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First trimester `retained abortion' — can it be termed `placenta accreta'?
International Journal of Gynecology & Obstetrics 65 Ž1999. 189]190
Case report
First trimester ‘retained abortion’ } can it be termed ‘placenta accreta’? D. DekaU Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India Received 13 August 1998; accepted 26 August 1998
Keywords: Retained abortion; Placenta accreta; Management
1. Introduction Morbid adhesions of the placenta-accreta, increta and percreta are very rare before 20 weeks of pregnancy and rarer still in the first trimester. They are usually diagnosed when difficulty is encountered at curettage and are termed ‘retained abortion’. Though hysterectomy is the treatment of choice, attempts at uterine conservation are worthwhile in patients who want to become fertile. Two extremely rare and challenging cases of first trimester missed abortion in nulliparous women, complicated by several unsuccessful attempts at uterine evacuation are described. 1.1. Case 1 A 25-year-old second gravida with history of failed evacuation of a 9-week missed abortion was referred to our tertiary center. She had had an illegal septic abortion 2 years previously. On exU
Corresponding author. Fax: q91 011 6862663.
amination, the uterus was at the 8]10-week size but the ultrasound revealed a dead 9]10-week crumpled fetus with no liquor amnii. Intracervical prostaglandin E 2 gel Ž0.5 mg. was administered. After 2 h the patient had bleeding per vagina, the cervix had dilated and products of conception were felt in the canal. The fetus was removed with ovum forceps but placental tissues could not be aspirated or curetted out. Under general anesthesia sharp curettage enabled removal of the placenta piece meal. The procedure was abandoned after 1 h when no tissues could be retrieved. As evacuation was incomplete, an injection of methotrexate Ž50 mg i.m.. was administered. Bleeding from the vagina occurred and was within normal limits. Ultrasound after 2 weeks showed an empty uterus. The patient subsequently conceived after 1 year and had a normal delivery. 1.2. Case 2 A 24-year-old primigravida was referred to us as a case of missed abortion at 10 weeks gestation
0020-7292r99r$20.00 Q 1999 International Federation of Gynecology and Obstetrics. PII: S 0 0 2 0 - 7 2 9 2 Ž 9 8 . 0 0 1 7 6 - 3
190
D. Deka r International Journal of Gynecology & Obstetrics 65 (1999) 189]190
and four unsuccessful attempts of uterine evacuation at different centers. In the third instance, there was a history of perforation of the posterior uterine wall during curettage, which was managed conservatively. The fourth attempt was under ultrasound guidance, but perforation again occurred during dilatation with Hegar’s dilator No. 8. During the last 3 weeks of intrauterine fetal death and four attempts at uterine evacuation, the patient had minimal bleeding. On examination, the uterus was of 8]10 weeks size. Ultrasound showed a dead fetus with low lying placenta. Several hypo- and hyper-echoic areas 2]3 mm in depth were seen in the decidua and myometrium overlying the placenta. Clot retraction time was 1 h, but fibrinogen levels were normal. Consent was obtained for hysterotomy. Intracervical prostaglandin E 2 gel was administered. After 20 min, the patient had abdominal pain and bleeding from the vagina. The cervix was open and products of gestation were felt in the canal. The fetus and part of placenta could be removed using ovum forceps. The rest of the placenta was removed using a blunt and sharp curette under ultrasound guidance until the uterus was empty. 2. Discussion It is claimed that these were cases of retained placenta and not accreta, but when conservative management is done, there can be no histopathological proof. The patients’ histories and clinical findings at curettage confirm the diagnosis of morbidly adherent placentae. As both patients desired conservation of the uterus, evacuation was a very difficult procedure, especially in the second patient who had a history of perforation of the uterus on two occasions. Monitoring her, while prostaglandin was being administered, was like sitting on a volcano, in the desperate attempt for uterine conservation at all costs. Prostaglandin E 2 causes collagen breakdown in
the cervix, resulting in cervical ripening. It also increases myometrial activity at any period of gestation, and in both the cases very effectively allowed cervical dilation and expulsion of the fetus and placenta. Use of methotrexate helped autolysis of any remaining chorionic villi, thereby preventing postabortal problems. Only four cases of morbid adhesions of the placenta in the first trimester of pregnancy, could be found in the literature } a case of first trimester placenta accreta diagnosed during curettage for which hysterectomy was done w1x, a case of placenta increta occurring in a blighted ovum for which hysterectomy was required w2x, a case of placenta percreta in the first trimester of pregnancy diagnosed at curettage, and subsequent hysterectomy w3x, and another case of placenta percreta w4x. In the first trimester of pregnancy, placentation is not yet completed. Abnormal trophoblastic invasion can, however, occur very early, and these rare events have been listed as ‘retained abortion’. when difficulty is encountered at curettage. The definition of such exceptional cases } ‘retained abortion’ or ‘placenta accreta’, need to be resolved. The management of such problems also deserve discussion, as more cases will be seen in the future, since rising trends of risk factors like medical termination of pregnancies and cesarean sections are apparent. References w1x Arrendondo F, Sabella V, Garza-Leal J. Placenta accreta during the first trimester of pregnancy. A case report. Gynecol Obstet-Mex 1995;63:279]281. w2x Gist RS, Vuong V, Brody S, Rees P, Landry D. Placenta increta occurring in a blighted ovum. South Med J 1996;89:545]547. w3x Woolcott R, Nicholl M, Gibson J. A case of placenta percreta presenting in the first trimester of pregnancy Aust NZ Jour. Obstet Gynaecol 1987;27:258]260. w4x Haider P. Placenta percreta in early gestation. J Pak Med Assoc 1990;40:274]275.
