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Uterine Septum As a Risk Factor for Placenta Accreta in Primigravid Woman

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Uterine Septum As a Risk Factor for Placenta Accreta in Primigravid Woman J Case Rep Images Obstet Gynecol 2019;5:100055Z08MS2019. Slate et al. 1 www.ijcriog.com CASE REPORT PEER REVIEWED OPEN| OPEN ACCESS ACCESS Uterine septum as a risk factor for placenta accreta in primigravid woman Meagan Slate, Caroline Shell ABSTRACT How to cite this article Introduction: Morbidly adherent placenta is a Slate M, Shell C. Uterine septum as a risk factor for rare obstetrical complication associated with placenta accreta in primigravid woman. J Case Rep significant maternal morbidity. Known risk Images Obstet Gynecol 2019;5:100055Z08MS2019. factors include a history of cesarean section, uterine instrumentation, placenta previa, and multiparity. Congenital uterine anomalies Article ID: 100055Z08MS2019 may be an additional risk factor for abnormal placentation. Case Report: A 28-year-old, healthy, primigravid woman presented status ********* post-vaginal delivery, complicated by retained doi: 10.5348/100055Z08MS2019CR placenta requiring manual extraction, dilation and curettage (D&C), and blood transfusion. Subsequent imaging revealed a persistently retained placenta with loss of the myometrial/ endometrial border, diagnostic of placenta INTRODUCTION accreta. The patient underwent bilateral uterine artery embolization for conservative Placenta accreta, defined as abnormal invasion management of placenta accreta, and of placental villi into the uterine myometrium, is a subsequent hysteroscopy revealed a significant potentially devastating obstetric complication and can uterine septum. Conclusion: Uterine anomalies result in massive postpartum hemorrhage. With mortality may increase a patient’s risk of abnormal rates as high as 7% in some studies, it is important to placentation. Persistently retained placenta diagnose the condition before delivery and attempted after initial D&C warrants detailed imaging [i.e., removal of the placenta [1]. Traditional risk factors for magnetic resonance imaging (MRI)] to rule out placenta accreta include placenta previa, prior cesarean abnormally adherent placenta. delivery, prior uterine instrumentation, multiparity, and advanced maternal age [2]. It has been proposed that Keywords: Placenta accreta, Primigravid, Uterine congenital uterine anomalies may also contribute to anomalies abnormal placentation; however, only a limited number of cases have been reported [3–5]. The gold standard treatment for placenta accreta has traditionally been Cesarean hysterectomy. However, Meagan Slate1, Caroline Shell2 numerous reports can be found in the literature of Affiliations: 1Resident (PGY4), Department of OBGYN, Si- successful use of conservative treatment that allows for nai Hospital of Baltimore, Baltimore, Maryland, USA; 2At- avoidance of hysterectomy and preservation of future tending, Department of OBGYN, Sinai Hospital of Balti- fertility in up to 80% of cases [6]. The optimal approach more, Baltimore, Maryland, USA. to conservative management of placenta accreta remains Corresponding Author: Meagan Slate, 2401 W Belvedere an active area of investigation, and therapies include Ave, Baltimore, Maryland 21215, USA; Email: Meagan- uterine devascularization and/or medical therapy with [email protected] methotrexate. It is well documented in the literature that Müllerian anomalies are associated with increased risk of miscarriage, intrauterine growth restriction (IUGR), and Received: 24 June 2019 preterm birth. Rarely has it been suggested that Müllerian Accepted: 22 October 2019 Published: 15 November 2019 anomalies are associated with abnormal placentation, and no case reports have linked uterine septa to placenta Journal of Case Reports and Images in Obstetrics and Gynecology, Vol. 5, 2019. ISSN: 2582-0249 J Case Rep Images Obstet Gynecol 2019;5:100055Z08MS2019. Slate et al. 2 www.ijcriog.com accreta. Here we present a case of a primigravid woman interface, posteriorly in the uterine corpus and fundus. who was diagnosed with placenta accreta in the absence of In addition, an area highly concerning for myometrial known risk factors and, after conservative management, invasion of the retained products, in conjunction with was subsequently found to have a uterine septum. the patient’s clinical picture, confirmed the diagnosis of placenta accreta. There was no evidence of placental percreta or invasion of the adjacent posterior structures. CASE REPORT She was also noted to have duplication of the left ureter. Treatment options were reviewed with the patient A healthy 28-year-old primigravid woman with a and her husband. They strongly desired conservative singleton pregnancy underwent an induction of labor at management with uterine artery embolization to preserve an affiliated