|Year : 2014 | Volume
| Issue : 2 | Page : 125-127
Conservative management of placenta accreta with injection methotrexate to preserve fertility
Sumit Sukla Das1, L Sushila Devi2, L Ranjit Singh1, Rameshwor Singh1
1 Department of Obstetrics and Gynaecology, RIMS, Imphal, Manipur, India
2 Department of Pathology, JNIMS, Imphal, Manipur, India
|Date of Web Publication||18-Sep-2014|
Dr. Sumit Sukla Das
Department of Obstetrics and Gynaecology, RIMS, Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Placenta accreta is described as anchoring placental villi directly contact the myometrium resulting in firm attachment of the placenta to the myometrium. The incidence of placenta accreta is increasing parallel to raising cesarean section rate. Women at greatest risk of placenta accreta are those who have myometrial damage caused by a previous cesarean delivery with either an anterior or posterior placenta previa overlying uterine scar. Control of bleeding is the main goal in such cases, which usually necessitates hysterectomy or hypogastric artery ligation; embolization of uterine artery that is done by expert interventional radiologists. However, alternative methods are useful when retaining fertility is important in young women with low parity. We present a 28-year old G5P2+0+2+2 who was admitted at 33 weeks of period of gestation for antepartum hemorrhage (APH) with previous cesarean. Even after conservative treatment for APH, she delivered still born preterm baby at 34 weeks with retained placenta where manual removal of placenta failed to remove the placenta. Placenta was removed piecemeal leaving major portion of placenta, which was morbidly adherent. After 13 days of delivery ultrasonography (USG) showed plenty of placental tissue in the uterine cavity with peripheral vascularity and increased serum beta-human chorionic gonadotrophin (β-hCG) level (1980mIU/ml). Injection methotrexate was administered on the 18 th post-partum day following the regime of 1, 3, 5 and 7 days. Repeat USG after 1 week of treatment showed decrease size in placental mass with a decrease in serum β-hCG level and after 6 th post-partum week D&E done with complete removal of placental tissue and at 8 th post-partum week USG shows normal with no retained products of conception and the patient was stable. Hence, methotrexate can thus be helpful as conservative treatment for placenta accreta in conserving the uterus and hence, the fertility.
Keywords: Conservative treatment, Methotrexate, Placenta accreta
|How to cite this article:|
Das SS, Devi L S, Singh L R, Singh R. Conservative management of placenta accreta with injection methotrexate to preserve fertility. J Med Soc 2014;28:125-7
|How to cite this URL:|
Das SS, Devi L S, Singh L R, Singh R. Conservative management of placenta accreta with injection methotrexate to preserve fertility. J Med Soc [serial online] 2014 [cited 2019 Jun 25];28:125-7. Available from: http://www.jmedsoc.org/text.asp?2014/28/2/125/141111
| Introduction|| |
Placenta accreta is a condition chacterized by abnormal adherence of either in whole or a part of the placenta to the myometrium. The true incidence of placenta accreta is difficult to quantify accurately, but it complicates approximately 1 in 2500 deliveries  and the risk of placenta accreta is approximately 0.1% with previous one caesarean section and close to 0.4%, 0.7%, 2-2.2% and nearly 3.5% with previous two, three, four and five or more cesarean section respectively.  It is mostly diagnosed after delivery when manual removal fails to remove the retained placenta. The wide range of complications may include severe postpartum hemorrhage, postpartum curettage, uterine perforation, shock, infection, loss of fertility, and even postpartum death. The most common treatment in developing countries is hysterectomy.
| Case Report|| |
A 28 years old aged Mrs. XYZ, G5P2+O+2+2 with 33 weeks of pregnancy with previous cesarean was admitted on January 22, 2013 in RIMS as a case of antepartum hemorrhage with bleeding per vaginum. It was not associated with pain abdomen or history of any trauma. Patient's first delivery was normal vaginal delivery at hospital, second delivery was full term caesarean section for placenta previa with a history of two medical termination of pregnancy.
On admission, patient's pulse rate was 101/min and blood pressure was 110/60 mmHg. Patient was afebrile and had mild pallor. On abdominal examination, cesarean scar was present, uterus was 32 weeks size, relaxed, with breech presentation, fetal heart sound of 152/min, and without scar tenderness. After 3 days of admission speculum examination shows: Slight bleeding was present from cervical os without other relevant findings.
Investigations revealed hemoglobin (Hb) of 8.0 g% with '"O'' positive blood group. Urine, liver and kidney functions were normal. Ultrasonography (USG) showed single live fetus in breech presentation with placenta in antero-lateral position.