Case report
First trimester ‘retained abortion’ } can it be termed ‘placenta accreta’? D. DekaU Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India Received 13 August 1998; accepted 26 August 1998
Keywords: Retained abortion; Placenta accreta; Management
1. Introduction Morbid adhesions of the placenta-accreta, increta and percreta are very rare before 20 weeks of pregnancy and rarer still in the first trimester. They are usually diagnosed when difficulty is encountered at curettage and are termed ‘retained abortion’. Though hysterectomy is the treatment of choice, attempts at uterine conservation are worthwhile in patients who want to become fertile. Two extremely rare and challenging cases of first trimester missed abortion in nulliparous women, complicated by several unsuccessful attempts at uterine evacuation are described. 1.1. Case 1 A 25-year-old second gravida with history of failed evacuation of a 9-week missed abortion was referred to our tertiary center. She had had an illegal septic abortion 2 years previously. On exU
Corresponding author. Fax: q91 011 6862663.
amination, the uterus was at the 8]10-week size but the ultrasound revealed a dead 9]10-week crumpled fetus with no liquor amnii. Intracervical prostaglandin E 2 gel Ž0.5 mg. was administered. After 2 h the patient had bleeding per vagina, the cervix had dilated and products of conception were felt in the canal. The fetus was removed with ovum forceps but placental tissues could not be aspirated or curetted out. Under general anesthesia sharp curettage enabled removal of the placenta piece meal. The procedure was abandoned after 1 h when no tissues could be retrieved. As evacuation was incomplete, an injection of methotrexate Ž50 mg i.m.. was administered. Bleeding from the vagina occurred and was within normal limits. Ultrasound after 2 weeks showed an empty uterus. The patient subsequently conceived after 1 year and had a normal delivery. 1.2. Case 2 A 24-year-old primigravida was referred to us as a case of missed abortion at 10 weeks gestation
0020-7292r99r$20.00 Q 1999 International Federation of Gynecology and Obstetrics. PII: S 0 0 2 0 - 7 2 9 2 Ž 9 8 . 0 0 1 7 6 - 3
190
D. Deka r International Journal of Gynecology & Obstetrics 65 (1999) 189]190
and four unsuccessful attempts of uterine evacuation at different centers. In the third instance, there was a history of perforation of the posterior uterine wall during curettage, which was managed conservatively. The fourth attempt was under ultrasound guidance, but perforation again occurred during dilatation with Hegar’s dilator No. 8. During the last 3 weeks of intrauterine fetal death and four attempts at uterine evacuation, the patient had minimal bleeding. On examination, the uterus was of 8]10 weeks size. Ultrasound showed a dead fetus with low lying placenta. Several hypo- and hyper-echoic areas 2]3 mm in depth were seen in the decidua and myometrium overlying the placenta. Clot retraction time was 1 h, but fibrinogen levels were normal. Consent was obtained for hysterotomy. Intracervical prostaglandin E 2 gel was administered. After 20 min, the patient had abdominal pain and bleeding from the vagina. The cervix was open and products of gestation were felt in the canal. The fetus and part of placenta could be removed using ovum forceps. The rest of the placenta was removed using a blunt and sharp curette under ultrasound guidance until the uterus was empty. 2. Discussion It is claimed that these were cases of retained placenta and not accreta, but when conservative management is done, there can be no histopathological proof. The patients’ histories and clinical findings at curettage confirm the diagnosis of morbidly adherent placentae. As both patients desired conservation of the uterus, evacuation was a very difficult procedure, especially in the second patient who had a history of perforation of the uterus on two occasions. Monitoring her, while prostaglandin was being administered, was like sitting on a volcano, in the desperate attempt for uterine conservation at all costs. Prostaglandin E 2 causes collagen breakdown in
the cervix, resulting in cervical ripening. It also increases myometrial activity at any period of gestation, and in both the cases very effectively allowed cervical dilation and expulsion of the fetus and placenta. Use of methotrexate helped autolysis of any remaining chorionic villi, thereby preventing postabortal problems. Only four cases of morbid adhesions of the placenta in the first trimester of pregnancy, could be found in the literature } a case of first trimester placenta accreta diagnosed during curettage for which hysterectomy was done w1x, a case of placenta increta occurring in a blighted ovum for which hysterectomy was required w2x, a case of placenta percreta in the first trimester of pregnancy diagnosed at curettage, and subsequent hysterectomy w3x, and another case of placenta percreta w4x. In the first trimester of pregnancy, placentation is not yet completed. Abnormal trophoblastic invasion can, however, occur very early, and these rare events have been listed as ‘retained abortion’. when difficulty is encountered at curettage. The definition of such exceptional cases } ‘retained abortion’ or ‘placenta accreta’, need to be resolved. The management of such problems also deserve discussion, as more cases will be seen in the future, since rising trends of risk factors like medical termination of pregnancies and cesarean sections are apparent. References w1x Arrendondo F, Sabella V, Garza-Leal J. Placenta accreta during the first trimester of pregnancy. A case report. Gynecol Obstet-Mex 1995;63:279]281. w2x Gist RS, Vuong V, Brody S, Rees P, Landry D. Placenta increta occurring in a blighted ovum. South Med J 1996;89:545]547. w3x Woolcott R, Nicholl M, Gibson J. A case of placenta percreta presenting in the first trimester of pregnancy Aust NZ Jour. Obstet Gynaecol 1987;27:258]260. w4x Haider P. Placenta percreta in early gestation. J Pak Med Assoc 1990;40:274]275.