Placenta percreta causing rupture of an unscarred uterus at the end of the first trimester of pregnancy: Case report

Spontaneous Rupture of the Unscarred Uterus: A Review of the Literature

Importance

Uterine rupture is defined as a nonsurgical disruption of all layers of the uterus. Most ruptures occur in the presence of a scar, usually secondary to a previous cesarean delivery. Rupture of an unscarred uterus is rare and is associated with severe maternal and neonatal outcomes.

Objective

To outline the literature on potential predisposing factors, clinical findings, and maternal and fetal outcomes of a rupture of an unscarred uterus.

Evidence Acquisition

PubMed was searched for the phrases "uterine rupture," "unscarred," and "spontaneous." Individual case reports, retrospective case series, and review articles in English between 1983 and 2020 were included.

Results

We found 84 case reports in 79 articles. The mean maternal age was 29.3 (SD, 5.7) years; 38 women (45.2%) were nulliparous. Uterine rupture occurred in 37% of the women at term; in 9.9%, the gestational age was ≤12 weeks. The most common clinical presentations were abdominal pain (77.4%), signs of hypovolemic shock (36.9%), fetal distress (31%), and vaginal bleeding (22.6%). The most common risk factors were the use of uterotonic drugs for induction or augmentation of labor and a prior curettage procedure. The most frequently ruptured site was the body of the uterus. Hysterectomy managed 36.9% of the ruptures. Four women died (4.8%). Perinatal mortality was 50.6%. Perinatal death was higher in developing than developed countries.

Conclusions and relevance

Although rare, spontaneous rupture of the unscarred uterus has serious consequences to the mother and the fetus and should be included in the differential diagnosis of acute abdomen in pregnancy.

Placenta percreta in primigravida with unscarred uterus complicated by uterine rupture and sudden maternal and fetal death: an autopsy case report

Placenta percreta is a rare, aggressive, and severe form of the placenta accreta spectrum. One of its most devastating effects is the sudden rupture of uterus. Uterine scarring is the leading risk factor for uterine rupture, although it can also happen, but rarely, in an unscarred uterus showing more severe repercussions. The present study reported a case of an Egyptian primigravida female, aged 29 years old, at 32 weeks of gestation who died suddenly due to uterine rupture complicating placenta percreta, the diagnosis of which was first settled during autopsy. There was no history of abdominal trauma. No medical history of significance was present. Autopsy denoted an intrauterine fetal death of 32 weeks gestational age. The fundus of the uterus had a laceration (rupture) of the uterine wall including the serosa and myometrium. The placenta has extensively infiltrated the fundus uterine wall and penetrated the myometrium and serosa. Histopathological examination of the ruptured site on the uterus confirms total invasion of the uterine wall by chorionic villi with the presence of hemorrhage and fibrin indicating placenta percreta. Uterine rupture due to placenta percreta may go unnoticed, especially when no associated high-risk factors exist. The current case depicts that placenta percreta is a rare but critical complication of pregnancy that may exist at any stage of pregnancy without any associated high-risk factors with unusual symptoms and leads to uterine rupture and sudden death.

Antepartum unscarred uterine rupture caused by placenta percreta: a case report and literature review

The main risk for uterine rupture is the presence of a uterine scar due to prior cesarean delivery or other uterine surgery. However, rupture in an unscarred uterus is extremely rare, and risk factors include multiple gestations, trauma, congenital anomalies, use of uterotonics and placenta accreta spectrum.

Placenta accreta spectrum, also known as morbidly adherent placenta, is becoming increasingly common and is associated with significant maternal and neonatal morbidity and mortality.

We report a case of unscarred uterine rupture due to placenta percreta in a multiparous woman that required emergency peripartum hysterectomy.

Placenta accreta spectrum on an unscarred uterus in the third-trimester pregnancy: two rare cases at Tu Du Hospital in Vietnam

Introduction and importance

Placenta accreta spectrum disorders (PASD) refer to an uncommon obstetrical conditions leading to significant life-threatening obstetrical issue for mothers and foetus during pregnancy. Rarely, this pathology can occur in the uterus without a history of uterine surgery, localize at unusual site of the uterus, and result in the spontaneous uterine rupture. We herein reported two unusual cases managed successfully in the third trimester of pregnancy at our tertiary referral hospital.

