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CONSERVATIVE MANAGEMENT OF PLACENTA ACCRETA,ITS OUTCOME ON FERTILITY AND SUBSEQUENT PREGNANCY – CASE REPORT

Dr.Reshmi S Nair, DGO, DNBConsultant

Vijayalakshmi Medical Centre Kochi

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GlimpsesTest Cases & Its Detailed AnalysisPlacenta Accreta - DiscussionRoadmap to Successful Subsequent

PregnancyConclusion & Take Away Message

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Case-126yr, P1L1A1, FTND in peripheral hospital, referred

with retained adherent placenta.h/o D&C - missed abortion, 1yr back .ANC uneventful.Baby had complex heart disease- and died on D-20

post surgery.She was hemodynamically stable.A decision for conservative expectant management was taken on grounds: Baby had remote chance of long term survival. She had no other living child. They were willing for expectant management. She was stable.

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Post natal day – 2. βhCG -1562mIU/ml Hb-10.5gm% TC-11500, CRP- 8.

USS :- placenta increta invading posterior uterine myometrium [9.7x4.5x5.8cm].

MRI – heterogenous mass 10.2x5x4.5cm in the region of posterior wall of uterus. Lesion is partially invading myometrium – Placenta increta.

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MonitoringMonitored with USS and βhCG on day 2 & day 3, and

then weekly.Antibiotics (cefixime and metrogyl) × 4 days. Uterotonics

(Pitocin and PGF2ɑ).Discharged on post natal D - 6.Beta HCG

–856mIU/ml→542→258→110→69→18→8→0.2mIU/ml.Hb., TC & CRP checked at each visit for evidence of

infection.USS- showed involuting uterus, with placental lobe

shrinking and no vascularity.Expelled placental lobe on day-116, which was sent for

HPE & confirmed diagnosis.

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Future FertilityShe conceived spontaneously 1yr later. 2nd trimester MS-AFP was 1.5MoM.Placenta was posterior with no evidence of

myometrial invasion by USS. No antenatal complications .LSCS done at 39weeks for breech and previous

increta. She again conceived 2yr later.MS- AFP-0.97MoM in 2nd trimester, placenta

anterior & no recurrence of placenta accreta.LSCS done at 39wks.Both babies alive and healthy.

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Case 225yr old G2P1L1, booking visit at 33w.

Had spontaneous onset of labour at 38w.

FTND normally of a baby of 3.35kg.

Expelled placenta with membranes. It looked incomplete.

A bedside USG confirmed a lobar adherent placenta.

There was no active uterine bleeding, she was hemodynamically stable and wanted to preserve her fertility.

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USS- heterogenous placental mass 8x5 cm at fundus with thinning of myometrium at postero-superior aspect.

MRI- heterogenous placental mass 8x5x6.5cm at fundus towards left side with focal myometrial invasion [1cm] and underlying thinning in postero-superior aspect – placenta increta.

Managed with prophylactic antibiotics, & discharged on postnatal day 6.

Monitored with USS, βhcg,TC, CRP weekly and expelled placenta on day 26 which was sent for HPE and confirmed.

She conceived spontaneously 3yr later and is now uneventful 24weeks pregnant.

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Case 3 25yr old primi, booking visit at 36wks, had leaking p/v at

39wks and delivered normally a 2.12kg baby. Placenta did not separate spontaneously and manual

removal of placenta [piecemeal] was done ↓SAB. Bleeding was WNL. USS done to check completeness showed a hypo-intense

mass at fundus 6x5cm. MRI –heterogenous mass 8x5x7cm in the region of fundus

of uterus extending to cornual region. Lesion is partially invading myometrium – placenta increta.

Patient was keen to conserve her uterus and there was no active uterine bleeding. Managed expectantly as cases before.

She expelled the placental lobe on 58th day. She has one more child conceived spontaneously in another country.

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Discussion

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Placenta AccretaPlacenta accreta is an

uncommon but potentially lethal complication of pregnancy.

Occurs when the placenta is abnormally adherent to the uterine myometrium as a result of partial or complete absence of the decidua basalis and Nitabuch’s layer

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The incidence of placenta accreta ranges from 1 : 2500 to 1 : 533 births , with a tenfold increase reported over the last 50 years

Risk factors include placenta previa, ashermans syndrome, existence of prior Caesarean & hysterotomy scar and advanced maternal age or parity.

