Introduction
Placenta Increta is a rare condition
complicating third stage of labour. Its sequelae includes potentially lethal haemorrhage and loss of reproductive function. Therapy directed towards control of life threatening haemorrhage, frequently includes emergency hysterectomy, sacrificing future fertility. We present here a case of successful medical management of placenta increta.
Case Report
Mrs. XYZ, a 28 year old married housewife referred from private hospital as primigravida with 34 weeks of gestation with colour Doppler showing reversal of diastolic flow in umbilical arteries. Patient was taken up for emergency LSCS. Intraop finding - Baby delivered by vertex, cried immediately after birth. There was no plane of separation between placenta and myometrium. There was no active bleeding. Uterus was bicornuate with one rudimentary horn. Placental vessels were seen underneath serosa at fundus. Placenta increta was diagnosed. Decision to manage patient conservatively was taken as patient was stable. Placenta was left in situ and abdomen closed in layers. Patient was given injection Methotrexate 1 mg/kg im on day 1, 3 and 5 with citrovarum factor on day 2, 4 and 6. Oxytocin continued for 2nd postoperative day. Patient was monitored for vital parameters and bleeding per vaginum.
Serial colour Doppler studies were done on day 1, and followed up every weekly till 4 weeks.
Patient passed bits of placenta per vaginally, which were sent for histopathological examination. Patient was discharged on day 21 and followed up regularly. Colour Doppler on day 30 showed myometrium between fundus and placenta.
Discussion
Placenta Increta is a rare condition with an incidence of 1 in 540 in 1 in 93,000 deliveries. Basic pathology in this condition is absence of decidua basalis layer and imperfect development of fibrinoid layer. It can be managed conservatively with preservation of uterus in highly selected cases and careful follow up is required till entire placenta is absorbed.
Professor Arulkumaran et al in 1986 described for the first time successful management of placenta accreta with methotrexate. USG was repeated after 2 weeks1 which showed no placental mass. Raziel et al in 1992 described similar case in which complete placenta resolution occurred after 7 days of methotrexate treatment although part of placenta was removed manually.2 Patient conceived after 5 months. Legro et al performed hysteroscopy after 8 months of conservative management with methotrexate.3 No evidence of placental tissue was observed and patient had uncomplicated vaginal delivery after 2 year.
Hysterectomy has become the treatment of choice for placenta increta. However, conservative management is advocated in highly selected cases with careful follow up.
References
- Arulkumaran S, Ng CS, Ingemasson I, et al. Medical treatment of placenta accreta with methotrexate. Acta Obstet Gynaecol Scand 1986; 65 : 285-6.
- Raziel A, Golan A, Arielay S, Herman A, Caspi E. Repeated ultrasonography and intramuscular methotrexate in the conservative management of residual adherent placenta. J Clin Ultrasound 1992; 20 : 288-90.
- Legro RS, Price FV, Caritis SN. Non-surgical management of placenta percreta. A case report Obstet Gynaeol 1994; 83 : 847-9.
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