Conservative management of morbidly adherant placenta – A case report and review of literature

Managing Placenta Accreta Spectrum: A case report on combining conservative care with uterine angioembolization

INTRODUCTION

Placenta Accreta Spectrum (PAS) stands out as one of the most significant complications in pregnancy, capable of causing maternal morbidity and mortality.

PRESENTATION OF CASE

In this report, we aim to discuss a case involving unsatisfactory conservative care coupled with uterine angioembolization, resulting in multiple hospitalizations due to placental infection and eventual hysterectomy.

DISCUSSION

Both conservative and non-conservative approaches have been utilized to mitigate maternal complications and mortality associated with Placenta Accreta Syndrome. While uterus-preserving methods play a crucial role, leaving the placenta in situ can lead to numerous severe long-term complications. Previous Research highlights the limitations of conservative management in the case of placenta accreta, necessitating careful patient selection due to potential morbidity and the risk of secondary hysterectomy.

CONCLUSION

invasive placentation poses challenges in obstetrics, presenting a risk of severe maternal morbidity and mortality. Conservative management poses limitations and risks, emphasizing the need for further research and evidence-based guidelines to enhance the management of PAS.

Comprehensive management of Jehovah's Witness in pregnancy

Jehovah's Witness (JW) is a denomination of Christianity which has many-fold higher morbidity and mortality compared to the general population as they refuse blood transfusion. Information is scanty regarding guidelines on the optimal approach to pregnant ladies of JW faith. In this review we have attempted to analyse the ways and techniques available which can be used to reduce the morbidity and mortality of these women. In antenatal care, haematological status can be optimised to reduce modifiable risk factors, namely anaemia by parenteral iron therapy from the second trimester onwards especially in patients who do not respond to oral iron therapy. In severe cases, erythropoietin serves as an effective alternative to blood transfusion. During the intrapartum period, using antifibrinolytics, cell salvage, bloodless surgical techniques, and uterine cooling for patients undergoing caesarean delivery have been proven effective. To conclude, complications of pregnant JW patients may be reduced if they comply with the preventives and targeted monitoring during the various phases of pregnancy. Further studies are warranted as this population exists as a minor group but is growing worldwide.

KEY MESSAGES

CURRENT RESEARCH QUESTIONS

The modified radical peripartum cesarean hysterectomy (Soleymani-Alazzam-Collins technique): a systematic, safe procedure for the management of severe placenta accreta spectrum

BACKGROUND

The prevalence of placenta accreta spectrum is rising worldwide. The severe end of the spectrum where the placenta has invaded other organs is fortunately rare, however, few surgical techniques for such a complex hysterectomy have been described in the literature.

OBJECTIVE

This study aimed to describe a stepwise, systematic technique for radical cesarean hysterectomy for placenta accreta spectrum to investigate outcomes for women with severe, invasive placenta accreta spectrum who were hysterectomized using this technique.

STUDY DESIGN

This was a retrospective cohort study undertaken at a large UK tertiary referral center. A total of 24 cases of elective primary cesarean hysterectomy with a confirmed intrapartum diagnosis of severe percreta (Federation of Gynecology and Obstetrics grades 3b and 3c) were identified between 2011 and 2020. Among those cases, 16 had standard care (surgical technique dependent on surgeon's preference), and 8 had a radical peripartum hysterectomy using the Soleymani-Alazzam-Collins technique as described. Nonparametric testing was used because of sample size.

RESULTS

The Soleymani-Alazzam-Collins technique resulted in significantly less blood loss (P=.032), more transverse incisions (P=.009), and less intensive care unit admissions (P=.046). Furthermore, there was no significant difference in theater time.

CONCLUSION

The Soleymani-Alazzam-Collins technique demonstrated a significant improvement in outcomes for women with severe placenta accreta spectrum, without increasing surgical time.

Conservative approach: Intentional retention of the placenta

Intentional retention of the placenta (IRP), or 'conservative' treatment or management, entails opening the uterus, delivering the baby, tying and cutting the umbilical cord at its placental insertion site, leaving the placenta in the uterus and waiting for its complete spontaneous resorption in women with placenta accreta spectrum (PAS). The uterine preservation rate with this approach is about 78%, and severe maternal morbidity about 6%; these rates are respectively lower and higher in subgroups of women with placenta percreta. IRP has become a recommended option for women with PAS reluctant to undergo caesarean-hysterectomy and wanting to preserve their fertility, after appropriate information about the uterine preservation rate, but also the risk of a subsequent emergency hysterectomy due to unpredictable haemorrhage and/or infection, and the need for follow-up with regular visits for several months. Some authorities also recommend IRP when hysterectomy is at very high risk of surgical complications.

