El espectro de placenta acreta en la etapa temprana y final del embarazo. Un repaso a través de la imagen / Placenta Accreta Spectrum in Early and Late Pregnancy from an Imaging Perspective, A Scoping Review

Los trastornos del espectro de placenta acreta (EPA) (en orden ascendente en función de la profundidad de la invasión: acreta, increta y percreta) plantean un desafío diagnóstico y de tratamiento. El examen patológico o la evaluación por técnicas de diagnóstico por imagen no son muy fiables si se consideran como herramientas diagnósticas independientes. Sin embargo, un diagnóstico temprano es de gran importancia, ya que la mortalidad materna y fetal aumentan de forma drástica si la paciente se encuentra en unas instalaciones inadecuadas en la tercera fase del parto. Es imperativo adoptar un enfoque multidisciplinario para el diagnóstico (que incorpore la evaluación clínica, por imagen e histopatológica), en particular en los casos con complicaciones. Para la evaluación mediante imagen, la modalidad diagnóstica de preferencia en la mayoría de los escenarios es la exploración mediante ecografía; las pacientes son derivadas para la resonancia magnética (RM) cuando los resultados de la ecografía son ambiguos, no concluyentes o no permiten una visualización adecuada de la placenta. Este artículo repasa las características ecográficas y de RM de los trastornos del EPA (centrándonos principalmente en la RM), examinamos las imágenes placentarias normales y los puntos débiles de las técnicas de diagnóstico por imagen en cada sección. Por último, comentamos los hallazgos de imagen de los trastornos del EPA en el primer trimestre. Por ultimo comentaremos los hallazgos de imagen de los trastornos del EPA en el primer trimestre y en la cicatriz de cesárea anterior.(AU)

Placenta accreta spectrum (PAS) disorders (with increasing order of the depth of invasion: accreta, increta, percreta) are quite challenging for the purpose of diagnosis and treatment. Pathological examination or imaging evaluation are not very dependable when considered as stand-alone diagnostic tools. On the other hand, timely diagnosis is of great importance, as maternal and fetal mortality drastically increases if patient goes through the third phase of delivery in a not well-suited facility. A multidisciplinary approach for diagnosis (incorporating clinical, imaging, and pathological evaluation) is mandatory, particularly in complicated cases. For imaging evaluation, the diagnostic modality of choice in most scenarios is ultrasound (US) exam; patients are referred for MRI when US is equivocal, inconclusive, or not visualizing placenta properly. Herewith, we review the reported US and MRI features of PAS disorders (mainly focusing on MRI), going over the normal placental imaging and imaging pitfalls in each section, and lastly, covering the imaging findings of PAS disorders in the first trimester and cesarean section pregnancy (CSP).(AU)

The use of methotrexate in conservative treatment of placenta accreta spectrum disorders.

Aim of the study: This article reports on a series of patients with placenta accreta spectrum (PAS) disorder who were treated conservatively with Methotrexate (MTX) administration with or without embolization. We investigate whether there is a place for MTX in conservative treatment of PAS.Methods: We present a single-center retrospective case series of five patients. In all patients, diagnosis was unexpected and not made prenatally.Conclusion: The benefits should be weighed against the possible drug toxicity. Today high-quality evidence is lacking. PAS covers a broad spectrum of pathology, standardization in prenatal and postnatal diagnosis can help to compare evidence on treatment.

Clinical analysis of second-trimester pregnancy termination after previous caesarean delivery in 51 patients with placenta previa and placenta accreta spectrum: a retrospective study.

