About the Authors

Dr. Kumkum Avasthi, MD (Obst. & Gynae), Prof. & Head

Dr. Sunil K. Juneja DNB (Obst. & Gynae) Asstt. Prof.

Dr. Anupama Goel Senior Resident

Abstract

We present a case of placenta accreta after a full term vaginal delivery in a 27 years old multigravida with an unscarred uterus. Though Surgery has been the mainstay of treatment. An alternative but unsubstantiated treatment is to leave the placenta undelivered and treat the patient with methotrexate as we have managed our case in haemodynamically stable patient.

Introduction

Placenta accreta remains a serious obstetric complication with mortality rate of around 7%1. It is a placental disorder in which the anchoring placental villi directly contact the myometrium leading to incomplete separation at time of delivery & may result in substantial intrapartum morbidity & mortality.

Case History

A patient J. K. 27 years, P3 A0 presented with postpartum haemorrhage with retained placenta after a full term vaginal delivery 6 hours back in a private nursing home where manual removal of placenta was tried but failed so she was refered to Dayanand Medical College and Hospital on 5.6.2002. Her previous two vaginal deliveries were uneventful.

On admission she was conscious, cooperative, Pulse-100/ mt, BP-110/60 mm of Hg, Resp. rate -20 / mt, Afebrile, Pallor +, no cyanosis/ edema, Chest-NAD, CVS -NAD.

On abdominal examination: Uterus was 20 weeks size, well contracted , bleeding per vaginum – moderate in amount .

Management

Investigations

B +ive. , Hb was 7.5 gms %, TLC, DLC Platelets, Coagulation profile, Renal function tests, Liver function tests were with in normal limits.

An ultrasound of Abdomen showed - Uterus enlarged to postpartum size. Endometrial cavity showed extensive air, fluid and echogenic material. suggestive of Placenta. No definite uterine wall invasion seen . No adenexal mass , No free fluid in lower Abdomen.

Resuscitative measures started and blood transfused, put on broad spectrum antibiotics. Patient was shifted to operation theater . Pelvic examination under G.A. revealed that the placenta was adherent and could not be separated from uterine wall yet the condition of patient was stable .Vitals were maintained and there was minimal bleeding per vaginum. Hence a decision for conservative management taken.

Tab Methotrexate was started in the doses of 5 mg TDS for 5 days. Daily TLC, DLC was done which remained within normal limits, size of the uterus decreased and was not palpable after 7 days , Bleeding P/V remained within normal limits and was not foul smelling. Patient was discharged after 10 days of admission in a stable condition.

On subsequent visit after 15 days – Patient remained afebrile , no evidence of infection observed . On Pelvic examination – os was open, products felt in the uterine cavity , uterus size enlarged to 8 weeks size , nontender . mobile. A repeat ultra sound lower Abdomen showed - bulky uterus having placental tissue.

She was readmitted and Tab Methotrexate 5 mg TDS X 5 days was given again after all the investigations were done. TLC and DLC remained within normal limits. Vaginal culture showed no growth of organism. She was discharged after five days of admission in a satisfactory condition. On follow up after two weeks she had no complaints . On Pelvic examination – os closed, uterus multiparous size , nontender , fornics free . Ultrasound at that time showed normal sized uterus, Endometrial thickness was 19 mm and echogenic.

Follow up

One month after second course of chemotherapy patient was asymptomatic and vaginal examination revealed anteverted, normal sized, firm, mobile, uterus with no adenexal mass. Ultrasound confirmed the clinical findings , endometrial thickness being 9 mm . Subsequent two follow ups at monthly intervals showed normal pelvic findings.

Discussion

The incidence of placenta accreta is increasing & reported incidence is that 1 in 18,000 pregnancies². Predisposing factors for invasive implantation include previous ceasarian delivery or any other source of uterine scarring, placenta previa, advanced maternal age and multiparity.

Prenatal diagnosis is crucial for appropriate management planning to be performed. Transabdominal grayscale sonography is 100% sensitive for anterior placenta accreta yet MRI remains the modality of choice for posterior uterine lesion³.

Two strategies for management of placenta accreta have been described , namely surgical removal of the uterus and conservative management i.e. chemotherapy or selective embolisation of pelvic blood vessels & balloon occlusion of aorta.

Mussali et al in 2000 managed three cases of placenta accreta with methotrexate⁴ & succeeded in preserving the uterus in two cases.

Andrew⁵ in 2001 successfully treated a case of placenta percreta with methotrexate.

Conclusion

Chemotherapy does place the patient at continued risk for massive haemorrhage however and requires prolonged intensive observation. But it preserves the reproductive capabilities and is a reasonable option in well selected haemodynamically stable patients of adherent placenta.

References

1. Risk of Hemorrhage and Scarring in Placenta Accreta Published by the American Academy of Family Physicians American Family Physician August 1999.
2. Aboulafia . Y, Lavie O, Grisarn S G , Conservative surgical management of acute abdomen caused by placenta percreta in the 2nd trimester. Am.J. Obstet Gynaecol 1994: 170:1388-9.
3. Levine D, Hulka.C. A. ,Ludmir J et al . Placenta accreta : Evaluation with colour Doppler U.S , Power Doppler U .S . and MR imaging .Radiology 1997:205:773-6.
4. Mussalli GM, Shah J, Berch DJ, Elimian A, Tejani N, Manning FA.Placenta accreta and methotrexate therapy: three case reports. J Perinatol 2000 Jul-Aug; 20 (5) :331-4
5. Andrew Sonin . Nonoperative Treatment of Placenta Percreta AJR 2001;177;1301-1303 American Roentgen Ray Society.