Prophylactic intraoperative uterine or internal iliac artery embolization in planned cesarean for pernicious placenta previa in the third trimester of pregnancy: An observational Study (STROBE compliant)

The aim of this study was to evaluate the efficacy and safety of prophylactic intraoperative bilateral uterine or internal iliac artery embolization in planned cesarean for pernicious placenta previa in the third trimester of pregnancy.The patients with pernicious placenta previa were retrospectively included from January 2011 to May 2018, being divided into embolization group and control group. Intraoperative uterine artery embolization (UAE) or internal iliac artery embolization (IIAE) was undertaken to stop intrapartum and postpartum hemorrhage in embolization group.There were no significant differences on age, pregnancy times, gestational age, neonatal weight, neonatal asphyxia, prenatal bleeding, placental implantation, and mortality between embolization group and control group (P > .05). The amount of intraoperative and postoperative bleeding in embolization group was significantly greater than that in control group (P < .05). However, the hysterectomy rate in the embolization group was significantly lower than that in the control group (P < .05). Two (6.25%, 2/32) cases had undergone the second time embolotherapy after 8 hours of cesarean surgery because of severe vaginal bleeding. One case (3.13%, 1/32) died of diffuse intravascular coagulation because of hemorrhagic shock in embolization group. Transient and self-remitted lumbosacral pain was present in 28 (95%, 28/32) patients and no other severe interventional complications were reported in embolization group. All babies in 2 groups were healthy at half to 5 years' follow-up.The prophylactic intraoperative embolization of bilateral UAE or IIAE may be an effective strategy to treat intractable peripartum hemorrhage and preserve the fertility in patients with pernicious placenta previa.

Conservative Management of Placenta Accreta Spectrum

The purpose of this review was to assist obstetricians and gynecologists in considering the most appropriate conservative treatment option to manage women with placenta accreta spectrum according to their individual need and local expertise of the heath care team. The issue is challenging, as the quality of evidence with regard to efficacy is poor, and is mainly based on retrospective studies with limited sample size.

Infectious complications in morbidly adherent placenta treated with leaving placenta in situ: a cohort series and suggested approach. J Matern Fetal Neonatal Med 2018;32:3520-3525. [PMID: 29671364 DOI: 10.1080/14767058.2018.1465918]

Background: The aim of this study is to assess the clinical and microbiological features of infections in patients with morbidly adherent placenta (MAP) treated by leaving placenta in situ (LPIS). Materials and methods: Retrospective analysis of MAP cases who were treated by LPIS between 2 May 2010 and 15 March 2017. The inclusion criteria were gestational age at or above 24 weeks, prenatal diagnosis, elective operation, and complete data. Results: Nineteen MAP cases were treated by LPIS during the study period. The mean ± SD duration for total placental resorbtion was 145 ± 47 days. Three patients were readmitted to the hospital because of fever (3/19). A total of 65 culture samples were taken from the patients during their follow- up periods. In four cases (4/12) cervical cultures showed positive growth [Escherichia coli (2), Klebsiella pneumoniae (1), mixed culture with Enterococcus spp. and E. coli (1)]. Fifteen (15/26) urine samples were sterile, three were polymicrobial. In eight cases, urine culture revealed E. coli growth (one E. coli and Enterococcus spp.). Three out of 16 (3/16) surgical incision samples revealed growth of E. coli. No bacterial growth was detected in blood cultures. Susceptibility results of Gram-negatives indicate that the resistance rates of beta-lactam antibiotics are high (14/20, 70%). No secondary surgical intervention occurred during the study period due to infection. Conclusions: Majority of postpartum cervical discharge, fever, and increased CRP levels do not represent morbid infections and/or sepsis. With early detection, and implementation of antibiotherapy (combination of an aminoglycoside and clindamycin), they can be easily controlled and secondary surgical interventions can be prevented.

Safety and efficacy of preoperative abdominal Aortic balloon occlusion in placenta increta and/or percreta

BACKGROUND

With the increase of cesarean deliveries globally, the incidence of placenta adhesive disorder has been on the rise greatly which is associated closely with maternal and infant morbidity and mortality. We sought to investigate the safety and efficacy of preoperative transfemoral balloon occlusion of abdominal aorta in cesarean section of women with placenta increta or percreta.