BACKGROUNDS: Pregnancy termination during the second trimester in patients with placenta previa and placenta accreta spectrum (PAS) is a complex and challenging clinical problem. Based on our literature review, there has been a relative increase in the number of such cases being treated by hysterotomy and/or local uterine lesion resection and repair. In the present study, a retrospective analysis was conducted to compare the clinical outcomes when different management strategies were used to terminate pregnancy in the patients with placenta previa and PAS. METHODS: A total of 51 patients who underwent pregnancy termination in the second trimester in Beijing Obstetrics and Gynecology Hospital between June 2013 and December 2018 were retrospectively analyzed in this study. All patients having previous caesarean delivery (CD) were diagnosed with placenta previa status and PAS. RESULTS: ① Among the 51 patients, 16 cases received mifepristone and misoprostol medical termination, 15 cases received mifepristone and Rivanol medical termination, but 1 of them was transferred to hysterotomy due to failed labor induction, another 20 cases were performed planned hysterotomy. There was no placenta percreta cases and uterine artery embolization (UAE) was all performed before surgery.② There were 31 cases who underwent medical termination and 30 cases were vaginal delivery. Dilation and evacuation (D&E) were used in 20 cases of medical abortion failure and in all 30 cases of difficult manual removal of placental tissue. ③ A statistically significant difference was found among the three different strategies in terms of gestational weeks, the type of placenta previa status, main operative success rate and ß-HCG regression time (P < 0.05). ④ There were 4(7.8%) cases who were taken up for hysterectomy because of life-threatening bleeding or severe bacteremia during or after delivery and hysterotomy. The uterus was preserved with the implanted placenta partly or completely left in situ in 47(92.2%) cases. Combined medical and/or surgical management were used for the residual placenta and the time of menstrual recovery was 52(range: 33 to 86) days after pregnancy termination. CONCLUSIONS: Terminating a pregnancy by vaginal delivery through medical induction of labor may be feasible if clinicians have an overall understanding of gestational age, the type of placenta previa status, the type of placenta accreta, and patients concerns about preserving fertility. A collaborative team effort in tertiary medical centers with a very experience MDT and combined application of multiple methods is required to optimize patient outcomes.

Severe toxic effects of low-dose methotrexate treatment for placenta accreta in a patient with methylenetetrahydrofolate reductase mutations.

WHAT IS KNOWN AND OBJECTIVE: Low-dose methotrexate (LDMTX) has been widely used for many decades in clinical settings, with good safety profiles compared with those of high-dose methotrexate. LDMTX is also used as one of the off-label conservative therapies in treating placenta accreta (PA). Until now, only a few mild adverse drug reactions (ADRs) have been published after short-term use of LDMTX, and no severe cases have been reported. CASE SUMMARY: We present a case of a 30-year-old female who developed acute severe oral ulcerative mucositis with degree IV myelosuppression and degree III hepatic injury, after three doses of LDMTX to treat placenta accrete. The symptoms gradually improved after leucovorin rescue and supportive treatments. WHAT IS NEW AND CONCLUSION: The present case provides the first severe ADR report for the short-term use of LDMTX for treating PA, indicating that potentially life-threatening complications can also occur when using LDMTX. Early recognition and immediate leucovorin rescue could result in a favourable outcome.

High-Dose Methotrexate Treatment in a Breastfeeding Mother with Placenta Accreta: A Case Report.

BACKGROUND: Morbidly placenta accreta as a cause of postpartum morbidity is increasing in incidence. One conservative option is use of methotrexate as an adjuvant therapy for the management of placenta accreta. There is concern that use of methotrexate in a lactating mother could potentially expose her neonate to harmful effects of this medication. CASE REPORT: Here we report a 29-year-old woman subjected to methotrexate treatment for placenta accreta. Her child was delivered at 32 weeks weighing 3 lbs. On postpartum day 5, this patient was diagnosed with placenta accreta and treated with intramuscular methotrexate for 3 consecutive days. She received 92 mg methotrexate intramuscularly daily, and was advised not to breastfeed. She collected milk samples on day 2, the 0 hour before the second dose and at 1, 2, 4, 8, 12, and 24 hours after taking the dose. A high-performance liquid chromatography mass spectrometry method was developed to measure methotrexate and its metabolite 7-hydroxymethotrexate levels in milk samples. DISCUSSION: Very low levels were found for both methotrexate and 7-hydroxymethotrexate in the milk samples obtained. The results indicate that methotrexate or its metabolite receded to minimum concentration over a period of 24 hours. CONCLUSION: This case report found the relative infant dose of methotrexate to be 0.11%. Methotrexate does transfer into breast milk, although the levels detected were very low. However, caution should still be used in counseling mothers regarding breastfeeding with this toxic drug.

