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

Protocolo para el manejo de placenta percreta con cesárea, embolización uterina e histerectomía diferida

Introducción. El objetivo de este artículo fue dar a conocer el protocolo institucional del manejo de la placenta percreta como un procedimiento varias horas después de la cesárea, con embolización de arterias placentarias de forma selectivas, previo a la práctica de la histerectomía, y presentar los resultados. Métodos. Estudio de serie de casos, donde se evaluaron las pacientes con placenta percreta, manejadas durante un año en un hospital de cuarto nivel de complejidad en la ciudad de Bogotá, D.C., Colombia. Se efectuó cesárea fúndica y se dejó la placenta in situ, 48 a 72 horas después se realizó embolización ultra selectiva y luego de 2 a 3 días se procedió a practicar la histerectomía vía abdominal. Resultados. Se evaluaron 5 pacientes, con paridad de 3,8 embarazos promedio, con diagnóstico de placenta percreta. El tiempo promedio de espera entre la embolización y la histerectomía fue de 1,6 días. No se presentaron complicaciones asociadas a la embolización, ni morbimortalidad materno fetal. Los volúmenes de sangrado en promedio durante la histerectomía de cada paciente fueron de 1160 ml. Conclusión. Existen datos limitados sobre el tratamiento óptimo del acretismo placentario. La sospecha diagnóstica permite planificar de forma favorable el manejo intraparto y, es por ello, que el surgimiento de nuevas técnicas, como la embolización de arterias placentarias, constituyen alternativas para un manejo más seguro de las pacientes.

Successful treatment of placenta accreta spectrum disorder using management strategy of serial uterine artery embolization combined with standard weekly and a 8-day methotrexate/folinic acid regimens at 7 weeks of gestation

OBJECTIVE

We describe our experience with serial uterine artery embolization (UAE) combined with standard weekly methotrexate and a eight-day methotrexate/folinic acid (MTX/FA) treatment regimen in the management of placenta accreta spectrum (PAS) disorder at 7 weeks of gestation.

CASE REPORT

A 38-year-old woman, gravida 2 para 0, with a history of myomectomy, was referred for ultrasound (US) evaluation due to suspected cervico-isthmic pregnancy. Transvaginal US image showed a viable embryo with a disproportionately bigger placenta encircling the fetus and completely covering the internal os of the cervix at 7 weeks of gestation. Color Doppler imaging revealed diffuse intraplacental and periplacental vascularity. Patient chose to terminate the pregnancy but attempted to preserve the uterus for future fertility following counseling. Serial UAE procedures were performed using Gelfoam and metallic microcoils. Two courses of a standard weekly MTX and a eight-day MTX/FA treatment regimen were administered to accelerate placental regression. The beta-hCG gradually decreased to a normal level, and an ultimate resolution of the PAS disorder was observed at 110 days after treatment.

CONCLUSION

Early diagnosis of the PAS disorder could result in better obstetric outcome through earlier intervention using serial UAE combined with standard weekly and a eight day MTX//FA regimen in the first trimester of pregnancy.

Serial Uterine Artery Embolization for the Treatment of Placenta Percreta in the First Trimester: A Case Report

Two patients with placenta percreta underwent uterine artery embolization (UAE) for abnormally invasive placenta (AIP) in the first trimester. Patient 1 had a 9-week cervical ectopic, while Patient 2 had a 9-week cesarean scar pregnancy. Elective termination of pregnancy was performed in both patients. UAE was performed with tris-acryl gelatin microspheres as well as gelfoam until stasis and was repeated in cases of revascularization. Both patients were followed with US/MRI/MRA scans and β-hCG levels. Revascularization occurred in both patients following UAE, requiring multiple embolizations to achieve complete placental involution. Serial bland UAE may be an effective technique in the treatment of first-trimester AIP, with the distinct advantage of maintaining a patient's fertility.

LEVEL OF EVIDENCE

Level IV.