METHODS

We conducted a retrospective study of 31 patients with placenta increta or percreta diagnosed by ultrasound and/or magnetic resonance imaging. The observation group included 19 patients who received transfemoral abdominal aorta balloon occlusion for preoperative prophylaxis, while the other 12 patients in the control group did not receive any preoperative interventional managements. Clinical outcomes were compared between the two groups.

RESULTS

Patients in observation group had significantly less estimated blood loss during surgery than those in control group (1.2 L versus 3.15 L, P = 0.006). The average transfusion volume of the observation group was significantly lower than the control group (0.8 L versus 1.95 L, P = 0.017). Seventy-nine percent (15 of 19) patients in the observation group and 50% (6 of 12) in the control group had their uterus successfully retained (P = 0.093). No peripheral tissues including bladder, ureter, and bowel were injured in all patients. Neonatal weight and Apgar scores of 1 min and 5 min had no statistical difference (P = 0.513 and P = 1, respectively) between the two groups. The mean radiation exposure time of fetus in the observation group was 22.68 ± 8.07 s and mean radiation exposure dose was 4.20 ± 1.49 mGy. Both operation time and postoperative hospital stay had no statistical difference between the two groups (2 versus 2.75 h, P = 0.063; 7.0 versus 6.5 d, P = 0.846). No patients had long-term complications after 6-8 wk follow-up.

CONCLUSIONS

Application of preoperative transfemoral abdominal aorta balloon occlusion during cesarean section is a safe and effective strategy for patients with placenta increta and/or percreta. It could reduce intraoperative blood loss and enhance the possibility of uterus preservation and ensure the safety of life from severe complications.

Uterine Artery Embolization for Management of Primary Postpartum Hemorrhage Associated with Placenta Accreta

Objective To evaluate the efficacy and safety of uterine artery embolization (UAE) in the management of primary postpartum hemorrhage associated with placenta accreta. Methods We retrospectively reviewed the medical records of patients with placenta accreta between January 2010 and August 2014. Totally 18 women (mean age 30.8±4.2 years) of primary massive postpartum hemorrhage with diagnosis of placenta accrete received treatment of UAE after delivery. Images of DSA and medical records were reviewed. Technical success was defined as control of bleeding after embolization. The complications, control of hemorrhage and recurrent bleeding of the placenta left inside the uterus were retrospectively collected for assessment. Results All patients underwent transcatheter embolization of bilateral uterine arteries. The technical success rate of embolization was 100%. Bleeding was controlled in 17 of 18 patients (94%) during follow-up period (median 18 months, 3-31months) without further bleeding recurred. One patient with placenta percreta undertook an emergent hysterectomy along with surgical bladder repair after UAE because of persistent uterine bleeding. Eight patients had postembolization syndrome and no other complications occurred. Conclusion Uterine artery embolization is an effective and safe treatment for the management of primary postpartum massive hemorrhage associated with placenta accreta.

Macroscopic Hematuria due to Placenta Percreta: Report of Two Cases and Short Review

Herein we present two cases of pregnant women with placenta percreta and severe hematuria during the 24th and 35th weeks of pregnancy, respectively. A timely sonographic diagnosis was feasible in the first case and cesarean section was performed during the 29th week. During the operation, the placenta was invading the bladder wall and concomitant hysterectomy with cystotomy and bladder wall reconstruction was performed. The second case presented in our emergency department with vaginal bleeding during the 35th weeks of pregnancy. She underwent an emergency cesarean section with uterine preservation, cystotomy, and bladder reconstruction.

Management of Abnormal Placenta Implantation with Methotrexate: A Review of Published Data

Abnormally invasive placenta is characterized by direct attachment of chorionic villi to the uterine wall. This adherent placenta traditionally has been managed by peripartum hysterectomy. Nowadays, there is a lot of interest toward gradual shift from traditional management of invasive placentation to conservative ones leaving the placenta in situ to avoid the surgical morbidity of hysterectomy and loss of future fertility. Administration of methotrexate (MTX), as an adjunctive antimetabolite drug, resulted in conflicting data during conservative management of abnormal placentation. This review assessed all published data on efficacy and safety of MTX therapy as conservative management of invasive placentation. Fifty-three articles including one prospective cohort study, 2 retrospective cohort studies, 10 case series and 40 case reports were identified. Conservative management has beneficial effects on the avoidance of major surgery with the consequent morbidity and the preservation of future fertility. Infection and vaginal bleeding were main complications of MTX therapy. Although MTX therapy may result in accelerated involution or expulsion of placenta and has some beneficial effects on hemorrhagic events, but there is not enough evidence on its efficacy and safety to recommend its routine uses in all cases of invasive placenta.

