A unique complication of intrauterine synechiae and recurrent accreta: a multidisciplinary approach to minimize morbidity in high risk pregnancies
Abstract Number: F-62
Abstract Type: Case Report/Case Series
Placenta accreta is a serious complication of pregnancy with abnormal attachment of the placenta to the myometrium. It can result in hemorrhage, need for peripartum hysterectomy, and maternal mortality. We present a patient with history of a conservatively managed placenta accreta and the complications in her subsequent pregnancy.
A 35 year old G2P0101 with a history of placenta accreta conservatively managed in a prior pregnancy was admitted at 23 weeks for short cervix and “uterine synechiae.” A 19 week sonogram showed a shelf of tissue that separated the uterus into two compartments with possible adherence of the placenta to the band. Of note, the fetus was confined to the superior uterine compartment. Ultrasound at 21 weeks showed that a loop of umbilical cord prolapsed into the inferior uterine compartment while the fetus was contracted in the superior compartment secondary to oligohydramnios (figure 1). MRI at 23 weeks revealed intrauterine septation and persistent oligohydramnios in the superior compartment. No evidence of placenta accreta was noted.
The patient was counseled by maternal fetal medicine, anesthesia, neonatology, and gynecologic oncology regarding maternal and neonatal risks. She was offered termination but chose to continue the pregnancy. An interdisciplinary plan of care was made in the event she started to bleed, ruptured her membranes or went into labor.
At 24w2d, the patient’s membranes ruptured and she was noted to have heavy vaginal bleeding. The patient underwent an emergent classical cesarean section because of concern for placental abruption. Because of excessive bleeding and suspected accreta a total abdominal hysterectomy was performed. Estimated blood loss for the procedure was 3 Liters and she received 3 units PRBC’s, 2 units FFP, and 5 liters of Crystalloid.
At delivery, the infant had molding of the skull and a club foot due to intrauterine positioning. Despite surfactant, positive pressure ventilation, and resuscitation attempts the neonate expired. The patient’s postoperative course was uncomplicated.
Patients with a history of conservatively managed placenta accreta present a unique challenge to providers caring for them in subsequent pregnancies. Their care requires a multidisciplinary approach in order to decrease maternal and neonatal morbidity and mortality.