She was managed conservatively monitoring fetal growth and correction of anemia. On 29 th January (33 weeks of pregnancy), she had one episode of bleeding per vaginum and Hb% was 7 g%, and one unit of packed red blood cells (PRBC) was transfused. On 31 st January (33 weeks 2 days of pregnancy), patient went into preterm labor and delivered a still born baby weighing 1.3 kg vaginally with no evidence of any congenital deformity or placenta did not revealed any feature of abruption. Manual removal of placenta (MRP) under general anesthesia failed to remove the placenta and only small fragments of placenta were removed. Placenta with cord was left in situ. Histo-pathological examination of the placenta revealed normal placental tissue. Vital signs were stable, and the patient was administered injection oxytocin and tablet misoprostol 200 mcg intra-vaginally twice in a day. Her Hb% was 6.6 g%, and there was no bleeding per vagina. Broad spectrum antibiotic was administered. Patient again received two units of PRBC. Uterus was 20 weeks size non-tender. On 5 th February (5 th day post-partum), under general anesthesia MRP attempted, but only a small portion of placenta could be removed due to morbid adhesion. Patient was counseled about the complications of adherent placenta and also hysterectomy.
Tablet misoprostol 200 mcg intra-vaginally and broad spectrum antibiotic were administered. During lying in period small bits of placental tissue was expelled per vaginum. USG on 11 th post-partum day showed bulky uterus (12.2 cm × 5.3 cm) and endometrial cavity showed hyper-echoic lesion (6.6 cm × 2 cm) suggestive of retained products of conception with peripheral vascularity and serum beta-human chorionic gonadotropin (β-hCG) was 1980 mIU/ml. Hemogram, liver function test and kidney function test were within normal limits with Hb% of 10 g%. Injection methotrexate was administered on the 16 th day following the regime of 1, 3, 5 and 7 with injection folinic acid on alternate days. On the 26 th post-partum day, serum β-hCG was decreased remarkably (76.4 mIU/ml) with a decrease in placental mass and without any peripheral vascularity and uterine size decreased to 14-16 weeks size.
On the 28 th post-partum day patient was discharged with oral antibiotics, hematinics and multivitamins with advice to repeat trans-vaginal USG, serum β-hCG and complete hemogram after 1 week and attend out-patient department with reports. On 35 th post-partum day serum β-hCG decreased to 12.2 mIU/ml. She had no more episodes of bleeding per vaginum or foul smelling discharge per vaginum. At 6 weeks post-partum, D&E was done and retained placental piece was removed. On histological examination, -it was found to be normal placental tissue with adherent minimal myometrial fibers suggestive of placenta accreta. At 8 weeks post-partum day, patient's serum β-hCG level and USG were normal.
| Discussion|| |
The incidence of placenta accreta is increasing largely due to the increase in cesarean deliveries worldwide. Patients at risk for abnormal placentation should be assessed antenatally by USG with or without adjunct magnetic resonance imaging (MRI) if indicated. The incidence of placenta accreta is considered between 1 in 7000 to as high as 1 in 540 pregnancies.  It is a life -threatening condition associated with high maternal morbidity and mortality rate being as high as 7%.  The risk factors for placenta accreta are previous uterine surgery (like cesarean sections, myomectomy), previous D & E, placenta previa, advanced maternal age, multi parity, Asherman's syndrome and presence of fibroids. 
The mainstay of management in cases of placenta accreta is abdominal hysterectomy bringing an end to fertility and may cause serious social and psychological consequences. Leaving the placenta in situ is possibly the most important aspect of conservative treatment and there has been a gradual shift toward its management, which involves uterine conservation and leaving the adherent placenta in situ with either:
- Adjuvant treatment with methotrexate  in some cases or
- By simply awaiting its spontaneous resorption.
It is also possible to do wedge resection of the area where the placenta is adherent. Bilateral uterine artery embolization, argon beam coagulation of the placental bed and uterine artery or anterior division of internal iliac artery has been mentioned with varying success.
Methotrexate has also been described as an adjuvant therapy for the conservative management of placenta accreta.  Tong, et al pioneered the conservative method by administering systemic methotrexate. The outcome varies widely ranging from expulsion at 7 days to progressive resorption in roughly 6 months.  It has been hypothesized that methotrexate acts by inducing placental necrosis and expediting a more rapid involution of placenta. This contradicts the belief that methotrexate acts on rapidly dividing cells, given that trophoblast proliferation fails to occur at term. There is lack of consensus regarding optimal dose, frequency, or route of administration. In this patient methotrexate was administered in the dose of 1 mg/kg body weight on day 1, 3, 5 and 7 and follow-up to ensure the resolution of placental tissue was done with a combination of clinical assessment, ultrasound examination and serum β-hCG assay. ,, Significant reduction of β-hCG to low levels does not guarantee that uterine hemorrhage will not occur, and it has been omitted with no apparent deleterious effects in a number of cases. ,, USG is useful in assessing the placental involution ,, and has been combined with color Doppler imaging to determine placental vascularity. ,
| Conclusion|| |
Conservative management appears to be a safe alternative to the extirpative management and is a logical option in well selected hemodynamically stable patients with desire for future reproductive function of adherent placenta. Antepartum diagnosis should be improved among patients with a high risk profile for placenta accreta using USG and in selected cases by MRI in order to optimize conservative strategy.
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