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. 2023 Dec 26;13(1):135.
doi: 10.3390/jcm13010135.

Placenta Accreta Spectrum Prophylactic Therapy for Hyperfibrinolysis with Tranexamic Acid

Tiyasha Hosne Ayub  1 , Brigitte Strizek  1 , Bernd Poetzsch  2 , Philipp Kosian  1 , Ulrich Gembruch  1 , Waltraut M Merz  1
Affiliations

Placenta Accreta Spectrum Prophylactic Therapy for Hyperfibrinolysis with Tranexamic Acid

Tiyasha Hosne Ayub et al. J Clin Med. .

Abstract

Background: To report on prophylactic therapy for hyperfibrinolysis with tranexamic acid (TXA) during expectant management (EM) in the placenta accreta spectrum (PAS).

Methods: This is a monocentric retrospective study of women with PAS presenting at our hospital between 2005 and 2021. All data were retrospectively collected through the departmental database.

Results: 35 patients with PAS were included. EM was planned in 25 patients prior to delivery. Complete absorption of the retained placenta was seen in two patients (8%). Curettage was performed in 14 patients (56%). A hysterectomy (HE) was needed in seven (28%) patients; 18 patients (72%) underwent uterus-preserving treatment without severe complications. The mean duration of EM was 107 days. The mean day of onset of hyperfibrinolysis and beginning of TXA treatment was day 45. The mean nadir of fibrinogen level before TXA was 242.4 mg/dL, with a mean drop of 29.7% in fibrinogen level.

Conclusions: Our data support EM as a safe treatment option in PAS. Hyperfibrinolysis can be a cause of hemorrhage during EM and can be treated with TXA. To our knowledge, this is the first cohort of patients with EM of PAS in whom coagulation monitoring and use of TXA have been shown to successfully treat hyperfibrinolysis.

Keywords: D-dimer; disseminated intravascular coagulopathy; expectant management; fibrinogen; hyperfibrinolysis; placenta accreta spectrum; tranexamic acid.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
(A–C) PAS in 34 + 0 weeks of gestation with loss of decidua, bladder wall interruption, placental bulge, and exophytic mass hypervascularity. (D,E) Placenta in situ on day 13 after CS with persistent bladder wall interruption. (F) Placenta in situ on day 63 after CS with a diameter of about 3.5 cm, well separated from the uterine wall, without perfusion. (G) Day 122 after CS; fluid-filled uterine cavity surrounded by a hyperechogenic rim.
Figure 2
Figure 2
(A): A large area of PAS is seen on the front wall of the uterus after abdominal access by a supraumbilical midline incision. (B) Uterine fundal longitudinal incision on the back wall of the uterus avoiding the placenta. (C) Closed uterotomy after leaving the placenta in situ.
Figure 3
Figure 3
Placenta accreta spectrum: management and outcome. EM—expectant management; CS—cesarean section; HE—hysterectomy.
Figure 4
Figure 4
(A) Placenta in situ on day 9 after CS. (B) Placenta in situ on day 15 after CS. (C) Regressively altered placenta in situ on day 64 after CS. (D) Placenta in situ well separated from the uterine wall without perfusion on day 106 after CS. (E) Day 194 after CS with a hyperechogenic rim around a fluid-filled uterine cavity.
Figure 5
Figure 5
Fibrinogen during EM and treatment with TXA in 11 patients. The days when TXA therapy was started are highlighted in bold. The mean day of initiating TXA therapy after CS was day 45 (arrow).
Figure 6
Figure 6
D-dimer during EM and treatment with TXA in six patients. The days when TXA therapy was started are highlighted in bold. The mean day of initiating TXA acid therapy after CS was day 45 (arrow).
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