Re: Placenta percreta
From: art fougner, md (evsono@pipeline.com)
Fri Aug 1 08:04:27 2003
The use of methotrexate gets mixed reviews, but may be helpful - good
luck to you and your patient.
art
Ultrasound Obstet Gynecol. 2002 Jul;20(1):90-3. Related Articles, Links
Antenatal diagnosis of placenta percreta with planned in situ retention
and methotrexate therapy in a woman infected with HIV.
Henrich W, Fuchs I, Ehrenstein T, Kjos S, Schmider A, Dudenhausen JW.
Department of Obstetrics and Radiology, Charite, Campus Vichow-Clinic,
Berlin, Germany. wolfgang.henrich@charite.de
Placenta percreta is a rare obstetric condition associated with
potentially life-threatening hemorrhage. Diagnosis in advance of
delivery permits a planned delivery and preparation for blood
transfusions and planned Cesarean hysterectomy, which is the common
treatment. We report a case of placenta percreta in an HIV-positive
patient which was diagnosed in the second trimester using conventional
and extended field of view ultrasound imaging and color Doppler. At 36
weeks the infant was delivered by Cesarean section and the placenta was
left in situ. Postoperatively the patient was treated with
methotrexate. Four weeks later, the patient delivered the placenta
spontaneously. Early or late postpartum hemorrhage did not occur and
postoperative recovery was uneventful.
PMID: 12100427 [PubMed - indexed for MEDLINE]
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2: Obstet Gynecol. 2002 Jun;99(6):981-2. Related Articles, Links
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Failure of methotrexate and internal iliac balloon catheterization to
manage placenta percreta.
Butt K, Gagnon A, Delisle MF.
Division of Maternal Fetal Medicine, Department of Obstetrics and
Gynecology, University of British Columbia, Vancouver, British Columbia,
Canada.
BACKGROUND: Placenta percreta is a rare but potentially lethal
condition. Previously described conservative measures to avoid
life-threatening hemorrhage and preserve fertility include use of
methotrexate and uterine artery embolization. CASE: A woman with
suspected placenta percreta diagnosed on ultrasound in the second
trimester was delivered by classic, fundal cesarean at 30 weeks'
gestation for bleeding and premature rupture of membranes. The placenta
was left in situ, and she was treated with methotrexate. Postpartum
bleeding 1 week later was managed by internal iliac balloon
catheterization and manual transcervical removal of the placenta, which
resulted in hysterectomy and required massive blood transfusion.
CONCLUSION: Placenta percreta managed conservatively with methotrexate
and internal iliac balloon catheterization resulted in serious
morbidity.
PMID: 12052585 [PubMed - indexed for MEDLINE]
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3: J Perinatol. 2000 Jul-Aug;20(5):331-4. Related Articles, Links
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Placenta accreta and methotrexate therapy: three case reports.
Mussalli GM, Shah J, Berck DJ, Elimian A, Tejani N, Manning FA.
Department of Obstetrics and Gynecology, Columbia University College of
Physicians and Surgeons, New York, NY, USA.
Placenta accreta is a complication that is rising in incidence. The
reported experience of methotrexate treatment in the conservative
management of placenta accreta is scant. Three cases of placenta
accreta managed with methotrexate are presented. Case 1: A woman had an
antenatal diagnosis of placenta percreta. A successful manual placental
removal occurred on post-cesarean day 16. Case 2: A woman had retention
of a placenta accreta after a term vaginal delivery. Successful
dilation and curettage were performed on postpartum day 37. Case 3: A
woman had an antenatal diagnosis of placenta previa-percreta with
bladder invasion. A simple hysterectomy was performed on post-cesarean
day 46. Conservative management and methotrexate treatment resulted in
uterine preservation in two of our three patients; however, this
treatment did not prevent significant delayed hemorrhage. In view of
the rapid resolution of vascular invasion of the bladder, methotrexate
may have an important role in the management of placenta percreta with
bladder invasion. The utility of methotrexate treatment with the
conservative management of placenta accreta requires further evaluation.
PMID: 10920795 [PubMed - indexed for MEDLINE]
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4: Ultrasound Obstet Gynecol. 1997 Feb;9(2):131-8. Related Articles,
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Links
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Placenta previa percreta with bladder involvement: new considerations
and review of the literature.
Silver LE, Hobel CJ, Lagasse L, Luttrull JW, Platt LD.
Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center
Burns & Allen Research Institute, UCLA School of Medicine, USA.
