Case Report
0 1992 by John Wiley & Sons, Inc.
J Clin Ultrasound 20:288-290, May 1992 CCC 0091-2751/92/040288-03$04.00
Repeated Ultrasonography and Intramuscular Methotrexate in the Conservative Management of Residual Adherent Placenta Arie Raziel, MD, Abraham Golan, MD, Shlomo Ariely, MD, Arie Herman, MD, and Eliahu Caspi, MD
The incidence of adherent placenta, a potentially severe pregnancy complication, is increasing due to inclusion of cases without microscopic documentation, better case reporting, and the possibility of a true increase in incidence (Reed 1980). While emergency hysterectomy has reduced maternal mortality, conservative management preserves the child-bearing function. In selected cases when no post-partum hemorrhage exists, treatment should ideally combine uterine preservation with low post-partum morbidity. The value of serial ultrasonographic examinations, serum human chorionic gonadotropin monitoring, and the option of methotrexate (MTX) treatment is presented in a selected case of nonbleeding, adherent placenta treated conservatively when future child-bearing was strongly desired. CASE REPORT
A 36-year-old gravida 4, para 0 was admitted in labor at 40 weeks, menstrual age (MA). Past obstetric history revealed three early induced abortions. The present uneventful pregnancy occurred shortly following lysis of intrauterine adhesions by curettage, insertion of an intrauterine device, and estrogen therapy for 2 months. Oxytocin augmentation along with an epidural block were initiated because of hypotonic contractions. A 3900 g female infant with an Apgar score of 9 at 1 minute, and 10 at 5 minutes, was delivered by vacuum extraction. The third stage was characterized by minimal blood loss and non-expulsion of the placenta for a period of 1 From the Department of Obstetrics and Gynecology, Assaf Harofe Medical Centre, Zerifin; affiliated with Sackler School of Medicine, Tel-Aviv University, Israel. For reprints contact Arie Raziel, MD, Department of Obstetrics and Gynecology, Assaf Harofe Medical Centre, Zerifin 70300, Israel. 288
hour. Manual exploration of the uterine cavity revealed a firmly adherent placenta implanted in the upper uterine corpus without a cleavage plane. Small fragments weighing a total of 250 g were removed manually. Ultrasound examination confirmed that more than half of the placental mass was still firmly embedded in the uterine wall (Figure 1). Blood loss remained minimal, and all hemodynamic parameters were stable. The blood pressure, temperature, fluid intake/ output, fundal height, and vaginal bleeding were closely monitored. Intravenous cefazolin, 1 gram every 8 hours and metronidazole, 0.5 g, every 12 hours were given after obtaining vaginal and cervical cultures. The serum P-human chorionic gonadotropin (p-hCG) level was 1945 mIU/mL. Repeated abdominal ultrasonic examinations performed every other day showed no shrinkage of the placenta, thus 20 mg MTX was injected intramuscularly on the 4th and 5th postpartum days. Liver and kidney function tests performed to avoid MTX toxicity, were found to be normal. MTX was discontinued on the 6th post partum day, at which time serum P-hCG levels fell from 647 mIU/mL to 190 mIU/mL. Antibiotics were continued for a mild fever of 37.6" C. Necrotic fragments of the placenta were spontaneously expelled beginning on the 7th postpartum day (Figure 2). Serial ultrasound examinations revealed gradual shrinkage of the remaining implanted placenta. The fever disappeared following removal of loosely adherent placental fragments protruding from the cervix on the 11th postpartum day. Vaginal examination prior to the patient's discharge on the following day indicated a wellcontracted uterus and closed cervix. Serum P-hCG levels were 22 mIU/mL, and ultrasound
MTX IN ADHERENT PLACENTA
289
FIGURE 1. Immediate postpartum longitudinal scan of the uterus showing a large amount of residual placental tissue (11.5 cm x 8.7 cm) (P, placenta; U, uterine wall).
confirmed that the uterine cavity and myometrium were fre,e of placental tissue. A diagnostic hysteroscopy was planned but eventually not carried out as the patient conceived spontaneously 5 months postpartum. At her 26th week, MA, the pregnancy was proceding uneventfully.
Discussion The present case report of adherent placenta justified conservative management as the patient
desired future pregnancies. Methotrexate therapy, with frequent monitoring by serial ultrasound examinations and serum P-hCG levels, was followed in 10 days by expulsion of the previously adherent placental tissue. The intrapartum and postpartum management of adherent placentae remains controversial. The classical review of Fox' recommended immediate hysterectomy because at that time maternal mortality was increased fourfold using conservative treatment. Options for nonsurgical management were recommended by Read et a1.2
FIGURE 2. Longitudinal view of the uterus on postpartum day 7, showing shrinkage of placental tissue (8.9 cm x 6.7 cm x 3.5 crn) (P, placenta; U, uterine Wall). VOL. 20, NO. 4, MAY 1992
290
CASE REPORT: RAZIEL ET AL.