Placenta accreta spectrum: accreta, increta, and percreta

Placenta accreta can lead to hemorrhage, resulting in hysterectomy, blood transfusion, multiple organ failure, and death. Accreta has been increasing steadily in incidence owing to an increase in the cesarean delivery rate. Major risk factors are placenta previa in women with prior cesarean deliveries. Obstetric ultrasonography can be used to diagnose placenta accreta antenatally, which allows for scheduled delivery in a multidisciplinary center of excellence for accreta. Controversies exist regarding optimal management, including optimal timing of delivery, surgical approach, use of adjunctive measures, and conservative (uterine-sparing) therapy. We review the definition, risk factors, diagnosis, management, and controversies regarding placenta accreta.

Management of two placenta percreta cases

Placental invasion anomalies are divided into three according to invasion of uterine wall as placenta accreta, increta and percreta. In placenta percreta, the most severe but the least common form, the placenta invades the full thickness of the uterine wall and also it can attach to adjacent organs in the abdomen like the bladder and rectum. It is a potentially life treating condition. There is no recommended management strategy for placenta percreta. We herein report two cases managed differently and discuss the management options in the light of the literature.

Morbidly Adherent Placenta: Interprofessional Management Strategies for the Intrapartum Period

"Morbidly adherent placenta" is a term that describes the continuum of placenta accreta, increta, and percreta. The incidence of this type of abnormal placentation has increased significantly over recent decades. The reason is probably multifactorial but, partly, because of factors such as the increasing number of cesarean births. Women at greatest risk are those who have myometrial damage caused by a previous cesarean birth, with either anterior or posterior placenta previa overlying the uterine scar. This condition poses significant risks of morbidity and/or mortality to the pregnant woman and her fetus. A multidisciplinary approach to care throughout pregnancy is essential. This article describes the classification of morbidly adherent placenta, risk factors, methods of diagnosis, potential maternal and fetal complications, and intrapartum clinical management strategies to optimize outcomes.

Preservation of fertility and subsequent childbirth after methotrexate treatment of placenta percreta: a case report

Introduction

Placenta percreta is associated with maternal morbidity and mortality. A hysterectomy is often needed to control the bleeding in such cases. However, it has been advocated that placenta percreta be managed conservatively to avoid massive pelvic bleeding and to preserve the patient’s fertility. Here, we present a case of placenta percreta diagnosed by magnetic resonance imaging, and treated with systemic administration of methotrexate.

Case presentation

A 27-year-old nulliparous Japanese woman at 39 gestational weeks had an uncomplicated vaginal delivery of a 3244-g infant. However, her placenta was not delivered, and we could not remove it manually. Contrast-enhanced magnetic resonance imaging indicated deep myometrial invasion by placental tissue and the whole placenta was strongly enhanced. Seven days post-partum, her serum human chorionic gonadotropin level was 12,656IU/L. Our patient hoped to preserve her uterus for a future pregnancy. She therefore received 13 courses of methotrexate (50mg/week, intravenous injection). Her serum human chorionic gonadotropin level was undetectable 97 days after the first methotrexate injection. At 117 days post-partum, she had a labor-like pain every three minutes and delivered the placenta. Our patient regained normal menses and at follow-up remained in good health. Two years later, she delivered a healthy daughter.

Conclusion

We should try to detect placenta percreta in high-risk patients by any means. For low-risk patients, we should give a diagnosis swiftly and control any intrauterine infection and massive bleeding.

Placenta Accreta and Total Placenta Previa in the 19th Week of Pregnancy

Placentation disorders are the result of impaired embedding of the placenta in the endometrium. The prevalence of these disorders is estimated to be around 0.3 %. A history of previous prior uterine surgery (especially cesarean section and curettage) is the most common risk factor. Impaired placentation is differentiated into deep placental attachment; marginal, partial and total placenta previa; and placenta accreta, increta and percreta. Treatment depends on the severity of presentation and ranges from expectant management to emergency hysterectomy. In most cases, preterm termination of pregnancy is necessary. We report here on the case of a 39-year-old woman with placenta accreta and total placenta previa who underwent hysterectomy in the 19th week of pregnancy.

Maternal outcome after conservative management of placenta percreta at caesarean section: a report of three cases and a review of the literature

Retaining the placenta in situ at caesarean section for placenta percreta and awaiting placental reabsorption is widely practiced; however, there is limited evidence on the efficacy and complications of this strategy. We present three cases of placenta percreta managed conservatively and note that all three women experienced significant complications. A review of the literature showed that despite initial conservative management, 40% of women subsequently require emergency hysterectomy and 42% will experience major morbidity.