Placenta previa percreta is a life-threatening condition. Antenatal
diagnosis is important to establish and to optimize a plan of
management. When bladder invasion occurs, other potential complications
can result, including massive hemorrhage and the development of
disseminated intravascular coagulation. Numerous modalities have been
used successfully to treat these patients, but hysterectomy at delivery
is the treatment most commonly used. A case of placenta previa percreta
with suspected bladder invasion was diagnosed in a 35-year-old woman by
routine office ultrasound examination at 19 weeks 6 days' gestation. She
was managed conservatively until 36 weeks 3 days' gestation, at which
time she underwent a modified classical Cesarean section after
amniocentesis to confirm fetal lung maturity. The placenta was left in
situ immediately postpartum. The patient underwent a prophylactic
embolization of her hypogastric arteries and received methotrexate
chemotherapy. Eight weeks later, she developed a low-grade coagulopathy
and underwent a total abdominal hysterectomy. Conservative management
intrapartum is thought to be appropriate, to avoid the risk of severe
hemorrhage at the time of delivery. However, elective hysterectomy
ought to be considered earlier (2-4 weeks postpartum) than the time
suggested in the literature, to avoid the development of further
complications, including coagulopathy.
PMID: 9132257 [PubMed - indexed for MEDLINE]
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5: Am J Obstet Gynecol. 1994 Aug;171(2):558-9. Related Articles, Links
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Comment in:
Am J Obstet Gynecol. 1995 May;172(5):1648-9.
Am J Obstet Gynecol. 1995 May;172(5):1649-50.
Failure of methotrexate treatment for term placenta percreta.
Jaffe R, DuBeshter B, Sherer DM, Thompson EA, Woods JR Jr.
Division of Maternal-Fetal Medicine, University of Rochester, NY.
Placenta percreta is a severe condition associated with maternal
morbidity and mortality even when surgery is performed electively.
Methotrexate has been suggested as a possible treatment modality for
adherent placenta to avoid catastrophic surgery. The purpose of this
report is to present a case where the placenta was left in situ to avoid
cystectomy at the time of cesarean section, with subsequent failure of
treatment with methotrexate.
PMID: 8059842 [PubMed - indexed for MEDLINE]
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6: Obstet Gynecol. 1994 May;83(5 Pt 2):847-9. Related Articles, Links
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Nonsurgical management of placenta percreta: a case report.
Legro RS, Price FV, Hill LM, Caritis SN.
Department of Obstetrics, Gynecology, and Reproductive Sciences,
University of Pittsburgh, School of Medicine, Magee-Women's Hospital,
Pennsylvania.
BACKGROUND: Although placenta percreta is rare, its sequelae include
potentially lethal hemorrhage and loss of reproductive function. Therapy
directed toward control of life-threatening hemorrhage frequently
includes emergency hysterectomy. CASE: A woman with placenta percreta,
suspected clinically and documented radiographically, was treated
nonsurgically. Following delivery, the placenta was left in situ and
methotrexate chemotherapy was initiated to aid destruction of the
trophoblastic tissue. Eight months later, hysteroscopy showed a normal
uterine cavity with only a small area of calcification at the presumed
implantation site. Two years later, the patient had a normal pregnancy
and vaginal delivery. CONCLUSION: Placenta percreta can be managed with
preservation of the uterus, but careful follow-up may be required until
the entire placenta has resorbed.
PMID: 8159372 [PubMed - indexed for MEDLINE]
At Thu, 31 Jul 2003, Karen Robertson wrote:
>
>Dear Colleagues,
>I am a sonographer working at Waikato Hospital in Hamilton, NZ. I am
>currently involved with a tricky case here with a hospital staff member
>(isn't it always)!
>She is a G4P3 lady with 2 prior c-sections, in her most recent pregnancy
>it became apparent very early on that she had a grade4 placenta praevia
>with increasing (as the term progressed) evidence of placenta
>increta/percreta. She wanted conservative management with a uterine
>sparing procedure so babe was delivered by classical c-section at 36
>weeks and the placenta was left in situ. The next day she came for
>uterine embolisation with a view to shutting down placental function,
>one uterine vessel was successfully embolised using coils, the other
>uterine artery was described as rudimentary only and was therefore not
>embolised. Immediately post embolectomy ultrasound showed placental
>vascularity was reduced with a small amount of echogenic fluid seen
>superiorly within the uterus. Subsequently ultrasound every 3-4 days
>have shown increasing vascularity of placenta with an increase in the
>amount of fluid within the cavity. Vessels appear to indent the
>posterior wall of the bladder and there is no appreciable myometrium
>between the placenta/bladder interface.
>We need to have a plan should she haemorrhage and an MRI was attempted
>with a view to assessing degree of bladder invasion but had to be
>abandoned due to metallic coils from the recent embolisation. Should we
>attempt another embolisation? What experience have the forum members had
>with Methotrexate?
>Does anyone have any suggestions at this point - all information would
>be gladly received as this is the first time we have had such a case
>here.
>Thanking you in anticipation......
>Karen.
--
art fougner, md
ich bin ein New Yorker