Case presentation

Two pregnant women were hospitalized at our maternity hospital for a dilemma diagnosis of PASD without history of previous caesarean scar. Following the suspected images of PASD on ultrasound combined with a hematoma anterior to the body of the uterus, especially a sudden onset of abdominal pain and intraperitoneal fluid without a clear etiology, we made the suspected diagnosis of uterine rupture associated with PASD. Moreover, a gradual reduction of hemoglobin concentration also supported this diagnosis. Both cases underwent immediately caesarean hysterectomy for saving the life of the mother and baby following suspicion.

Clinical discussion

PASD associated with an unscarred uterus is an uncommon placentation during pregnancy. Although an extremely rare cases, PASD may be present without association with placenta praevia. Timely management by caesarean hysterectomy can avoid adverse maternal-foetal outcomes.

Conclusion

PASD can be appeared on the uterus without a previous uterine scar, thus leading to unexpected complications during pregnancy. Closely strict monitoring helps avoiding the materno-foetal mortality. Further data is needed to summarize this rarely uncommon entity.

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Physicians should be aware of PASD although unscarred uterus and without placenta previa.

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A sudden onset of abdominal pain and intraperitoneal fluid, diagnosis of uterine rupture can be made.

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Following image of PASD on ultrasound combined with a hematoma anterior to the body of uterus is potential.

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Gradually decreased Hemoglobin concentration may support for this diagnosis.

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Timely surgery by caesarean hysterectomy can save the life of mothers and infants.

Searching for placenta percreta: a prospective cohort and systematic review of case reports

BACKGROUND

Placenta percreta is described as the most severe grade of placenta accreta spectrum and accounts for a quarter of all cases of placenta accreta spectrum reported in the literature.

OBJECTIVE

We investigated the hypothesis that placenta percreta, which has been described clinically as placental tissue invading through the full thickness of the uterus, is a heterogeneous category with most cases owing to primary or secondary uterine abnormality rather than an abnormally invasive form of placentation.

STUDY DESIGN

We have evaluated the agreement between the intraoperative findings using the International Federation of Gynecology and Obstetrics classification with the postoperative histopathology diagnosis in a prospective cohort of 101 consecutive singleton pregnancies presenting with a low-lying placenta or placenta previa, a history of at least 1 prior cesarean delivery and ultrasound signs suggestive of placenta accreta spectrum. Furthermore, a systematic literature review of case reports of placenta percreta, which included histopathologic findings and gross images, was performed.

RESULTS

Samples for histologic examination were available in 80 of 101 cases of the cohort, which were managed by hysterectomy or partial myometrial resection. Microscopic examination showed evidence of placenta accreta spectrum in 65 cases (creta, 9; increta, 56). Of 101 cases included in the cohort, 44 (43.5%) and 54 (53.5%) were graded as percreta by observer A and observer B, respectively. There was a moderate agreement between observers. Of note, 11 of 36 cases that showed no evidence of abnormal placental attachment at delivery and/or microscopic examination were classified as percreta by both observers. The systematic literature review identified 41 case reports of placenta percreta with microscopic images and presenting symptomatology, suggesting that most cases were the consequence of a uterine rupture. The microscopic descriptions were heterogeneous, and all descriptions demonstrated histology of placenta creta rather than percreta.

CONCLUSION

Our study supported the concept that placenta accreta is not an invasive disorder of placentation but the consequence of postoperative surgical remodeling or a preexisting uterine pathology and found no histologic evidence supporting the existence of a condition where the villous tissue penetrates the entire uterine wall, including the serosa and beyond.

First-trimester uterine rupture: a case report and systematic review of the literature

OBJECTIVE

This study aimed to present a case of first-trimester uterine rupture and perform a systematic review to identify common presentations, risk factors, and management strategies.

DATA SOURCES

Searches were performed in PubMed, Ovid, and Scopus using a combination of key words related to "uterine rupture," "first trimester," and "early pregnancy" from database inception to September 30, 2020.

STUDY ELIGIBILITY CRITERIA

English language descriptions of uterine rupture at ≤14 weeks of gestation were included, and cases involving pregnancy termination and ectopic pregnancy were excluded.

METHODS

Outcomes for the systematic review included maternal demographics, description of uterine rupture, and specifics of uterine rupture diagnosis and management. Data were extracted to custom-made reporting forms. Median values were calculated for continuous variables, and percentages were calculated for categorical variables. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklist for case reports and case series.