and Clark et al.3 who advocated expectant management in carefully selected cases. This approach depends upon the availability of ample blood and its components and suitable antibiotics for the potential complications of infection and hemorrhage. Although hysterectomy remains the recommended treatment for most patients, uterine conservation is justified in certain cases when subsequent pregnancy is strongly desired. Such management may include curettage, local excision and repair, or oversewing of the implantation site (Clark3). Current use of MTX was first suggested by Arulkumaran et aL4 The sensitivity of chorionic tissue to MTX has been verified in many cases of both trophoblastic gestational disease (Berkowitz') and abdominal pregnancy with intraperitoneal placental attachment (St. Clair'). Its applicability to the treatment of adherent placenta postpartum, however, remains an open question. We used 20 mg MTX on the 4th and 5th postpartum days because of the absence of placental absorption verified by serial ultrasound examination. MTX was discontinued shortly thereafter when p-hCG levels dropped from 1945 to 641 then 190 mIU/mL. The MTX treatment probably reduced placental vascularity, thereby leading to its separation and expulsion. Fox' mentioned three principal ethiological factors for placenta accreta: previous manual removal of placenta, uterine curettage, and uterine sepsis. Read2 found a trend of lower parity in his series, although multiparity continues to be an
etiological factor similar to older age during pregnancy. He disagreed with the high peak incidence at an age of 31 to 35 years previously published by Fox.' In light of the above, the woman presented here is no doubt at tremendous risk for placenta accreta in this current pregnancy. In summary, conservative management of an adherent placenta, with or without MTX therapy, offers a useful option in selected cases where future childbearing is desired, and post partum bleeding remains minimal. This approach requires serial ultrasonographic examinations and P-hCG follow-up. Watchful monitoring for complications such as hemorrhage and infection is necessary. REFERENCES 1. Fox H: Placenta accreta 1945-1969. Obstet Gynecol Surv 27:475, 1972.
2. Read JA, Cotton DB, Miller FC: Placenta accreta: Changing clinical aspects and outcome. Obstet Gynecol 56:31, 1980. 3. Clark SL, Koonings PP, Phelan JP: Placenta previdaccreta and prior cesarean section. Obstet Gynecol 66239, 1985. 4. Arulkurmaran S, Ingemarsson I, Ratman S: Medical treatment of placenta accreta with methotrexate. Acta Obstet Gynecol Scand 65285, 1986. 5. Berkowitz RS, Goldstein DP, Berenstein N R Ten year experience with methotrexate and folinic acid as primary treatment of gestational trophoblastic disease. Gynecol Oncol 23:111, 1986. 6. St. Clair JI, Wheeler DA, Fish SA: Methotrexate in abdominal pregnancy. JAMA 208:529, 1969.
JOURNAL OF CLINICAL ULTRASOUND
0 1992 by John Wiley & Sons, Inc.
J Clin Ultrasound 20:288-290, May 1992 CCC 0091-2751/92/040288-03$04.00
Repeated Ultrasonography and Intramuscular Methotrexate in the Conservative Management of Residual Adherent Placenta Arie Raziel, MD, Abraham Golan, MD, Shlomo Ariely, MD, Arie Herman, MD, and Eliahu Caspi, MD
The incidence of adherent placenta, a potentially severe pregnancy complication, is increasing due to inclusion of cases without microscopic documentation, better case reporting, and the possibility of a true increase in incidence (Reed 1980). While emergency hysterectomy has reduced maternal mortality, conservative management preserves the child-bearing function. In selected cases when no post-partum hemorrhage exists, treatment should ideally combine uterine preservation with low post-partum morbidity. The value of serial ultrasonographic examinations, serum human chorionic gonadotropin monitoring, and the option of methotrexate (MTX) treatment is presented in a selected case of nonbleeding, adherent placenta treated conservatively when future child-bearing was strongly desired. CASE REPORT
A 36-year-old gravida 4, para 0 was admitted in labor at 40 weeks, menstrual age (MA). Past obstetric history revealed three early induced abortions. The present uneventful pregnancy occurred shortly following lysis of intrauterine adhesions by curettage, insertion of an intrauterine device, and estrogen therapy for 2 months. Oxytocin augmentation along with an epidural block were initiated because of hypotonic contractions. A 3900 g female infant with an Apgar score of 9 at 1 minute, and 10 at 5 minutes, was delivered by vacuum extraction. The third stage was characterized by minimal blood loss and non-expulsion of the placenta for a period of 1 From the Department of Obstetrics and Gynecology, Assaf Harofe Medical Centre, Zerifin; affiliated with Sackler School of Medicine, Tel-Aviv University, Israel. For reprints contact Arie Raziel, MD, Department of Obstetrics and Gynecology, Assaf Harofe Medical Centre, Zerifin 70300, Israel. 288
hour. Manual exploration of the uterine cavity revealed a firmly adherent placenta implanted in the upper uterine corpus without a cleavage plane. Small fragments weighing a total of 250 g were removed manually. Ultrasound examination confirmed that more than half of the placental mass was still firmly embedded in the uterine wall (Figure 1). Blood loss remained minimal, and all hemodynamic parameters were stable. The blood pressure, temperature, fluid intake/ output, fundal height, and vaginal bleeding were closely monitored. Intravenous cefazolin, 1 gram every 8 hours and metronidazole, 0.5 g, every 12 hours were given after obtaining vaginal and cervical cultures. The serum P-human chorionic gonadotropin (p-hCG) level was 1945 mIU/mL. Repeated abdominal ultrasonic examinations performed every other day showed no shrinkage of the placenta, thus 20 mg MTX was injected intramuscularly on the 4th and 5th postpartum days. Liver and kidney function tests performed to avoid MTX toxicity, were found to be normal. MTX was discontinued on the 6th post partum day, at which time serum P-hCG levels fell from 647 mIU/mL to 190 mIU/mL. Antibiotics were continued for a mild fever of 37.6" C. Necrotic fragments of the placenta were spontaneously expelled beginning on the 7th postpartum day (Figure 2). Serial ultrasound examinations revealed gradual shrinkage of the remaining implanted placenta. The fever disappeared following removal of loosely adherent placental fragments protruding from the cervix on the 11th postpartum day. Vaginal examination prior to the patient's discharge on the following day indicated a wellcontracted uterus and closed cervix. Serum P-hCG levels were 22 mIU/mL, and ultrasound
MTX IN ADHERENT PLACENTA
289
FIGURE 1. Immediate postpartum longitudinal scan of the uterus showing a large amount of residual placental tissue (11.5 cm x 8.7 cm) (P, placenta; U, uterine wall).