Retrospective analysis: Conservative treatment of placenta increta with methotrexate.

AIM: To evaluate the efficacy of conservative treatment with methotrexate against placenta increta by two different routes of administration through retrospective analysis. METHODS: A total of 54 women diagnosed with placenta increta after vaginal delivery were enrolled in this retrospective study. The participants accepted conservative management with methotrexate through either intravenous injection or local multi-point injection under ultrasound guidance. The treatment was considered effective if no hysterectomy was mandatory during the follow-up period. RESULTS: Out of the 54 cases, 21 patients were treated with methotrexate intravenously (group 1), and 33 patients received local multi-point injection to the placenta increta under ultrasound guidance (group 2). No maternal death occurred. In group 1, 10 patients expelled the placentas spontaneously, 7 patients underwent uterine curettage and 4 patients underwent hysterectomy for uncontrollable post-partum hemorrhage and infection. In group 2, 25 patients expelled placentas spontaneously and 8 patients underwent uterine curettage with no incidence of hysterectomy. The success rate in group 1 and group 2 was 17/21 and 33/33, respectively. The average time of the spontaneous placenta expulsion was 79.13 ± 29.87 days in group 1 and 42.42 ± 31.83 days in group 2. CONCLUSION: Local multi-point methotrexate injection under ultrasound guidance is a better alternative for patients with placenta increta, especially for preserving fertility.

How do we manage blood product support in the massively hemorrhaging obstetric patient?

Obstetric hemorrhage remains a leading cause of maternal mortality with more than 140,000 deaths annually worldwide. Abnormal placentation has increased to become the most common diagnosis requiring massive blood transfusion in obstetrics, with uterine atony a close second. At our institution, as well as nationwide, there has been a steady increase in pregnancies complicated by abnormal placentation, including accreta, increta, and percreta. Providers at our facility created the New England Center for Placental Disorders in May 2015 to address these complex patients. The incidence of accreta has actually increased 10-fold over the past 50 years, becoming the most common reason for cesarean hysterectomy in highly industrialized countries. The most common risk factor for accreta is repeat cesarean sections, particularly those with associated placenta previa. Contemporary cesarean section rates have risen, with more than 1.2 million women having had a cesarean section in the United States in 2014. We present a case vignette of a multiparous woman presenting with heavy vaginal bleeding at 30 weeks' gestation with imaging concerning for placenta accreta and possible percreta. We describe our approach to the management of these complicated patients.

Management of Abnormal Placenta Implantation with Methotrexate: A Review of Published Data.

Abnormally invasive placenta is characterized by direct attachment of chorionic villi to the uterine wall. This adherent placenta traditionally has been managed by peripartum hysterectomy. Nowadays, there is a lot of interest toward gradual shift from traditional management of invasive placentation to conservative ones leaving the placenta in situ to avoid the surgical morbidity of hysterectomy and loss of future fertility. Administration of methotrexate (MTX), as an adjunctive antimetabolite drug, resulted in conflicting data during conservative management of abnormal placentation. This review assessed all published data on efficacy and safety of MTX therapy as conservative management of invasive placentation. Fifty-three articles including one prospective cohort study, 2 retrospective cohort studies, 10 case series and 40 case reports were identified. Conservative management has beneficial effects on the avoidance of major surgery with the consequent morbidity and the preservation of future fertility. Infection and vaginal bleeding were main complications of MTX therapy. Although MTX therapy may result in accelerated involution or expulsion of placenta and has some beneficial effects on hemorrhagic events, but there is not enough evidence on its efficacy and safety to recommend its routine uses in all cases of invasive placenta.

Preservation of fertility and subsequent childbirth after methotrexate treatment of placenta percreta: a case report.