RESULTS

Overall, 61 cases of first-trimester uterine rupture were identified, including our novel case. First-trimester uterine ruptures occurred at a median gestation of 11 weeks. Most patients (59/61 [97%]) had abdominal pain as a presenting symptom, and previous uterine surgery was prevalent (44/61 [62%]), usually low transverse cesarean delivery (32/61 [52%]). The diagnosis of uterine rupture was generally made after surgical exploration (37/61 [61%]), with rupture noted in the fundus in 26 of 61 cases (43%) and in the lower segment in 27 of 61 cases (44%). Primary repair of the defect was possible in 40 of 61 cases (66%), whereas hysterectomy was performed in 18 of 61 cases (30%). Continuing pregnancy was possible in 4 of 61 cases (7%).

CONCLUSION

Uterine rupture is an uncommon occurrence but should be considered in patients with an acute abdomen in early pregnancy, especially in women with previous uterine surgery. Surgical exploration is typically needed to confirm the diagnosis and for management. Hysterectomy is not always necessary; primary uterine repair is sufficient in more than two-thirds of the cases to achieve hemostasis. Continuing pregnancy, although uncommon, is also possible.

Imaging evaluation of uterine perforation and rupture

Uterine perforation and rupture, denoting iatrogenic and non-iatrogenic uterine wall injury, respectively, are associated with substantial morbidity,and at times mortality. Diverse conditions can result in injury to both the gravid and the non-gravid uterus, and imaging plays a central role in diagnosis of such suspected cases. Ultrasound (US) is the initial imaging modality of choice, depicting the secondary signs associated with uterine wall injury and occasionally revealing the site of perforation. Computed tomography can be selectively used to complement US findings, to provide a more comprehensive picture, and to investigate complications beyond the reach of US, such as bowel injury. In certain scenarios, magnetic resonance imaging can be an important problem-solving tool as well. Finally, catheter angiography is a valuable tool with both diagnostic and therapeutic capability, with potential for fertility preservation. In this manuscript, we will highlight the clinical and imaging approach to uterine perforation and rupture, while emphasizing the value of various imaging modalities in this context. In addition, we will review the multi-modality imaging features of uterine perforation and rupture and will address the role of the radiologist as a crucial member of the management team. Finally, a summary diagrammatic depiction of imaging approach to patients presenting with uterine perforation or rupture is provided.

Uterine body placenta accreta spectrum: A detailed literature review

Placenta accreta spectrum (PAS) is a major obstetrical problem whose incidence is rising. Current guidelines recommend screening of all women with placenta previa and risk factors for PAS between 20 and 24 weeks. Risk factors, diagnosis, and management of previa PAS are well established, but an apparently normal location of the placenta does not exclude PAS. Literature data are scarce on uterine body PAS, which carries a high risk of maternal and neonatal adverse outcome, but is still easily missed on prenatal ultrasound. We conducted a comprehensive review to identify possible risk factors, clinical presentations, and diagnostic modalities of uterine PAS. A total of 133 cases were found during a 70-year period (1949-2019). The vast majority of them presented with signs of uterine rupture, even prior to the viability threshold of 24 weeks (up to 45%). Major risk factors included previous cesarean delivery, uterine curettage, uterine surgery, Asherman's syndrome, manual removal of the placenta, endometritis, high parity, young maternal age, in vitro fertilization, radiotherapy, uterine artery embolization, and uterine leiomyoma. Diagnosis was pre-symptomatic in only 3% of cases. Future studies should differentiate between previa PAS and uterine body PAS.

First Trimester Uterine Rupture: A Case Report and Literature Review

The aim is to report a case of spontaneous uterine rupture in the first trimester of pregnancy and to review the literature on the topic.

METHODS

A literature search was performed using PubMed and Scopus. Relevant English articles were identified without any time or study limitations. The data were aggregated, and a summary statistic was calculated.

RESULTS

A 35-year-old gravida 5, para 2 was admitted at our department because of fainting and abdominal pain. The woman had a first-trimester twin pregnancy and a history of two previous cesarean sections (CSs). Suspecting a uterine rupture, an emergency laparotomy was performed. The two sacs were completely removed, and the uterine rupture site was closed with a double-layer suture. The patient was discharged from hospital four days later in good condition. On the basis of this experience, a total of 76 case reports were extracted from PubMed and included in the review. Fifty-three patients out of 76 (69.74%) underwent previous surgery on the uterus. Most women (67.92%) had a CS, and in this group a cesarean scar pregnancy (CSP) or a placenta accreta spectrum (PAS) disorder was found to be the etiology in 77.78% of cases. Furthermore, 35.85% of the women had hysterectomy after uterine rupture. Twenty-three patients out of 76 (30.26%) had an unscarred uterus. Of this group, most women presented a uterine anomaly (43.48%). Moreover, 17.39% of these women had a hysterectomy.

