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Conservative Management of the Morbidly Adherent Placenta: a Case Series
Abstract Number: T-80
Abstract Type: Case Report/Case Series
With the rising prevalence of morbidly adherent placentation (MAP), physicians are seeking alternative approaches to decrease morbidity and mortality as a result of hemorrhage-related complications. One conservative method involves leaving the placenta in situ, allowing for regression of vascular structures before a delayed hysterectomy. In this case series we present two patients with placenta percreta who were successfully managed with interval hysterectomies.
A 26 y/o G4P1 with history of a c/s x1 presented with known placenta previa and percreta. At 32w5d, she underwent a scheduled c/s under general anesthesia in which the percreta was found to extend into the parametrium. Intraop EBL was 500cc and no blood products were transfused. The placenta and uterus were left in place with plans to undergo delayed hysterectomy 6-12 weeks later. She was followed with weekly U/S and CBC. She presented to the ED 8 weeks postop with vaginal bleeding and lower extremity ecchymosis. Fibrinogen was <70mg/dL, and she was immediately recognized to have disseminated intravascular coagulation. She underwent an emergency hysterectomy, under general anesthesia, resulting in 5L EBL. She was taken back to the OR that night for bleeding complications. She received a total of 16u PRBCs, 12u FFP, 4u cryo, and 2 packs of platelets during her hospitalization, and was discharged home on POD6.
A 35 y/o G3P2 with history of c/s x2 presented with known placenta previa and percreta. She underwent a scheduled c/s, under general anesthesia, at 34w1d in which the percreta was noted to involve the right pelvic sidewall and bladder. Intraop EBL was 400cc and no blood products were transfused. The placenta and uterus were left in situ, with plans to undergo delayed hysterectomy at 8 weeks. She was followed with weekly U/S, CBC, and fibrinogen. Five weeks postop, she was admitted to the hospital after her fibrinogen was noted to be 107mg/dL. She was asymptomatic. The next morning her fibrinogen decreased to 76mg/dL, and she urgently underwent uterine artery embolization by IR followed by hysterectomy. Intraop EBL was 2400cc. She received a total of 4u cryo, 2u FFP, and 1u PRBC during her hospital course, and was discharged on POD3.
In this case series we treated two placenta percreta pts with conservative management. Both presented earlier than their scheduled procedures and required urgent interventions due to developing DIC. While cesarean hysterectomy remains the most common approach for women with MAP, conservative management is becoming more prevalent due to reduced blood loss (1750 versus 3700 ml) and decreased rate of transfusions (57 vs 86%) (1,2). This approach, however, is not without risks and remains controversial as many patients require further surgery, often emergently, and may experience significant morbidity due to DIC, sepsis, and hemorrhage (3).
1. Fitzpatrick 2014
2. Wright 2011
3. Pather 2014