INTRODUCTION: Placenta percreta is associated with maternal morbidity and mortality. A hysterectomy is often needed to control the bleeding in such cases. However, it has been advocated that placenta percreta be managed conservatively to avoid massive pelvic bleeding and to preserve the patient's fertility. Here, we present a case of placenta percreta diagnosed by magnetic resonance imaging, and treated with systemic administration of methotrexate. CASE PRESENTATION: A 27-year-old nulliparous Japanese woman at 39 gestational weeks had an uncomplicated vaginal delivery of a 3244-g infant. However, her placenta was not delivered, and we could not remove it manually. Contrast-enhanced magnetic resonance imaging indicated deep myometrial invasion by placental tissue and the whole placenta was strongly enhanced. Seven days post-partum, her serum human chorionic gonadotropin level was 12,656IU/L. Our patient hoped to preserve her uterus for a future pregnancy. She therefore received 13 courses of methotrexate (50mg/week, intravenous injection). Her serum human chorionic gonadotropin level was undetectable 97 days after the first methotrexate injection. At 117 days post-partum, she had a labor-like pain every three minutes and delivered the placenta. Our patient regained normal menses and at follow-up remained in good health. Two years later, she delivered a healthy daughter. CONCLUSION: We should try to detect placenta percreta in high-risk patients by any means. For low-risk patients, we should give a diagnosis swiftly and control any intrauterine infection and massive bleeding.

Methotrexate management for placenta accreta: a prospective study.

OBJECTIVE: To observe efficacy following methotrexate (MTX) management in women with placenta accreta. METHODS: Twenty-four stable patients with placenta accreta were treated with MTX. Beta-hCG values, vascular indices of the residual placenta, and other clinical characteristics were collected prospectively and were compared between the success and failure groups. RESULTS: After MTX management, the residual placentas were expulsed spontaneously in 33.3% of the patients. This was done through dilatation and curettage (D & C) in 45.8% of the patients. The residuals in the uterine wall were completely absorbed within 5.7 months. In the patients who were successfully treated with MTX, their beta-hCG values and vascular indices of the placentas decreased faster than those of failure patients (P < 0.05). Those (20.8%) failing MTX management and subsequent D & C showed that their vascular indices persisted high levels and some even experienced elevations despite significantly decreased hCG values. CONCLUSIONS: MTX management, when the beta-hCG value and vascular indices of placenta decreased significantly, is a conservative option for a stable patient with placenta accreta in China. 3D power Doppler ultrasound should be utilized for the follow-up of this condition.

Inserción de balones intraarteriales ilíacos previa a la realización de cesárea ante la sospecha de acretismo placentario / Iliac artery occlusion balloons for suspected placenta accreta during cesarean section

La hemorragia masiva obstétrica continúa siendo una de las causas principales de morbimortalidad materna. Deben identificarse cuáles son los factores de riesgo asociados a esta enfermedad para adoptar un correcto plan terapéutico y disponer de los recursos necesarios. Se presenta un caso en el que se insertaron balones intraarteriales ilíacos previamente a la realización de la cesárea ante la sospecha de un acretismo placentario. Se describe el tratamiento perioperatorio y se analizan las distintas opciones terapéuticas con sus ventajas e inconvenientes, desde el uso de protocolos de administración de hemoderivados y factores procoagulantes y otras maniobras de control de la hemorragia, hasta la realización de histerectomía (AU)

Massive obstetric hemorrhage still remains a major cause of maternal mortality and morbidity. The risk factors associated with this pathology must be identified in order to schedule the appropriate delivery with the necessary resources. A case is presented of an iliac artery occlusion with intravascular balloons for suspected placenta accreta during cesarean section. The perioperative treatment, as well as an analysis of the treatment options is described, along with their advantages and disadvantages, from the use of postpartum hemorrhage protocols, blood transfusion and procoagulant factors, and other maneuvers to control bleeding, until the hysterectomy (AU)

Log-linear human chorionic gonadotropin elimination in cases of retained placenta percreta.

PURPOSE: To describe the human chorionic gonadotropin (hCG) elimination rate in patients with intentionally retained placenta percreta. METHODS: Medical records for cases of placenta percreta with intentional retention of the placenta were reviewed. The natural log of the hCG levels were plotted versus time and then the elimination rate equations were derived. RESULTS: The hCG elimination rate equations were log-linear in three cases individually (R (2) = 0.96-0.99) and in aggregate R (2) = 0.92). The mean half-life of hCG elimination was 146.3 h (6.1 days). CONCLUSION: The elimination of hCG in patients with intentionally retained placenta percreta is consistent with a two-compartment elimination model. The hCG elimination in retained placenta percreta is predictable in a log-linear manner that is similar to other reports of retained abnormally adherent placentae treated with or without methotrexate.