CONCLUSION

According to the literature, the current pandemic use of CS explains most cases of first-trimester uterine rupture.

Laparoscopic hysterectomy to manage uterine rupture due to placenta percreta in the first trimester: A case report

Placenta percreta causing uterine rupture is a rare complication of pregnancy. It is most commonly diagnosed after the second trimester and can lead to significant morbidity necessitating abdominal hysterectomy of a gravid or immediately postpartum uterus. We describe a patient who presented with abdominal pain at 13 weeks of gestation and was diagnosed with placenta percreta during laparoscopy for presumed appendicitis. Intraoperatively, placenta was seen perforating the uterine fundus and 1 l of hemoperitoneum was evacuated. However, the uterus was hemostatic and the patient was stable, so the procedure was terminated. The patient was then transferred to a tertiary care center, where she ultimately underwent an uncomplicated laparoscopic gravid hysterectomy. We conclude that placenta percreta can occur in the first trimester even in patients without traditional risk factors. In stable patients, it is appropriate to consider minimally invasive hysterectomy with utilization of specific techniques to minimize intraoperative blood loss.

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Uterine rupture due to placenta percreta can present in the first trimester.

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Minimally invasive laparoscopic hysterectomy can provide definitive treatment with decreased surgical morbidity and shorter convalescence.

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Blood loss and allogenic transfusion can be minimized with appropriate hemostatic techniques and surgical planning.

Placenta percreta causing spontaneous uterine rupture and intrauterine fetal death in an unscared uterus: A case report

INTRODUCTION

Placenta percreta is a rare; a life-threatening disorder of placentation and one of the components of the placenta accreta spectrum. It can lead to uterine rupture, an obstetric catastrophe that can be associated with increased maternal and fetal morbidity and mortality.

PRESENTATION OF CASE

We present an unusual case of spontaneous uterine rupture due to placenta percreta in an unscarred uterus of a multiparous woman leading to spontaneous intrauterine fetal death. She presented with hypovolaemic shock following spontaneous rupture of the uterus and subsequent intra-peritoneal bleeding.

DISCUSSION

Uterine rupture occurs commonly in a scarred uterus from some form of trauma or injudicious use of oxytocics. However, uterine rupture occurring in the absence of prior scar or use of oxytocics is a rarity. Placenta percreta is an unusual cause of uterine rupture and subsequent intra-uterine fetal death. Placenta percreta occurs when the uterine wall is invaded by the placenta up to the level of the serosa. A high index of suspicion and thorough review of the patient is required for making this diagnosis. Misdiagnosis is associated with dare consequences of increased maternal morbidity and mortality.

CONCLUSION

Placenta percreta is a rare disorder of placentation that can cause uterine rupture which can easily be misdiagnosed. Prompt diagnosis and institution of the appropriate care can help prevent catastrophic outcomes as demonstrated in the case reported.

Unscarred Uterine Rupture: A Retrospective Analysis

INTRODUCTION

Uterine rupture is a catastrophic obstetrical emergency associated with a significant feto-maternal morbidity and mortality. Many risk factors for uterine rupture, as well as a wide range of clinical presentations, have been identified.

OBJECTIVES

To analyze the frequency, predisposing factors, and maternal and fetal outcomes of uterine rupture.

METHODS

A retrospective analysis of cases of unscarred uterine rupture was conducted at the Department of Obstetrics and Gynecology, RIMS, Imphal from June 1, 2010 to June 30, 2012.

RESULTS

Our analysis comprised 13 cases. Of these, 30.8 % were booked cases. Most of the cases (46.2 %) were Para 2. Uterine rupture occurred at term in 10 cases. The rupture occurred due to mismanaged labor (30.8 %), the use of oxytocin (23 %), instrumental delivery (15.4 %), obstructed labor (15.4 %), induction by prostaglandin gel (7.7 %), and placenta percreta (7.7 %). Maternal deaths and perinatal deaths were 30.8 and 53.8 %, respectively. Sub-total hysterectomy was done in 8 cases and in 1 patient laparotomy with repair was performed.

CONCLUSION

Ruptured uterus causes a high risk in patients. An unscarred uterus can undergo rupture even without etiological or risk factors. The patients with mismanaged labor, grand multiparas, and obstructed prolonged labor must be managed by properly trained personnel at a tertiary care center in order to avoid the morbidity or mortality.

