Management of Abnormal Placenta Implantation with Methotrexate: A Review of Published Data

Abnormally invasive placenta is characterized by direct attachment of chorionic villi to the uterine wall. This adherent placenta traditionally has been managed by peripartum hysterectomy. Nowadays, there is a lot of interest toward gradual shift from traditional management of invasive placentation to conservative ones leaving the placenta in situ to avoid the surgical morbidity of hysterectomy and loss of future fertility. Administration of methotrexate (MTX), as an adjunctive antimetabolite drug, resulted in conflicting data during conservative management of abnormal placentation. This review assessed all published data on efficacy and safety of MTX therapy as conservative management of invasive placentation. Fifty-three articles including one prospective cohort study, 2 retrospective cohort studies, 10 case series and 40 case reports were identified. Conservative management has beneficial effects on the avoidance of major surgery with the consequent morbidity and the preservation of future fertility. Infection and vaginal bleeding were main complications of MTX therapy. Although MTX therapy may result in accelerated involution or expulsion of placenta and has some beneficial effects on hemorrhagic events, but there is not enough evidence on its efficacy and safety to recommend its routine uses in all cases of invasive placenta.

Conservative management of placenta increta: case report and literature review

Placenta increta, a rare complication of pregnancy, is associated with significant postpartum hemorrhage often requiring emergency hysterectomy. We report a case of conservative management, with a combination of parenteral methotrexate, serial ultrasound and β-hCG assessment. Serum β-hCG levels were undetectable after 8 weeks of therapy. A scan at 6 months showed complete involution of the uterus. Review of the literature discussing the diagnostic tools, clinical features, management and outcome of pregnancies with placenta increta.

Placenta increta; conservative management – a successful outcome. Case report and literature review

Placenta increta, a rare complication of pregnancy, is associated with significant postpartum hemorrhage often requiring emergency hysterectomy. We report a case of conservative management, with a combination of parenteral methotrexate, serial ultrasound and Doppler assessment, followed by interval manual removal of placenta.

Late postpartum hemorrhage after hemostatic square suturing technique: a case report

BACKGROUND

Hemostatic square suturing is a useful technique for postpartum hemorrhage, but some complications may occasionally occur.

CASE

A 36-year-old pregnant woman with placenta previa and percreta at 35 weeks' gestation complicated with massive vaginal bleeding. An emergency cesarean section was performed, and placenta previa with percreta and uterine atony were noted. A hemostatic square suture was placed to compress the uterus and stopped the hemorrhage successfully. The estimated blood loss was approximately 2,200 mL. Thirty-seven days after operation, massive vaginal bleeding developed and the ultrasonography showed a 6.84 x 5.71-cm complex intrauterine mass. The patient was treated with intravenous oxytocin, rectal misoprostol, and blood transfusion. The beta-human chorionic gonadotropin levels returned to normal level on day 70 postoperatively, and ultrasonography revealed no obvious intrauterine mass.

CONCLUSION

Late postpartum hemorrhage may result from the use of hemostatic square suture technique.

[Case report: seventeen year old primipara with placenta increta, treated with methotrexate]

A seventeen year old girl in her first pregnancy had a normal vaginal delivery of a healthy male infant. Afterwards, the placenta was retained and subsequent MRI and ultrasound confirmed placenta increta. There was no history of prior uterine surgery. Conservative treatment with methotrexate was chosen in order to conserve the uterus. During the following nine weeks after birth remnants of the placenta were gradually expelled from the uterus. Subsequently MRI and ultrasound confirmed an empty uterus. When the diagnosis of placenta increta is confirmed the current recommendation is hysterectomy to prevent life threatening bleeding or infection. Conservative treatments have been described to avoid hysterectomy with methotrexate as being one of the options.

Partial placenta increta and methotrexate therapy: three case reports

The term placenta accreta is used to describe any placental implantation in which there is abnormally firm adherence to the uterine wall. This condition complicates 1/2,500 deliveries and is rising in incidence. Abnormal placentation is associated with increased maternal morbidity and mortality from severe hemorrhage, uterine perforation, infection and loss of fertility. The reported experience of methotrexate treatment in the conservative management of placenta accreta is scant. Three cases of partial placenta increta managed with methotrexate are described. The patients were assessed with clinical surveillance, serum beta human chorionic gonadotrophin (beta-hCG) and imaging (ultrasonography and magnetic resonance in one case). In all cases conservative management with methotrexate resulted in undetectable serum beta-hCG, a decrease in the size of partial placenta retained, and undetectable vascularization.