Anestesia y reanimación en un caso de placenta pércreta / Anaesthesia and recovery in a case of placenta percreta

La placenta pércreta es un subtipo de acretismo placentario, en el que este órgano invade la totalidad de la pared uterina, llegando a afectar a los órganos circundantes. Se trata de una afección de alto riesgo quirúrgico, que por lo general va a requerir una histerectomía obstétrica. Presentamos el caso de una gestante de 36 años, con diagnóstico de placenta pércreta con invasión de vejiga e intestino. Durante la intervención desarrolló un cuadro de shock hipovolémico, que precisó transfusión masiva de hemoderivados y apoyo inotrópico. Fueron necesarias 3 reintervenciones sucesivas debido a la hemorragia, realizándose, en una de ellas, embolización selectiva de las arterias hipogástricas. Precisó 13 días en Cuidados Intensivos. El volumen total de hemoderivados transfundidos fue de 43 concentrados de hematíes, 28 unidades de plasma y 8 pools de plaquetas. Se destaca la importancia del diagnóstico prenatal precoz, para poder llevar a cabo un planteamiento adecuado de la intervención, en la que se cuente con un equipo multidisciplinario (cirujanos generales, urólogos, cirujanos vasculares), además de anestesiólogos y obstetras experimentados(AU)

Placenta percreta is a sub-type of placenta accreta in which this organ invades the whole uterine wall and affects the adjacent organs. It is a condition with a high surgical risk which generally requires an obstetric hysterectomy. We present the case of a 36 year-old pregnant woman diagnosed with placenta percreta with bladder and intestinal invasion. She suffered a hypovolaemic shock during surgery which required a massive transfusion of blood products and inotropic support. Three further successive surgeries were required due to the bleeding, with selective embolisation of the hypogastric arteries being performed in one of them. She required 13 days in intensive care. The total volume of blood products transfused was, 43 units of red cells, 28 units of plasma, and 8 platelet pools. The importance of early prenatal diagnosis is emphasised in order to adequately plan the operation, and should include a multidisciplinary team (general surgeons, urologists, vascular surgeons), as well as experienced anaesthesiologists and obstetricians(AU)

Hemorragia obstétrica masiva en una paciente con placenta pércreta / Massive obstetric haemorrhage in a patient with placenta percreta

Presentamos el caso de una paciente de 38 años con diagnóstico prenatal de placenta previa. Al iniciar la cesárea programada se evidenció una placenta pércreta. Tras un sangrado masivo incoercible a pesar de haberse realizado una histerectomía de urgencia, fue necesario embolizar los vasos mediante radiología intervencionista, evolucionando posteriormente sin incidencias(AU)

We present a case of a 38 year-old patient with prenatal diagnosis of placenta praevia. When the elective caesarean began it was found a placenta accreta. In spite of an emergency hysterectomy, embolisation using interventional radiography was needed after a massive obstetric haemorrhage. The post-operative period progressed without incidents(AU)

Approaches to reduce urinary tract injury during management of placenta accreta, increta, and percreta: a systematic review.

OBJECTIVE: A systematic review of the literature was conducted to answer the following question: are there enhancements to standard peripartum hysterectomy technique that minimize unintentional urinary tract (UT) injury in pregnancies complicated by invasive placental attachment (INPLAT)? METHODS: A PubMed search of English language articles on INPLAT published by June 2010 was conducted. Data regarding the following parameters was required for inclusion in the quantitative analysis of the review's objective: (1) type of INPLAT, (2) details pertaining to medical and surgical management of INPLAT, and (3) complications, if any, associated with management. An attempt was made to identify approaches that may lower the risk of unintentional UT injury. RESULTS: Most cases (285 of 292) were managed by hysterectomy. There were 83 (29%) cases of unintentional UT injury. Antenatal diagnosis of INPLAT lowered the rate of UT injury (39% vs. 63%; P = 0.04). Information regarding surgical technique or medical management was available for 90 cases; 14 of these underwent a standard hysterectomy technique. Methotrexate treatment and 11 modifications of the surgical technique were associated with 16% unintentional UT injury rate as opposed to 57% for standard hysterectomy (P = 0.002). The use of ureteral stents reduced risk of urologic injury (P = 0.01). Multiple logistic regression analysis identified antenatal diagnosis as the significant predictor of an intact UT. CONCLUSIONS: Antenatal diagnosis of INPLAT is paramount to minimize UT injury. Utilization of management modifications identified in this review may reduce urologic injury due to INPLAT.