Invasive placentation and uterus preserving treatment modalities: a systematic review

Purpose

We present a systematic review to evaluate failure rates (secondary hysterectomy or maternal mortality) and success rates (subsequent menstruation or pregnancy) after different uterus preserving treatment modalities in women with invasive placentation.

Methods

A review of English, German or Dutch language-published research, using Medline and Embase databases, was performed. Studies of any design were included.

Results

Ten cohort studies and 50 case series or case reports were included. Expectant management reported a secondary hysterectomy in 55/287 (19%), maternal mortality in 1/295 (0.3%), a subsequent menstruation in 44/49 (90%) and a subsequent pregnancy in 24/36 (67%). Embolization of the uterine arteries described a secondary hysterectomy in 8/45 (18%), a subsequent menstruation in 8/13 (62%) and a subsequent pregnancy in 5/33 (15%). Methotrexate therapy presented a secondary hysterectomy in 1/16 (6%), a subsequent menstruation in 4/5 (80%) and a subsequent pregnancy in 1/2 (50%). Uterus preserving surgery showed a secondary hysterectomy in 24/77 (31%), maternal mortality in 2/55 (4%), a subsequent menstruation in 28/34 (82%) and a subsequent pregnancy in 19/26 (73%).

Conclusions

This review indicates that different uterus preserving treatment modalities may be effective in managing invasive placentation. Despite the extensive review of the literature, no conclusions about the superiority of any modality can be drawn.

Laparoscopic management of placenta increta after late first-trimester dilation and evacuation manifesting as an unusual uterine mass

Placenta increta is a rare and potentially life-threatening complication of pregnancy. The initial symptoms are generally vaginal bleeding during difficult placental removal in the third trimester. However, placenta increta may complicate first- and early second-trimester pregnancy loss. The diagnosis may be difficult during early pregnancy because the lesion is difficult to identify. Herein is reported the case of a woman with a diagnosis of placenta increta that caused prolonged bleeding after a late first-trimester abortion and manifested as an unusual lower segment uterine mass. Management included laparoscopy, and the placental tissue was completely removed successfully and uneventfully.

Placenta accreta in the first trimester of pregnancy: sonographic findings

In a case of histologically confirmed placenta increta, decidual protrusion into the myometrium was observed sonographically at 6 weeks' gestation, corresponding to placental protrusion from a disrupted placental-uterine wall interface seen in the later part of the first and second trimester. It is hypothesized that the histologic finding of decidual scarcity in placenta accreta is not a cause but rather an end result of the recruitment of trophoblasts across the decidual-placental interface in a maternal attempt at healing and/or repair in the presence of uterine injury, disease, or malformation that accounts for the associated factors and course of the condition.

Litigation in Obstetrics: a Lesson Learnt and a Lesson to Share

A perfect baby is the expectation of all parents, and a perfect outcome is the mission of obstetrics. Every obstetrician dreads to hear that there is an unexpected maternal mortality and/or severe fetal injury at the hospital. The role of a perceived public expectation of perfection in obstetric medicine reflects a belief that bad outcomes in obstetrics should not be tolerated and that every maternal-fetal injury merits financial compensation and punishment. What has brought these troubling times to obstetric medicine? The drivers behind malpractice crises are the four leading interest groups in the medical-legal debate: pregnant patients and their environment (husband, parents, relatives, friends, legislators, and the media), health-care providers, insurance companies, and trial attorneys. Litigation in obstetrics is the result of a complex of events when malpractice (presumed or real) impacts on the attitude of pregnant women and their environment. In such complexity, information is mandatory but may often be misinterpreted. If messages are not tailored to the receiver's capacity, communicating well with the pregnant patient becomes crucial. Therefore, to reduce medical-legal issues in obstetrics, increasing attention and an applicable standard of obstetric care to avoid negligence and medical errors should go along with better communication with pregnant women. Communication should be clear, targeted, effective, flexible, and empathic to share a common language and decisions. This review briefly presents and discusses some of the most frequently encountered medical-legal claim cases in obstetric practice. In-depth review of pregnancy-related deaths and major morbidities can help determine strategies needed to continue making pregnancy safer.