Magnetic resonance imagining (MRI) and serial beta-human chorionic gonadotrophin (beta-hCG) follow up for placenta percreta

BACKGROUND

Placenta percreta is a rare obstetric condition associated with life-threatening hemorrhage. MR imaging has a role in prenatal diagnosis of these cases. However, its role in the postnatal diagnosis and in the follow up yet to be established.

CASE

A 33-year-old patient has adherent placenta following spontaneous delivery at 37 weeks gestation. MR imaging diagnosed placenta percreta. Intramuscular methotrexate treatment was initiated with follow up with serial beta-human chorionic gonadotrophin (beta-hCG). In spite of dropping of the level of beta-hCG, the trophoblastic tissue was still present 6 weeks postnatally where the patient complained of vaginal bleeding where she opted to abdominal hysterectomy.

CONCLUSION

Patients who are suitable for non-surgical therapy, T2-weighted MR imaging may, in conjunction with serial beta-hCG assays, provide an alternative treatment modality for cases of placenta percreta.

Conservative management of placenta accreta and unruptured interstitial cornual pregnancy using methotrexate

We describe two cases which demonstrate methotrexate (mtx) to be an effective alternative to surgery in two serious complications of early pregnancy, namely placenta accreta diagnosed at attempted evacuation of retained products of conception and interstitial cornual pregnancy diagnosed at laparoscopy.

Alternative conservative management of placenta accreta. A case report

BACKGROUND

Placenta accreta is a rare event in pregnancy and may cause life-threatening hemorrhage. This obstetric complication is a diagnostic and management challenge. When the condition is diagnosed, medical management is usually employed first for hemostasis. If the bleeding cannot be controlled, conservative surgical management is attempted, but hysterectomy is often required for definitive care.

CASE

The diagnosis of placenta accreta was made intraoperatively at cesarean section undertaken for breech presentation. The placenta was densely adherent to the anterior lower uterus. Severe hemorrhage, which resulted from attempts to manually remove it, was treated with oxytocin, carboprost tromethamine and methylergonovine without success. The uterus was everted to provide access to the placental site, which was excised; the myometrial defect was sutured closed. Three Foley balloons were used to provide uterine tamponade. Methotrexate was administered prophylactically. These measures effectively controlled the hemorrhage.

CONCLUSION

Because placenta accreta might not be diagnosed antepartum or during labor, especially when no risk factors are present, adequate preparations cannot be made. If it is diagnosed at the time of cesarean section, a combined conservative approach may prove helpful in controlling bleeding and avoid hysterectomy and hypovolemia.

Placenta accreta and methotrexate therapy: three case reports

Placenta accreta is a complication that is rising in incidence. The reported experience of methotrexate treatment in the conservative management of placenta accreta is scant. Three cases of placenta accreta managed with methotrexate are presented. Case 1: A woman had an antenatal diagnosis of placenta percreta. A successful manual placental removal occurred on post-cesarean day 16. Case 2: A woman had retention of a placenta accreta after a term vaginal delivery. Successful dilation and curettage were performed on postpartum day 37. Case 3: A woman had an antenatal diagnosis of placenta previa-percreta with bladder invasion. A simple hysterectomy was performed on post-cesarean day 46. Conservative management and methotrexate treatment resulted in uterine preservation in two of our three patients; however, this treatment did not prevent significant delayed hemorrhage. In view of the rapid resolution of vascular invasion of the bladder, methotrexate may have an important role in the management of placenta percreta with bladder invasion. The utility of methotrexate treatment with the conservative management of placenta accreta requires further evaluation.

Placenta percreta with silent rupture of the uterus

We report a case of placenta percreta diagnosed by ultrasound and color doppler image at the fourteenth week of gestation. Initial approach was a trial of IM methotrexate followed by total hysterectomy, during which was observed a rupture of the uterus with the adherence of the placenta to the posterior region of the bladder. We also present a literature review on the incidence of placenta percreta, etiology, diagnosis, treatment, and complications.

