|Year : 2015 | Volume
| Issue : 1 | Page : 36-38
Management of placenta accreta by uterine artery embolization: A case report
Neeta Natu1, Kailash Patel2, Nootan Chandwaskar1, Akanksha Chauhan1, Avneet Arora1, Ravindra Kumar3
1 Department of Obstetrics and Gynecology, Central Research Laboratory, Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh, India
2 Department of Imaging & Interventional Radiology, Central Research Laboratory, Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh, India
3 Departments of Obstetrics and Gynecology, Central Research Laboratory, Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh, India
|Date of Submission||09-Apr-2014|
|Date of Acceptance||26-Nov-2014|
|Date of Web Publication||6-Apr-2015|
Department of Obstetrics and Gynecology, Sri Aurobindo Medical College and PG Institute, Indore - Ujjain State Highway near MR10 Crossing, Sanwer Road, Indore - 453 111, Madhya Pradesh
Placenta accreta is one of the most serious complications of pregnancy and is frequently associated with severe obstetric hemorrhage, usually necessitating hysterectomy. Here, we are appending a case in the literature one with placenta accreta with previa. Uterine artery embolization was performed for the management of postpartum hemorrhage after subtotal hysterectomy.
Keywords: accreta, placenta, uterine artery embolization
|How to cite this article:|
Natu N, Patel K, Chandwaskar N, Chauhan A, Arora A, Kumar R. Management of placenta accreta by uterine artery embolization: A case report. Tanta Med J 2015;43:36-8
|How to cite this URL:|
Natu N, Patel K, Chandwaskar N, Chauhan A, Arora A, Kumar R. Management of placenta accreta by uterine artery embolization: A case report. Tanta Med J [serial online] 2015 [cited 2017 Jun 22];43:36-8. Available from: http://www.tdj.eg.net/text.asp?2015/43/1/36/154555
| Introduction|| |
Placenta accreta is a general term used to describe the clinical condition when part of the placenta, or the entire placenta, invades and is inseparable from the uterine wall. When the chorionic villi invade only the myometrium, the term placenta increta is appropriate, whereas placenta percreta describes invasion through the myometrium and serosa, and occasionally into adjacent organs, such as the bladder. Most cases of placenta accreta are associated with placenta previa, which is defined as partial or complete localization of the placenta in the lower uterine segment  .
The estimated incidence of placenta accreta is 1.7 per 10 000 maternities. The incidence is considerably higher in women with both a previous cesarean delivery and placenta previa, occurring in around one in every 20 such women  .
Placenta accreta is associated with major pregnancy complications, including life-threatening maternal hemorrhage, large-volume blood transfusion, and peripartum hysterectomy , .
Here, we are reporting a case of placenta accreta diagnosed by ultrasound. Uterine artery embolization was performed in one patient for the management of postpartum hemorrhage.
| Case report|| |
A 25-year-old G3P1L1A1 woman with a pregnancy of 8 months visited to us with the complaint of spasmodic and nonradiating pain in the abdomen. Pain was severe in intensity and associated with severe backache since last 1 day. There was no history of blurring of vision, headache, and bleeding per vagina in past. Patient perceived fetal movements well. Patient's previous ultrasound scans from 20 weeks of pregnancy showed placenta previa with accreta. Pregnancy was continuing and she had no complaints all through pregnancy.
On clinical examination, patient was found conscious, afebrile, pallor, and dehydrated. Tachycardia was observed with pulse rate of 120/min. Blood pressure was 120/80 mmHg. Abdomen examination revealed uterus of around 32 weeks and was tensed and tender to touch. Fetal heart sounds were normal. Transverse scar of previous cesarean section was present over the lower abdomen. There was no bleeding per vagina. Ultrasound scan at the time of admission showed single living intrauterine fetus of 30.5 weeks of gestation with placenta previa with accreta; amniotic fluid was adequate and estimated fetal weight was 1.6 kg. Patient was immediately taken for emergency Cesarean section, as patient had acute pain in the abdomen and was in labor. Two units of blood were also arranged before surgery as patient was anemic (hemoglobin = 8.8 g/dl).
