Conservative management of abnormally invasive placenta complicated by local hyperfibrinolysis and beginning disseminated intravascular coagulation

Abstract

Introduction: Abnormally invasive placenta (AIP) is often associated with high maternal morbidity. In surgical treatment, caesarean hysterectomy or partial uterine resection may lead to high perioperative maternal blood loss. A conservative treatment by leaving the placenta in utero after caesarean delivery of the baby is an option to preserve fertility and to reduce peripartum hysterectomy-related morbidity. Nevertheless, due to increased placental coagulation activity as well as consumption of clotting factors, a disseminated intravascular coagulation (DIC)-like state with secondary late postpartum bleeding can occur.

Purpose: Systematic review after the presentation of a case of conservative management of placenta percreta with secondary partial uterine wall resection due to vaginal bleeding, complicated by local hyperfibrinolysis and consecutive systemic decrease in fibrinogen levels.

Methods: Systematic PubMed database search was done until August 2019 without any restriction of publication date or journal RESULTS: Among 58 publications, a total of 11 reported on DIC-like symptoms in the conservative management of AIP, in the median on day 59 postpartum. In most cases, emergency hysterectomy was performed, which led to an almost immediate normalization of coagulation status but was accompanied with high maternal blood loss. In two cases, fertility-preserving conservative management could be continued after successful medical therapy.

Conclusion: Based on these results, we suggest routinely monitoring of the coagulation parameters next to signs of infection in the postpartum check-ups during conservative management of AIP. Postpartum tranexamic acid oral dosage should be discussed when fibrinogen levels are decreasing and D-Dimers are increasing.

Keywords: Abnormal invasive placenta; Conservative management; Disseminated intravascular coagulation; Fibrinogen levels; Placenta in situ; Placenta percreta.

Fig. 1

Abdominal sonography in 22 + 6 weeks of gestation, sagittal view, b-mode. Suspected percrete area of the placenta (marked with arrows) with typical bulging into the bladder (B) and thinning of the myometrium (M). Fetal head (FH), placenta (P), amniotic fluid (AF)

Fig. 2

Transvaginal sonography in 22 + 6 weeks of gestation, colour mode, glassbody mode. Pattern of vascularisation at the interface between placenta and bladder wall with bridging vessels. Bladder wall is marked with arrows

Fig. 3

Intraoperative image, day 55 postpartum. Anterior uterine wall before the partial resection with the placenta still in situ and the percrete area visible from the outside (marked with arrows) after surgical preparation and separation of the adhesive bladder wall. The bladder wall itself was not invaded by placenta tissue, as suspected in ultrasound

Fig. 4

Intraoperative image, day 55 postpartum. Anterior uterine wall after partial uterine resection and reconstruction. Cranial visible the fundal incision from the cesarean section

Fig. 5

a–c Rotational Thromboelastometric analysis in citrated blood samples (ROTEM®, TEM International, Munich, Germany) showing the clot formation (mm) over time (s) at the beginning of surgery. The INTEM® (phospholipids and ellagic acid to initiate intrinsic clotting; (a) and EXTEM® (tissue factor to initiate extrinsic clotting; (b) analysis with prolonged clot formation times (CFT, seconds) and reduced clotting amplitudes after a clotting time (CT, seconds) of 5, 10, 20, 30 min (A5-A30; mm) and clot formation angle (α, degrees) reflect the concomitant consumption of clotting factors for the intrinsic and extrinsic pathway of coagulation. The reduced amplitudes of the fibrinogen related clot formation at different time points (A5-A30) as well as the prolonged CT in the FIBTEM® Test (Inhibition of platelet activity using cytochalasin to reflect clot tracing dependent on fibrinogen; (c) show the reduced functional fibrinogen fraction in clot formation