Placenta increta presenting as delayed postabortal hemorrhage

Placenta increta presenting as delayed postabortal hemorrhage Andrew J. Walter, MD, Ann E. McCullough, MD, Maitray D. Patel, MD, and Jeffrey L. Cornella, MD Placenta increta is a life-threatening complication of pregnancy characterized by placental villi invasion into the underlying myometrium. Usually, presentation is in the early postpartum period with hemorrhage during difficult placental removal. Placenta increta may also complicate first and early second-trimester pregnancy loss. Previous reports described immediate postcurettage hemorrhage, which required emergency hysterectomies.1– 4 A woman with placenta increta who presented with heavy vaginal bleeding 3 months after an uncomplicated missed abortion is described. Case A 30-year-old gravida 2, para 1, was admitted for episodic heavy vaginal bleeding 17 weeks after an uncomplicated suction curettage for an 11-week missed abortion. Obstetric history included a primary, low-transverse cesarean for twins at 36 weeks’ gestation 2 years before. The woman reported normal menstrual cyclicity with her last menstrual period 2 weeks before presentation. Examination on admission found no active bleeding and a palpably normal uterus. Quantitative hCG was normal, serum human placental lactogen level was undetectable and hemoglobin stabilized at 8.0 g/dL. Color Doppler ultrasound showed focal intramyometrial hypervascularity in the anterior, lower-uterine segment, with a normal endometrial stripe. Magnetic resonance imaging (MRI) showed a focal intramural collection of vessels (Figure 1). On the basis of imaging findings, an acquired uterine arteriovenous malformation was suspected. Intrauterine manipulation was contraindicated, so the woman was offered angiographic embolization versus vaginal hysterectomy; she opted for hysterectomy. Gross examination of the intact uterus found no arteriovenous malformations or uterine defects. In the lower anterior-uterine segment cesarean scar there was a 3-cm diameter oval area of myometrial hemorrhage, which extended nearly through the uterine wall. Microscopic examination confirmed placenta increta. From the Departments of Gynecologic Surgery, Laboratory Medicine/Pathology, and Diagnostic Radiology, Mayo Clinic Scottsdale, Scottsdale, Arizona.

846 0029-7844/99/$20.00 PII S0029-7844(98)00571-7

Figure 1. Sagittal gadolinium-enhanced T1-weighted magnetic resonance image shows a subtle, anterior-uterine contour bulge (arrow) with underlying aberrant vessels and nonenhancing linear scar located consistent with prior cesarean incision.

Comment A MEDLINE search from 1966 –1997 using the search terms “placenta accreta,” “increta,” and “first-secondtrimester pregnancy,” identified 18 symptomatic cases. All reports documented immediate and significant postcurettage bleeding, which required emergency abdominal hysterectomies for definitive management.1– 4 Delayed hemorrhage was not reported. The cause of the delay between curettage for missed abortion and significant, episodic hemorrhage is unknown; however, our case suggests that in women at risk for invasive placentation who have had recent spontaneous or therapeutic abortions and present with abnormal uterine bleeding, placenta increta should be considered when imaging studies find a focal area of aberrant myometrial vascularity.

References 1. Berchuck A, Sokol RJ. Previous cesarean section, placenta increta, and uterine rupture in second-trimester abortion. Am J Obstet Gynecol 1983;145:766 –7. 2. Ecker JL, Sorem KA, Soodak L, Robert DJ, Safron LE, Osathanondh R. Placenta increta complicating a first-trimester abortion. A case report. J Repro Med 1992;37:893–5. 3. Harden MA, Walter MD, Valente PT. Postabortal hemorrhage due to placenta increta: A case report. Obstet Gynecol 1990;75:523– 6. 4. Rashbaum WK, Gates EJ, Jones J, Goldman B, Morris A, Lyman WD. Placenta accreta encountered during dilation and evacuation in the second trimester. Obstet Gynecol 1995;85:701–3.

Received September 21, 1998. Received in revised form November 30, 1998. Accepted December 17, 1998.

Copyright © 1999 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.

Obstetrics & Gynecology