Cesarean scar pregnancy and early placenta accreta share common histology

OBJECTIVE

To determine, by evaluation of histological slides, images and descriptions of early (second-trimester) placenta accreta (EPA) and placental implantation in cases of Cesarean scar pregnancy (CSP), whether these are pathologically indistinguishable and whether they both represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

METHODS

The database of a previously published review of CSP and EPA was used to identify articles with histopathological descriptions and electronic images for pathological review. When possible, microscopic slides and/or paraffin blocks were obtained from the original researchers. We also included from our own institutions cases of CSP and EPA for which pathology specimens were available. Two pathologists examined all the material independently and, blinded to each other's findings, provided a pathological diagnosis based on microscopic appearance. Interobserver agreement in diagnosis was determined.

RESULTS

Forty articles were identified, which included 31 cases of CSP and 13 cases of EPA containing histopathological descriptions and/or images of the pathology. We additionally included six cases of CSP and eight cases of EPA from our own institutions, giving a total of 58 cases available for histological evaluation (37 CSP and 21 EPA) containing clear definitions of morbidly adherent placenta. In the 29 cases for which images/slides were available for histopathological evaluation, both pathologists attested to the various degrees of myometrial and/or scar tissue invasion by placental villi with scant or no intervening decidua, consistent with the classic definition of morbidly adherent placenta. Based on the reviewed material, cases with a diagnosis of EPA and those with a diagnosis of CSP showed identical histopathological features. Interobserver correlation was high (kappa = 0.93).

CONCLUSIONS

EPA and placental implantation in CSP are histopathologically indistinguishable and may represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

Prenatal diagnosis of abnormally invasive placenta reduces maternal peripartum hemorrhage and morbidity

OBJECTIVE

Abnormally invasive placenta (AIP) poses diagnostic and therapeutic challenges. We analyzed clinical cases with confirmed placenta increta or percreta.

DESIGN

Retrospective case series.

SETTING

Multicenter study.

POPULATION

Pregnant women with AIP.

METHODS

Chart review.

MAIN OUTCOME MEASURES

Prenatal detection rates, treatment choices, morbidity, mortality and short-term outcome.

RESULTS

Sixty-six cases were analyzed. All women and all but three fetuses survived; 57/64 women (89%) had previous uterine surgery. In 26 women (39%) the diagnosis was not known before delivery (Group 1), in the remaining 40 (61%) diagnosis had been made between 14 and 37 weeks of gestation (Group 2). Placenta previa was present in 36 women (54%). In Groups 1 and 2, 50% (13/26) and 62% (25/40) of the women required hysterectomy, respectively. In Group 1 (unknown at the time of delivery) 69% (9/13) required (emergency) hysterectomy for severe hemorrhage in the immediate peripartum period compared with only 12% (3/25) in Group 2 (p = 0.0004). Mass transfusions were more frequently required in Group 1 (46%, 12/26 vs. 20%, 8/40; p = 0.025). In 18/40 women (45%) from Group 2 the placenta was intentionally left in situ; secondary hysterectomies and infections were equally frequent (18%) among these differently treated women. Overall, postpartum infections occurred in 11% and 20% of women in Groups 1 and 2, respectively.

CONCLUSIONS

AIP was known before delivery in more than half of the cases. Unknown AIP led to significantly more emergency hysterectomies and mass transfusions during or immediately after delivery. Prenatal diagnosis of AIP reduces morbidity. Future studies should also address the selection criteria for cases appropriate for leaving the placenta in situ.

Conservative multidisciplinary management of placenta percreta following in vitro fertilization

Placenta percreta is an extremely rare and the most severe form of placental invasion, that is associated with severe maternal morbidity and mortality. We report a case of nulliparous woman who underwent 10 cycles of in vitro fertilization (IVF) without any known risk factors. We conserved her uterus by spontaneous vaginal delivery, leaving the placenta in situ, pelvic arterial embolization, and primary resection of the remaining placental tissues. This case demonstrates that repetitive IVF is a possible risk factor for placental invasion, and that conservation of the uterus can be achieved in such cases using a multidisciplinary approach.

Placenta percreta: rare presentation of haemorrhage in the second trimester

A 25-year-old woman, third gravid, with previous two miscarriages presented to the emergency at 17 weeks 2 days of gestation with complaints of pain in the abdomen for 1 day and decreased urine output for 2 days. She was in shock. There was no history of bleeding per vaginum, trauma, surgical procedure or medical illness. Her obstetrical history was marked by a spontaneous second trimester miscarriage at 24 weeks that was followed by fever for 1 week. Ultrasound revealed an extra uterine fetus with sac en caul secondary to uterine rupture. She was resuscitated and taken up for emergency salvage laparotomy. The ragged fundal rent was excised and uterine reconstruction was performed. Histology revealed placenta percreta. The patient had a rapid recovery.

