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Conservative management of invasive placental disease: Potential problem?
Abstract Number: SU-81
Abstract Type: Case Report/Case Series
Incidence of invasive placental disease is rising with increasing number of cesarean deliveries. Antenatally diagnosed placenta accreta, increta and percreta have traditionally been managed by scheduled preterm cesarean hysterectomy. Significant maternal morbidity and mortality is associated with acute hemorrhage and its complications. Multidisciplinary approach to management has been shown to have better outcomes. Conservative management with uterine preservation is attempted in patients who desire future fertility. We report a successful conservative management of a patient with complete placenta previa and placenta increta.
34 y/o G2P1 at 18.5 wga with one prior low transverse cesarean scar was found to have fetal occipital encephalocele and herniated cerebellum. There was complete placenta previa with entirely effaced anterior uterine wall at the level of the old cesarean scar adjacent to the bladder and a morbidly adherent placenta on antenatal ultrasound. The patient had a strong desire for future fertility and it was discussed that although a cesarean hysterectomy may be necessary, an attempt would be made to preserve the uterus. General anesthesia with intubation was performed. Radial arterial catheter was placed. Pfannenstiel incision was followed by midline vertical fundal hysterotomy with delivery of the fetus. On inspection of lower uterine segment, placenta percreta was noted. The entire placental tissue was left in situ and the hysterotomy was closed. EBL was 500 ml. Inpatient stay was 7 days for antibiotics and methotrexate. Beta HCG levels and LFTs were closely monitored. Outpatient follow-up was scheduled. HCG level decreased progressively, placental tissue size decreased on ultrasound and no bleeding episodes reported to-date.
Several case reports describe conservative strategies to preserve uterus for future fertility by leaving placental tissue in situ. In a case series, upto 22% patients required either primary or delayed hysterectomy. Primary hysterectomy was required due to acute hemorrhage; whereas delayed hysterectomy was necessary secondary to infection, hemorrhage or DIC. These patients may present emergently upto 22 weeks after delivery and anesthesiologists face the challenge to care for a patient with hemorrhage, sepsis or DIC in less than optimal conditions. Prolonged close followup is required and patients need to be educated to report to hospital earlier with symptoms of bleeding and fever. A planned procedure allows for adequate preparation, however, if these patients arrive in emergent situations the opportunity for adequate preparation is lost. Conservatively managed patients have been shown to have recurrent invasive placental disease in their future pregnancies. So, are we really avoiding the problem long term?
Jennifer Hunt, Journal of pregnancy, vol 2010,329618
ACOG committee opinion 529, July 2012
Sentilhes et al, Obstetrics and gynecology, vol 115,3,2010