Unexpected placenta accreta spectrum after the use of assisted reproductive technology in women with adenomyomectomy

Abstract

Placenta accreta spectrum (PAS) is a rare complication that can lead to life-threatening postpartum hemorrhage. PAS can sometimes occur unexpectedly, without placenta previa;such cases can lead to higher maternal mortality and morbidity than expected cases. Here, the authors report a case of unexpected PAS caused by assisted reproductive technology (ART) in a woman with adenomyosis. The patient was a 37-year-old Japanese primipara woman who presented to our hospital at 11 weeks gestation, later returning to her parents' house to give birth. The woman had adenomyosis and underwent adenomyomectomy, which was followed by an ART pregnancy. The patient was admitted to our hospital because of a life-threatening preterm birth, with a short cervix and no evidence of placenta previa. Despite strict perinatal management, preterm rupture of the membrane (PROM) occurred. During laparotomy, the small intestine, rectum, and both right and left ovaries were clumped together and severely adhered to the surface of the uterus. After delivery, manual partial removal of the placenta was performed, resulting in heavy bleeding from the implantation site, which was diagnosed as an unexpected PAS. Following several uterine compression efforts, we successfully preserved the uterus.

Keywords: adenomyosis; placenta accreta spectrum; preterm birth.

Figure 1.

Sagittal T2-weighted MRI at 30 weeks showed no evidence of placenta previa, and the placenta was mainly located on the posterior wall (T2).

Figure 2.

Coronal T2-weighted MRI at 30 weeks showed that the placenta was mainly located on the left fallopian tube angle. Because of the location of placentation with Figure 1, the uterine wall was extruded toward the left fallopian tube (circle). The MRI also showed a loss of continuity of the uterine wall (arrow), suggesting the presence of unexpected PAS.

Figure 3.

Intraoperative image. The Douglas fossa was completely closed because of strict adhesion between the uterine surface, bile ovary, sigmoid intestine, and small intestine.