Placenta percreta at 17 weeks with consecutive hysterectomy: a case report and review of the literature

Placenta percreta in early pregnancy is an extremely rare but life-threatening complication, for which very few cases have been reported in the literature worldwide, none from the United States. We report a patient with two previous cesarean deliveries, who presented with incomplete abortion at 17 weeks and underwent dilatation and curettage. She was found to have retained, adherent placenta that led to extensive hemorrhage, requiring emergency supracervical hysterectomy. Postoperative course was also complicated by severe consumption coagulopathy, necessitating reexploration after hysterectomy. Pathology revealed a placenta percreta. Patient lost more than 8000 cc blood through the 2 surgeries, received massive transfusions due to severe disseminated intravascular coagulopathy (DIC), and underwent a complicated surgery because of great difficulty in separating lower uterine segment and cervix from the bladder. Abnormal placentation in early pregnancy has increased in prevalence due to marked rise in cesarean deliveries and curettages in recent decades. We reviewed all reported cases of first and second trimester placenta percreta in the literature, to emphasize the early recognition of abnormal placentations in patients with risk factors, consider prenatal evaluation in such patients, anticipate complicated placental implantations during termination procedures, and prevent associated maternal morbidity and mortality.

Framing postpartum hemorrhage as a consequence of human placental biology: an evolutionary and comparative perspective

Postpartum hemorrhage (PPH), the leading cause of maternal mortality worldwide, is responsible for 35 percent of maternal deaths. Proximately, PPH results from the failure of the placenta to separate from the uterine wall properly, most often because of impairment of uterine muscle contraction. Despite its prevalence and its well-described clinical manifestations, the ultimate causes of PPH are not known and have not been investigated through an evolutionary lens. We argue that vulnerability to PPH stems from the intensely invasive nature of human placentation. The human placenta causes uterine vessels to undergo transformation to provide the developing fetus with a high plane of maternal resources; the degree of this transformation in humans is extensive. We argue that the particularly invasive nature of the human placenta increases the possibility of increased blood loss at parturition. We review evidence suggesting PPH and other placental disorders represent an evolutionarily novel condition in hominins.

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review

This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.

[Case study of a severe hemorrhage during a dilatation and curettage: Arteriovenous malformation or first trimester placenta accreta?]

A 27-year-old woman had a uterine curettage that was complicated by a severe hemorrhage. Ultrasonography and MRI showed a vascular lesion of the uterine fundus suspected to be an atypical arteriovenous malformation. The lesion spontaneously disappeared 2months later. The two most likely diagnoses are an arteriovenous malformation or a placenta accreta. The aim is to discuss the etiology of this serious complication from a case report of a severe hemorrhage during a uterine curettage.

Experience with Conservative Strategy of Uterine Artery Embolization in the Treatment of Placenta Percreta in the first Trimester of Pregnancy

OBJECTIVE

There is little prospective experience in the conservative treatment of placenta percreta during the first trimester in order to preserve uterine fertility. We describe herein our experience with uterine artery embolization (UAE) in the management of placenta percreta at 9 weeks of gestation.

CASE REPORT

A 36-year-old woman, gravida 3, para 1, was referred for ultrasonographic evaluation because of suspected molar pregnancy due to persistent vaginal spotting at 9 weeks of gestation. A Grade 3+ lacunar flow pattern with multiple bizarre and large irregular sonolucent spaces were observed. Color Doppler imaging revealed extensive turbulent lacunar blood flow perfusing throughout the whole surrounding uteroplacental tissues and fetus. The patient was informed of the situation and she had a strong desire to avoid surgery. Conservative management with bilateral UAE was performed using polyvinyl alcohol particles to promote involution and shedding of the abnormally adherent placenta. However, an unsatisfactory vessel-occluding effect caused by extensive collateral supply was still detected after repeated UAE. We, therefore, performed hysterectomy, and the patient had an uneventful postoperative course.

CONCLUSION

The efficacy and complications of UAE as a therapeutic modality for the conservative management of invasive placentation in the first trimester of pregnancy are not clear, as this is the first report of its kind. However, although UAE had failed in this case, it may still be a useful procedure as a prophylactic measure before surgical intervention, and hysterectomy can also be performed for better control of operative hemorrhage.