Post-evacuation haemorrhage due to an undiagnosed second trimester placenta accreta/percreta

Clinical analysis of second-trimester pregnancy termination after previous caesarean delivery in 51 patients with placenta previa and placenta accreta spectrum: a retrospective study

BACKGROUNDS

Pregnancy termination during the second trimester in patients with placenta previa and placenta accreta spectrum (PAS) is a complex and challenging clinical problem. Based on our literature review, there has been a relative increase in the number of such cases being treated by hysterotomy and/or local uterine lesion resection and repair. In the present study, a retrospective analysis was conducted to compare the clinical outcomes when different management strategies were used to terminate pregnancy in the patients with placenta previa and PAS.

METHODS

A total of 51 patients who underwent pregnancy termination in the second trimester in Beijing Obstetrics and Gynecology Hospital between June 2013 and December 2018 were retrospectively analyzed in this study. All patients having previous caesarean delivery (CD) were diagnosed with placenta previa status and PAS.

RESULTS

① Among the 51 patients, 16 cases received mifepristone and misoprostol medical termination, 15 cases received mifepristone and Rivanol medical termination, but 1 of them was transferred to hysterotomy due to failed labor induction, another 20 cases were performed planned hysterotomy. There was no placenta percreta cases and uterine artery embolization (UAE) was all performed before surgery.② There were 31 cases who underwent medical termination and 30 cases were vaginal delivery. Dilation and evacuation (D&E) were used in 20 cases of medical abortion failure and in all 30 cases of difficult manual removal of placental tissue. ③ A statistically significant difference was found among the three different strategies in terms of gestational weeks, the type of placenta previa status, main operative success rate and β-HCG regression time (P < 0.05). ④ There were 4(7.8%) cases who were taken up for hysterectomy because of life-threatening bleeding or severe bacteremia during or after delivery and hysterotomy. The uterus was preserved with the implanted placenta partly or completely left in situ in 47(92.2%) cases. Combined medical and/or surgical management were used for the residual placenta and the time of menstrual recovery was 52(range: 33 to 86) days after pregnancy termination.

CONCLUSIONS

Terminating a pregnancy by vaginal delivery through medical induction of labor may be feasible if clinicians have an overall understanding of gestational age, the type of placenta previa status, the type of placenta accreta, and patients concerns about preserving fertility. A collaborative team effort in tertiary medical centers with a very experience MDT and combined application of multiple methods is required to optimize patient outcomes.

Management strategies for patients with placenta accreta spectrum disorders who underwent pregnancy termination in the second trimester: a retrospective study

Background

The unique clinical features of pregnancy termination in the second trimester with concurrent placenta accreta spectrum (PAS) disorders place obstetricians in a complex and delicate situation. However, there are limited data on this rare and dangerous condition. The objective of this research was to investigate and evaluate the clinical management strategies of this patient group.

Methods

The medical records of patients who were diagnosed and treated in our hospital from December 2005 and December 2015 were retrospectively reviewed.

Results

A total of 29 patients were included in this analysis. A prenatal diagnosis was suspected in 8 (27.6%) patients, and the remaining 21 (72.4%) patients were diagnosed after pregnancy termination in the second trimester. In the subgroup with a prenatal diagnosis, a planned hysterotomy was performed in 7 patients who had total placenta previa and previous cesarean delivery. The remaining patient received medical termination. A subtotal hysterectomy was performed in 3 (10.3%) patients for life-threatening bleeding during hysterotomy, and the uterus was preserved with an in situ placenta in the remaining 5 patients. In the subgroup with a postnatal diagnosis, the implanted placenta remained partly or completely in situ in all 21 patients under informed consent. Ultimately, the implanted placenta remained partly or completely in situ in 26 (89.7%) patients in the two subgroups. With the application of adjuvant treatments, including uterine artery embolization and medication followed by curettage under ultrasound guidance, the implanted placenta was passed 76.6 (range: 19 to 192) days after termination. Uterus preservation was achieved in all 26 patients. The complications associated with conservative management included delayed postnatal hemorrhaging (2 cases, 7.7%), fever (6 cases, 23.1%), G1 transaminase disorder (4 cases, 15.4%), and myelosuppression (1 case, 3.8%). Seven women (26.9%) had a spontaneous pregnancy after conservative management, and no patient experienced recurrent PAS disorders.

Conclusions

Leaving the implanted placenta in situ is the preferred choice for patients with PAS disorders who underwent pregnancy termination in the second trimester and desired fertility preservation. Multiple adjuvant treatment modalities, either alone or in combination, may help to promote the passing or absorption of the implanted placenta under close monitoring.