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Placenta percreta, termination of pregnancy, methotrexate, expectant management, chorioamnionitis, urgent embolization and hysterectomy: a case report
Abstract Number: F-47
Abstract Type: Case Report/Case Series
A 35 yo G4P2 Hispanic woman with 2 previous C-sections was diagnosed at 25 wks by MRI with an extensive placenta percreta with a complete previa (Figure). Because the fetus was considered unsalvageable and the patient’s life was at risk, a KCl termination was performed at 25 wks in the IR suite, with the intent to manage expectantly. Methotrexate IM (50mg/m2) was given 1x/week 3 times. Repeat MRIs showed no change. The patient reported brownish discharge and mild right inguinal and flank pain throughout her stay. HCG level decreased over time however it was still at 13mIU/ml (normal <6mIU/ml) at 40 wks. An MRI at 40 wks showed a decreased volume and vascularity of the placenta with a visible plane between the placenta and rectus muscle. Cervical length was 7mm. The plan was to discharge the patient home with no intent to intervene unless urgently needed.
At 41 wks, the patient became febrile with fundal tenderness suggesting a chorioamnionitis. An urgent embolization followed by a hysterectomy was decided. Invasive monitoring included an arterial line and central line. Embolization of bilateral uterine arteries and hypogastric anterior division branches was conducted under GA in the IR suite; the patient was transferred to the OR for a total abdominal hysterectomy. The lower uterine segment was dehisced and the placenta had eroded through the bladder wall; the fetus was necrotic. There were excrescences on the uterine surfaces and peritoneum, suggesting that there indeed had been placenta that regressed. Total blood loss was 800ml and 4L LR and 2U PRBCs were given. The patient was extubated at the end of the case and monitored in the ICU. The recovery was overall uneventful and the patient was discharged home 8 days later.
Expectant management of placenta accreta with methotrexate has been suggested as a way to manage medically such cases(1). To our knowledge, this case may be the most extreme in terms of placental invasion and prompted the decision to terminate the pregnancy at 25 wks. Despite large doses of methotrexate, placental involution was slow and by far not complete by 12 wks. When chorioamnionitis complicated the course at 16 wks post TOP, an urgent embolization followed by extended surgery was decided. Future series will need to establish the best timing for embolization and surgery when placental involution is incomplete, as urgent interventions may not always result in a good outcome.
1. Arch Gynecol Obstet.2011;284:491-502