Failure of methotrexate treatment for term placenta percreta

Placenta percreta is a severe condition associated with maternal morbidity and mortality even when surgery is performed electively. Methotrexate has been suggested as a possible treatment modality for adherent placenta to avoid catastrophic surgery. The purpose of this report is to present a case where the placenta was left in situ to avoid cystectomy at the time of cesarean section, with subsequent failure of treatment with methotrexate.

Nonsurgical management of placenta percreta: a case report

BACKGROUND

Although placenta percreta is rare, its sequelae include potentially lethal hemorrhage and loss of reproductive function. Therapy directed toward control of life-threatening hemorrhage frequently includes emergency hysterectomy.

CASE

A woman with placenta percreta, suspected clinically and documented radiographically, was treated nonsurgically. Following delivery, the placenta was left in situ and methotrexate chemotherapy was initiated to aid destruction of the trophoblastic tissue. Eight months later, hysteroscopy showed a normal uterine cavity with only a small area of calcification at the presumed implantation site. Two years later, the patient had a normal pregnancy and vaginal delivery.

CONCLUSION

Placenta percreta can be managed with preservation of the uterus, but careful follow-up may be required until the entire placenta has resorbed.

Bovine retained placenta: effects of collagenase and hyaluronidase on detachment of placenta

A significant percentage of cows (11%) fail to release the placenta within 12 h postpartum. Failure of collagen breakdown seems to be related to the retention of placentas. Sections of placentomes incubated with bacterial collagenase caused an increase in placentome proteolysis (6.6-fold) and placentome collagenolysis (94-fold) within 4 h in a dose-related fashion (r = 0.94). Injections of collagenase (825 U/cc) into the placentomes, via umbilical vessels, decreased the cotyledon-caruncle binding force (determined by manometry) to 30 +/- 5 mm Hg from 97 +/- 2 mm Hg, and increased proteolysis by 42% within 8 h (r = -0.95). Hyaluronidase at various concentrations (400-8 250 U/cc) and at various incubation times (up to 8 h) was not effective. Hyaluronidase (825 U/cc) and collagenase (825 U/cc) were not synergistic in loosening cotyledon-caruncle attachment. A single 15-min collagenase pulse, given prior to perfusion with collagenase-free blood, was as effective in loosening cotyledon attachment as was a sustained 2-h perfusion of blood with collagenase added. It was concluded that collagenase caused collagenolysis and loosening of cotyledon from caruncle, but collagenolysis and cotyledon-caruncle separation were not facilitated by the presence of hyaluronidase.

Management of retained placenta using intraumbilical oxytocin injection

Manual removal of the placenta carries significant risk of hemorrhage and infection plus the risks associated with general anesthesia, if used. Transporting the patient from home or birthing center to hospital or from birthing room to delivery room or operating room is also disruptive to the patient and the initial parent-infant attachment process. The injection of oxytocin into the umbilical vein is a safe procedure that can cause placental separation and delivery, thus preventing the need for manual removal for some women. This technique can be useful in a nurse-midwifery practice in the management of a retained placenta or prolonged third stage of labor. The following review of current research and example of a protocol used in a nurse-midwifery service will provide guidance for incorporating this procedure into practice. As with any new technique, the need to continue to collect and publish outcome data is important.

The effect of oxytocin injection into the umbilical vein for the management of the retained placenta

In a single-blind study 51 patients with retention of the placenta were randomized into one of three groups: Group 1 was given 10 IU of oxytocin in 10 ml of sodium chloride into the umbilical vein; group 2 was given 10 ml of sodium chloride; group 3 was treated with manual removal of the placenta. No significant differences were recorded in groups 1 and 2, and no advantages were found in comparison with the procedure normally used.

Medical treatment of placenta accreta with methotrexate

Placenta accreta is a rare condition and is associated with considerable maternal morbidity and mortality. Though the surgical approach of hysterectomy is a definitive therapy, there are occasions when conservation of the uterus is desired by the patient. We report a case of placenta accreta successfully treated with intravenous methotrexate. After 2 weeks of treatment no signs of placenta could be visualized on ultrasound examination of the uterus. The patient was discharged after 15 days and has since been well. Such therapy may be useful in exceptional cases in institutions with adequate facilities for careful monitoring and management of the patient.