confirmed that the uterine cavity and myometrium were fre,e of placental tissue. A diagnostic hysteroscopy was planned but eventually not carried out as the patient conceived spontaneously 5 months postpartum. At her 26th week, MA, the pregnancy was proceding uneventfully.
Discussion The present case report of adherent placenta justified conservative management as the patient
desired future pregnancies. Methotrexate therapy, with frequent monitoring by serial ultrasound examinations and serum P-hCG levels, was followed in 10 days by expulsion of the previously adherent placental tissue. The intrapartum and postpartum management of adherent placentae remains controversial. The classical review of Fox' recommended immediate hysterectomy because at that time maternal mortality was increased fourfold using conservative treatment. Options for nonsurgical management were recommended by Read et a1.2
FIGURE 2. Longitudinal view of the uterus on postpartum day 7, showing shrinkage of placental tissue (8.9 cm x 6.7 cm x 3.5 crn) (P, placenta; U, uterine Wall). VOL. 20, NO. 4, MAY 1992
290
CASE REPORT: RAZIEL ET AL.
and Clark et al.3 who advocated expectant management in carefully selected cases. This approach depends upon the availability of ample blood and its components and suitable antibiotics for the potential complications of infection and hemorrhage. Although hysterectomy remains the recommended treatment for most patients, uterine conservation is justified in certain cases when subsequent pregnancy is strongly desired. Such management may include curettage, local excision and repair, or oversewing of the implantation site (Clark3). Current use of MTX was first suggested by Arulkumaran et aL4 The sensitivity of chorionic tissue to MTX has been verified in many cases of both trophoblastic gestational disease (Berkowitz') and abdominal pregnancy with intraperitoneal placental attachment (St. Clair'). Its applicability to the treatment of adherent placenta postpartum, however, remains an open question. We used 20 mg MTX on the 4th and 5th postpartum days because of the absence of placental absorption verified by serial ultrasound examination. MTX was discontinued shortly thereafter when p-hCG levels dropped from 1945 to 641 then 190 mIU/mL. The MTX treatment probably reduced placental vascularity, thereby leading to its separation and expulsion. Fox' mentioned three principal ethiological factors for placenta accreta: previous manual removal of placenta, uterine curettage, and uterine sepsis. Read2 found a trend of lower parity in his series, although multiparity continues to be an
etiological factor similar to older age during pregnancy. He disagreed with the high peak incidence at an age of 31 to 35 years previously published by Fox.' In light of the above, the woman presented here is no doubt at tremendous risk for placenta accreta in this current pregnancy. In summary, conservative management of an adherent placenta, with or without MTX therapy, offers a useful option in selected cases where future childbearing is desired, and post partum bleeding remains minimal. This approach requires serial ultrasonographic examinations and P-hCG follow-up. Watchful monitoring for complications such as hemorrhage and infection is necessary. REFERENCES 1. Fox H: Placenta accreta 1945-1969. Obstet Gynecol Surv 27:475, 1972.
2. Read JA, Cotton DB, Miller FC: Placenta accreta: Changing clinical aspects and outcome. Obstet Gynecol 56:31, 1980. 3. Clark SL, Koonings PP, Phelan JP: Placenta previdaccreta and prior cesarean section. Obstet Gynecol 66239, 1985. 4. Arulkurmaran S, Ingemarsson I, Ratman S: Medical treatment of placenta accreta with methotrexate. Acta Obstet Gynecol Scand 65285, 1986. 5. Berkowitz RS, Goldstein DP, Berenstein N R Ten year experience with methotrexate and folinic acid as primary treatment of gestational trophoblastic disease. Gynecol Oncol 23:111, 1986. 6. St. Clair JI, Wheeler DA, Fish SA: Methotrexate in abdominal pregnancy. JAMA 208:529, 1969.
JOURNAL OF CLINICAL ULTRASOUND