MRI combined with USS has a sensitivity of 100% in identifying placenta accreta.

Almost 50% of all cases of placenta accreta are diagnosed antepartum.

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Diagnostic Methods Ultrasound criteria for diagnosis Greyscale:● loss of the retroplacental sonolucent zone.● irregular retroplacental sonolucent zone.● thinning or disruption of the hyperechoic serosa–bladder interface.● presence of focal exophytic masses invading the urinary bladder.● abnormal placental lacunae.Colour Doppler:● diffuse or focal lacunar flow.● vascular lakes with turbulent flow. ● hypervascularity of serosa–bladder interface, markedly dilated vessels over peripheral subplacental zone.

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Placental Lacunae The presence and increasing number of lacunae within the placenta at

15–20 weeks of gestation - the most predictive USS signs of placenta accreta, [sensitivity of 79% and a positive predictive value of 92% ]. These lacunae may result in the placenta having a “moth-eaten” or “Swiss cheese” appearance

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MRIuterine bulging heterogeneous signal intensity within

the placenta dark intraplacental bands on T2-

weighted imaging

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Biochemical Markers

AFP > 2.5 MoM in second trimester.

Leakage of foetal alpha-fetoprotein into the mother’s circulation.

Up to 45% of women with placenta accreta have

elevated MSAFP levels in the absence of an obvious causes

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Managing Options for Morbidly Adherent Placenta

Caesarean hysterectomy

Extirpative approach [forced manual removal of the placenta in an attempt to obtain an empty uterus]

Conservative approaches –Medical.Uterine artery embolization Expectant [when vascularity is no longer present on

ultrasound examination of the placenta].

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Conservative management shall be considered...

only when the patient wishes to preserve her fertility.

when no active uterine bleeding is present.

Adequate discussion of the potential risks and benefits also is crucial

Conservative Management

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At the time of delivery, the cord and membranes should be ligated as high as possible.

Broad-spectrum antibiotics, for prophylaxis and

oxytocin should be administered during the initial 72 hours.

Ultrasound should be performed daily to monitor involution and placental vascularity, which should decrease over time.

Conservative Management

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Medical ManagementMethotrexate (1 mg/kg) on alternate days

administered when -

hCG levels plateauplacental vascularity persistsor placental involution fails after the initial 72-hour

period.

Controversy- After delivery, the trophoblasts are no longer dividing, thereby rendering methotrexate ineffective

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Follow Up AfterConservative Management

During the postpartum period, all patients are seen weekly until complete resorption of the placenta.[may take-6 months]

Ultrasonography and clinical examination are performed to detect hemorrhage, pain or signs of infection.

C-reactive protein and blood counts are checked to help choose antibiotics in case of endometritis.

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RCOG guidelinesThe woman should be warned of the risks of

bleeding and infection postoperatively.

Prophylactic antibiotics may be helpful in the immediate postpartum period to reduce the risk of infection.

Neither methotrexate nor arterial embolisation reduces these risks and neither is recommended routinely.

Measuring serum βhCG on a weekly basis to check its falls can reassure, but low levels do not guarantee complete placental resolution and so this should be supplemented by imaging.

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Advantages Preserve fertility[success

rate -78%] Avoid gravid

hysterectomy associated with mortality rate of 7.4%, 90% incidence of transfusion, 28%

incidence of postoperative infection,

5% incidence of ureteral injuries or fistula formation

Failure rate –18% infection – 18% Bleeding- 35%Disseminated

intravascular coagultion-7%.

Unpredictable - may need hysterectomy.

Disadvantages

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Subsequent PregnancyRecurrence of placenta accreta-16-28%.

Blood transfusion -90%.

Fistula -3.3%.

Uterine rupture-3.3%.

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ConclusionPlacenta Accreta - usually managed with Caesarean

hysterectomy. Conservative Mx is an option for patients who are

properly counselled and motivated, particularly, for who want the option of a future pregnancy and who agree close follow-up.

Adequate discussion of potential risk and benefit is crucial.

There is increased risk of sudden hemorrhage, infection and emergency surgery.

Successful conservative treatment for placenta accreta does not appear to compromise the subsequent fertility or obstetrical outcome.

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