Committee opinion no. 529: placenta accreta.

Placenta accreta is a potentially life-threatening obstetric condition that requires a multidisciplinary approach to management. The incidence of placenta accreta has increased and seems to parallel the increasing cesarean delivery 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 the uterine scar. Diagnosis of placenta accreta before delivery allows multidisciplinary planning in an attempt to minimizepotential maternal or neonatal morbidity and mortality. Gray scale ultrasonography is sensitive enough and specific enough for the diagnosis of placenta accreta; magnetic resonance imaging may be helpful in ambiguous cases. Although recognized obstetric risk factors allow the identification of most cases during the antepartum period, the diagnosis is occasionally discovered at the time of delivery. In general, the recommended management of suspected placenta accreta is planned preterm cesarean hysterectomy with the placenta left in situ because attempts at removal of the placenta are associated with significant hemorrhagic morbidity. However, surgical management of placenta accreta may be individualized. Although a planned delivery is the goal, a contingency plan for an emergency delivery should be developed for each patient, which may include following an institutional protocol for maternal hemorrhage management.

Éxito en el manejo conservador del acretismo placentario mediante embolización y metotrexato / Successful conservative management of placenta accreta via embolization and methotrexate

Introducción. La incidencia del acretismo placentario ha aumentado, y esta patología puede ser causa de hemorragia posparto subsidiaria de histerectomía. Existen sin embargo tratamientos conservadores alternativos a la cirugía. Caso clínico. Mujer de 38 años de edad, primigesta. Tras el parto, la placenta es extraída mediante desprendimiento manual y legrado. El diagnóstico es confirmado mediante ecografía y resonancia magnética. Se realiza embolización selectiva del vaso nutricio y administración de metotrexato. Tres días después de la embolización se produce la expulsión de la masa placentaria. Conclusiones. La embolización selectiva del vaso nutricio y el tratamiento coadyuvante con metotrexato constituyen una técnica conservadora que permite preservar el útero y así conservar la fertilidad. El caso que presentamos es, según lo descrito hasta ahora en la literatura, uno de los manejados conservadoramente que ha conseguido un intervalo de tiempo menor entre el parto y la expulsión placentaria definitiva (AU)

Introduction. The incidence of placenta accreta has risen and this entity can cause postpartum hemorrhage, often requiring obstetric hysterectomy. There are, however, alternative conservative treatments to surgery. Case report. A 38-year-old woman in her first pregnancy underwent manual removal of the placenta, with moderate hemorrhaging and subsequent curettage. The diagnosis was confirmed by ultrasound scan and magnetic resonance imaging. Selective embolization of the nutritional vessel was performed and methotrexate was administered. Three days after the embolization, the placental mass was expelled. Conclusions. Selective embolization of a nutritional vessel and adjuvant treatment with methotrexate are conservative techniques that allow preservation of both the uterus and fertility. According to previous reports in the literature, the time interval between delivery and definitive placental expulsion was lower in our case than in other conservatively managed cases (AU)

Conservative management of placenta increta: case report and literature review.

Placenta increta, a rare complication of pregnancy, is associated with significant postpartum hemorrhage often requiring emergency hysterectomy. We report a case of conservative management, with a combination of parenteral methotrexate, serial ultrasound and ß-hCG assessment. Serum ß-hCG levels were undetectable after 8 weeks of therapy. A scan at 6 months showed complete involution of the uterus. Review of the literature discussing the diagnostic tools, clinical features, management and outcome of pregnancies with placenta increta.