Conservative management of placenta accreta in a multiparous woman

Abstract

Placenta accreta refers to any abnormally invasive placental implantation. Diagnosis is suspected postpartum with failed delivery of a retained placenta. Massive obstetrical hemorrhage is a known complication, often requiring peripartum hysterectomy. We report a case of presumed placenta accreta in a patient following failed manual removal of a retained placenta. We describe an attempt at conservative management with methotrexate in a stable patient desiring future fertility. Treatment was unsuccessful and led to the development of a disseminated intrauterine infection complicated by a bowel obstruction, requiring both a hysterectomy and small bowel resection. In hemodynamically stable patients, conservative management of placenta accreta may involve leaving placental tissue in situ with subsequent administration of methotrexate. However, ongoing close observation is required to identify complications.

Figure 1

Transabdominal ultrasound image taken on postpartum day 17. This view of the uterine fundus demonstrates significant persistence of retained placental tissue approximately two weeks after methotrexate administration. Serum βhCG was 1571 UI/L. The distinction between the placental mass (dotted line) and myometrium (asterisk) is shown. Transabdominal ultrasound image taken on postpartum day 24. This view of the uterine fundus shows significant persistence of retained placental tissue approximately three weeks after methotrexate administration. Serum βhCG was 479 UI/L. The distinction between the placental mass (dotted line) and myometrium (asterisk) is depicted.

Figure 2

CT scan of the patient's abdomen on postpartum day 27 demonstrating the uterus with the retained placenta was demonstrated (arrow). The presence of dilated, fluid filled loops of small bowel with collapse of the large bowel confirmed the diagnosis of a mechanical small bowel obstruction. A possible adhesion was noted between the uterine fundus and the bowel (not shown here).