A 30-Year-Old Woman With an Abnormal Fetal Ultrasound

Craig Johnson, DO; Zachary Redus; Michael Mader, MD; Frederick Eruo, MD, MPH


April 25, 2017

Placenta accreta is potentially life-threatening to both mother and fetus. The immediate clinical consequence of placenta accreta is massive hemorrhage at the time of placenta removal, and it is the most common indication for emergency intra- or postpartum hysterectomy.[1]

Because placenta previa is a risk factor for placental accreta, patients commonly present with third-trimester painless vaginal bleeding. Such complications as hematuria may occur if placenta percreta is present, resulting from direct penetration into the bladder. Because of this, urinalysis is sometimes performed.

In a patient with imaging findings highly suggestive of placenta accreta, management must begin in the prenatal period. During this period, a multidisciplinary approach must be used to fully inform the patient and family of the potential outcomes and management options.

The risks and benefits of extirpative vs conservative management should be adequately discussed with the patient. Extirpative management, with a scheduled cesarean delivery and hysterectomy at 35-37 weeks of gestation, may be performed. If the patient opts for uterine conservation to allow subsequent pregnancy, measures can be implemented. Commonly, cesarean deliveries alone can be successful because most cases of placenta accreta are focal. Methotrexate administration and uterine artery embolization have been reported, and the literature has either demonstrated various results (with methotrexate) or suggested no benefit (with uterine artery embolization).[6]

Whether extirpative or uterine-conserving management is chosen, the delivery must be performed in a center with staff trained for complicated surgeries potentially involving the bowel or bladder; appropriate equipment and resources should be available to handle the many significant complications that may be encountered during the procedure. A blood bank capable of providing large volumes of blood in emergency situations is particularly important.[1,6]

Given the patient's findings on ultrasonography and MRI, a cesarean delivery was scheduled, with a high probability of hysterectomy. At the time of the cesarean delivery, the patient was at 36 weeks and 5 days of intrauterine gestation by ultrasonographic dating. As a result of the close approximation of the ureters and the increased risk for trauma during this procedure, the patient underwent bilateral ureteral stent placement for direct visualization of the ureters. After delivery of the fetus, a portion of the placenta remained tightly adhered to the uterus. The decision was made to proceed with cesarean supracervical hysterectomy.

The patient tolerated the procedure well. No complications were noted, and the patient was taken to the recovery room in stable condition. The pathologic findings were an area of thinning consistent with previous low transverse incision, with scar formation on the anterior surface of the uterus. This scarred area was focally and markedly thinned to 2 mm. The placenta was adherent to this area. Examination of the surgical specimen displayed a uterus with focal changes of placenta accreta. The patient was discharged to home from the hospital 4 days after surgery.


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