Placenta previa percreta left in situ - management by delayed hysterectomy: a case report
© Tikkanen et al; licensee BioMed Central Ltd. 2011
Received: 8 March 2011
Accepted: 25 August 2011
Published: 25 August 2011
Placenta percreta is an obstetric emergency often associated with massive hemorrhage and emergency hysterectomy.
We present the case of a 30-year-old African woman, gravida 7, para 5, with placenta percreta managed by an alternative approach: the placenta was left in situ, methotrexate was administered, and a delayed hysterectomy was successfully performed.
Further studies are needed to develop the most appropriate management option for the most severe cases of abnormal placentation. Delayed hysterectomy may be a reasonable strategy in the most severe cases.
Placenta accreta (PA) is characterized by abnormal invasion of the placenta into the myometrium. PA is defined as superficial invasion, placenta increta as middle layer invasion and placenta percreta as deep invasion, which is the most severe form of PA with an incidence of one in 7000. All three types are collectively known as placenta accreta. The incidence of PA has dramatically increased due to increasing Caesarean section rates [1, 2]. Although rare, PA is one of the most severe pregnancy complications. Maternal morbidity and mortality associated with PA is mainly caused by massive obstetric hemorrhage or emergency hysterectomy, and PA is often diagnosed during delivery or immediately post-partum leading to an obstetric emergency [1, 3, 4]. Studies suggest that antenatal diagnosis may reduce obstetric hemorrhage-related morbidity [5, 6]. Furthermore, in some cases a morbidly adherent PA can be left in situ[7, 8]. Such conservative management may allow delayed removal of the placenta to avoid massive hemorrhage during an attempted forced removal of the adherent placenta. We describe a case in which placenta percreta was left in situ. Subsequent post-partum hemorrhage was successfully managed by delayed hysterectomy.
PA causes considerable maternal morbidity and mortality and is the major indication for emergency peri-partum hysterectomy. Antenatal confirmation of PA diagnosis is often difficult [3, 9, 10]. The management is usually an elective cesarean delivery and hysterectomy, but this approach often causes massive hemorrhage and may cause injury of adjacent organs due to the morbidly adherent placenta . Delayed trans-vaginal removal of the placenta has also been described . Some studies suggests that leaving placenta in situ lowers the risk for subsequent hysterectomy and may hence be an option in cases when emergency hysterectomy is considered too risky or fertility needs to be preserved [7, 8, 12].
We describe a severe case of PA histopathologically defined as placenta percreta in which the placenta was left in situ. Subsequently, our patient had multiple emergency room visits and ultimately developed severe post-partum hemorrhage leading to delayed emergency hysterectomy. This case suggests that in some cases with placenta accreta and percreta, leaving placenta in situ may be an alternative management option allowing delayed hysterectomy. This management option may be safer than primary hysterectomy since delayed hysterectomy may be easier to perform than emergency hysterectomy immediately post-partum (due to placental involution and decreased uterine vascularity). We are currently developing a management algorithm for women with an antenatal diagnosis of placenta percreta in which the placenta is left in situ, combined with parenteral methotrexate and elective delayed hysterectomy (although methotrexate is not used in all maternal-fetal centers in such clinical situations). This is justified based on our experience of other cases of placenta accreta in which the placenta was left in situ. Total placental involution with no complications occurred in only one out of five such cases with the placenta left in situ.
Placenta percreta is an obstetric emergency often associated with massive hemorrhage leading to emergency hysterectomy. We describe a severe case of placenta percreta in which the placenta was left in situ, methotrexate administered and a delayed hysterectomy successfully performed. Delayed hysterectomy may be a reasonable management strategy in the most severe cases.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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