when the serum beta-human chorionic gonadotropin (HCG) decreased to the level as < 50%, and then underwent uterine curettage; and UAE group (n = 29) that underwent catheterization into the left uterine artery and then uterine curettage 48h after the successful embolization. The bleeding volume during suction curettage, side effects, admission day, and menstruation recover time were recorded.

RESULTS

The hospital stay of the UAE group was (14.4 +/- 1.67) days, significantly shorter than that of the medicine group [(39.3 +/- 4.71) days, P < 0.05]. No patient had to receive hysterectomy in the UAE group but 2 in the medicine group underwent hysterectomy. Seven patients showed liver dysfunction and 8 patients had nausea and slight vomit in the medicine group, and 15 patients with fever and 10 with light post-embolization syndromes were found in the UAE group. Menstruation resumed normal in all patients of the 2 groups one or two months later.

CONCLUSION

With the advantage of low risk of heavy bleeding and shorter admission day, UAE is safe and effective in treatment of pregnancy in uterine caesarean scar.

[Clinical analysis of 47 cases of placenta accreta in the second and third trimesters]

OBJECTIVE

To explore the clinical characters, diagnosis and treatment methods of placenta accreta.

METHODS

A retrospective analysis was made of 47 cases of placenta accreta admitted during May 1997 to May 2007 into Peking Union Medical College Hospital. They included 17 cases in the second trimester and 30 cases in the third.

RESULTS

Among all the patients, the incidence of placenta accreta was 0.262% (47/17 918). Most of these cases (81%, 38/47) experienced a uterine procedure. 30% (14/47) of the cases were found with placenta previa and 11% (5/47) with myoma in the current pregnancy. 11% (5/47) of all the cases suffered postpartum hemorrhage. In the 17 cases in the second trimester, 12 were diagnosed by ultrasonography and 5 by clinical evidence. While in the 30 cases in the third trimester, 8 were diagnosed by biopsy, 2 by ultrasonography, and 20 by clinical evidence. 45 cases were cured by conservative treatment, which included dilatation and curettage, uterine artery embolization (UAE) with or without methotrexate (MTX), tamping B-lynch suture, singly with MTX, and mifepristone. Only 2 cases received cesarean hysterectomy.

CONCLUSIONS

The incidence of placenta accreta seems on the rise. The incidence in the second trimester is higher than that in the third. In the second trimester, most cases can be diagnosed by ultrasonography after labor, and presently UAE is the best conservative management. While in the third trimester clinical evidence is the most frequent diagnostic approach. A majority of the cases could be cured by conservative therapies, which help them avoid a hysterectomy.