Intraoperatively, abdominal layers were found adherent to omentum and bladder ([Figure 1]a and b). Bladder was spontaneously perforated because of partial placental invasion. Urology surgeons were called for managing bladder perforation. On separating the layers, thin lower uterine segment was found. On opening lower uterine segment, bleeding occurred profusely. Baby was delivered and was resuscitated. Placenta was adherent to lower uterine segment from the previous scar site and was extending down up to cervix. Therefore, we were not able to separate whole placenta. Bleeding was uncontrolled, and therefore to overcome hypovolemic shock intraoperatively blood transfusion was started. Hemostatic suturing was performed but bleeding was uncontrolled. Decision of subtotal hysterectomy was taken. Patient lost about 4 l of blood and went into disseminated intravascular coagulation. Patient was put on noradrenaline and dopamine infusion, and 8 U of packed red blood cell and 2 U of fresh frozen plasma were given. Patient maintained blood pressure, pulse, and other vitals. Bladder repair was performed by surgeons with more hemostatic sutures. Abdomen was closed and abdominal drain was put. Vaginal packing was performed and patient was shifted to general ICU and was put on ventilator support. Postoperatively, patient was given 2 U of blood transfusion. Patient was maintaining blood pressure, pulse, and urinary output on ventilator, and postoperative period was uneventful. Patient was stable on second postoperative day and was taken off the ventilator, and no active bleeding was present. On seventh postoperative day, patient was stable and was shifted to ward. Patient was discharged after 2 weeks; condition on discharge was stable and had no complaints. After 1-week follow-up, patient had no complaints, no bleeding per vagina, was stable, and hemoglobin and other investigations were within normal limits.
|Figure 1: Intraoperative fi ndings showing perforated placenta with excessive bleeding (a, b).|
Click here to view
After 1 month, patient visited the hospital with complaints of dizziness and bleeding per vagina. Ultrasound was performed, which showed retained placental products and/or pelvic mass that was adherent to cervix and was not able to remove at the time of subtotal hysterectomy. MRI performed showed large 9 × 10 × 8 cm size heterogeneous signal intensity lesion in pelvis, which was seen in continuity with the cervix and occupying pelvic cavity and showing a smooth posterior wall. Uterine artery embolization was performed by interventional radiology members after cannulating bilateral uterine arteries superselectively ([Figure 2]). After uterine artery embolization, bleeding stopped completely from the same day. She was discharged after stabilization of condition and is now on regular follow-up. Follow-up ultrasound showed significant reduction in the size of mass.
|Figure 2: Radiology images of uterine artery embolization procedure (a, b).|
Click here to view
| Discussion|| |
Placenta accreta is near catastrophic events out of the deadliest complications, which are massive postpartum hemorrhage, acute inversion with placenta in situ, amniotic fluid embolism, and placenta previa with accreta or increta. Risk factors are previous cesarean section, submucous myoma, previous curettage, Asherman's syndrome, advanced maternal age, grand multiparity, smoking, and chronic hypertension , .
It is life-threatening complication; hence, mortality is high. Diagnosis-strong index of suspicion occurs when there is history of previous two sections. Once diagnosis is made cesarean section should be planned at tertiary center where facilities for massive transfusion, blood products, and critical care unit are present. Safest and most common treatment is Cesarean section and abdominal hysterectomy.
Prenatal identification of these cases and early referral to centers having a team of obstetricians, surgeons, anesthesiologists, and interventional radiologist will likely result in improved outcome. Interventions that may limit transfusion requirements include normovolemic hemodilution; selective embolization of uterine arteries by trained interventional radiologist can save the life of patient by minimal intervention in emergency situation  .
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
Parikh RM, Nakum K, Gokhle AV. Alternative management in a case of placenta accreta with previous caesarean. Int J Reprod Contracept Obstet Gynecol 2012; 1:58-60.
Fitzpatrick KE, Sellers S, Spark P, Kurinczuk JJ, Brocklehurst P, Knight M. Incidence and risk factors for placenta accreta/increta/percreta in the UK: a national case-control study. PLoS One 2012; 7:e52893.
Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol 2006; 107:927-941.
Bauer ST, Bonanno C. Abnormal placentation. Semin Perinatol 2009; 33:88-96.
Zahn CM, Yeomans ER. Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas. Clin Obstet Gynecol 1990; 33:422-431.
Pacheco LD, Gei AF. Controversies in the management of placenta accreta. Obstet Gynecol Clin North Am 2011; 38:313-322.
[Figure 1], [Figure 2]