institution, for cholestasis of pregnancy with future fertility. Interventional radiology performed elevated bile acids at 37 weeks gestation. Her starting bilateral uterine artery embolization through the right hemoglobin (Hb) was 13.8 g/dL. She had a vaginal common femoral artery using Gelfoam. Following delivery complicated by a retained placenta. After one the procedure, the patient’s vaginal bleeding slowed hour of expectant management, manual removal of the significantly. She was discharged home the following day placenta was performed. The patient was known to have a in stable condition. posterior placenta based on prior ultrasounds; however, Over several weeks, the patient’s vaginal bleeding no placental abnormalities were identified prior to slowed to light pink spotting. Her human chorionic delivery. The patient recovered well and was discharged gonadotropin (hCG) levels trended to zero and remained home on postpartum day #2. She returned to the hospital undetectable. Six months postpartum, the patient the same evening with complaints of palpitations, fever, complained of cramping and mild spotting. A transvaginal chills, shortness of breath, and pelvic pain. She reported ultrasound showed a subcentimeter calcified lesion significant vaginal bleeding, and her Hb level was 9.5. At within the endometrial cavity, concerning for retained the time of admission, she was tachycardic, tachypneic, products of conception (Figure 1). and febrile to 39.4°C. A transvaginal ultrasound showed The patient was again counseled on her options, and a diffusely thickened, heterogeneous endometrium, she elected to undergo operative hysteroscopy with D&C measuring 4.6 cm, consistent with retained products of to remove the remaining tissue. conception, as well as echogenic areas suggestive of air During the hysteroscopy, a large, midline, intrauterine concerning for endometritis. The patient was started on septum was noted to occupy the entire endometrial Gentamicin and Clindamycin. cavity. These findings were not reported on any previous She underwent a suction D&C the following imaging. Left cornual synechiae and a calcified lesion on morning. The pathology report read “markedly necrotic, the posterior wall of the uterus were also discovered. The hemorrhagic tissue with chorionic villi consistent with TruClear© (Medtronic, USA) operative hysteroscope was retained products of conception.” The procedure was used to carefully dissect the uterine septum until bilateral complicated by intraoperative hemorrhage, requiring tubal ostia could be appreciated. The synechiae and transfusion of two units of packed red blood cells for a Hb posterior uterine lesion were removed until the uterine of 7.3. Several hours later, the patient remained febrile cavity was restored to normal contours. Though previous and appeared septic with a leukocytosis of 18,600/mm³ imaging did not report evidence of an anomalous uterus, and an elevated lactate (3.5 mmol/L). Due to concerns for we remained cautious throughout the case to avoid worsening clinical status, ampicillin plus sulbactam was uterine perforation. The patient had minimal bleeding added to the patient’s antibiotic regimen. and was discharged home. The final pathology showed The patient’s clinical picture gradually improved only scant fragments of benign endometrial tissue with on hospital days #3 and #4 with normalization of her no evidence of chorionic villi or decidua. lactate, and resolution of her fever. Her white blood cell (WBC) count remained elevated at 18,000/mm³. A repeat transvaginal ultrasound was performed, which showed “retained products of conception, unchanged from her prior ultrasound.” At this point, the patient was transferred to our institution for further care. She continued to have abdominal pain and a moderate amount of bright red vaginal bleeding; however, her vital signs had normalized and she was no longer febrile. Given the patient’s history of persistently retained products of conception after a suction D&C, pelvic MRI Figure 1: Transvaginal ultrasound imaging six months was obtained to investigate the possibility of abnormal after bilateral uterine artery embolization for conservative placentation, despite the patient’s lack of risk factors. management of placenta accreta. Findings significant for a The T2-weighted MRI revealed loss of the hyperintense subcentimeter calcified lesion within the endometrial cavity, endometrial line at the endometrial–myometrial concerning for retained products of conception. Journal of Case Reports and Images in Obstetrics and Gynecology, Vol. 5, 2019. ISSN: 2582-0249 J Case Rep Images Obstet Gynecol 2019;5:100055Z08MS2019. Slate et al. 3 www.ijcriog.com DISCUSSION was successfully applied in this case. While the patient’s uterus remains in situ, she did require broad-spectrum Placenta accreta, defined as abnormal invasion of antibiotics
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