|
Case Report
Placenta Accreta Requiring
Hysterectomy Following
Endometrial Ablation
Marta C. Kolthoff, MD; Harold C. Wiesenfeld, MD, CM
Pregnancy after endometrial ablation is uncommon, with an estimated rate of
0.7%.1 These pregnancies
have been associated with complications such as disorders of abnormal
placental adherence, hemorrhage, preterm delivery, and hysterectomy.
Although rare, planned pregnancies following endometrial ablation
have been reported, but most are unintended and quite complicated.
A 49% termination rate has been reported for pregnancies conceived
after endometrial ablation. 2
The case presented here involves a potentially preventable and morbid
pregnancy outcome following endometrial ablation.
back to top
CASE REPORT
A 30-year-old woman (gravida 3, para 2-0-0-2) was referred at
22.1 weeks' gestation with heavy vaginal bleeding. The patient reported
no loss of fluid or contractions. The patient's history was remarkable
for endometrial cryoablation 1 year earlier for dysfunctional uterine
bleeding. She had been counseled that she could not become pregnant
again, and therefore did not use contraception following the procedure.
Her obstetric history was notable for a prior low transverse cesarean
delivery, followed by a successful term vaginal delivery. She spontaneously
conceived 6 months' postablation, and chose to continue the pregnancy.
She had experienced light vaginal bleeding during the first and
second trimesters.
On evaluation, the patient was
hemodynamically stable, and the
fetal heart rate was normal.
Ultrasonography demonstrated a
succenturiate placental lobe
extending over the internal cervical
os, consistent with placenta
previa. During admission, the
patient experienced further heavy vaginal bleeding. The
patient and her husband were
counseled extensively on the
high-risk nature of the pregnancy,
including the probability that the
bleeding would continue due to
the placental abnormalities. They
were also counseled that the
pregnancy may not reach reasonable
fetal viability due to recurrent
hemorrhage. The morbidity
and mortality associated with
periviability were discussed as
well. The couple decided to
proceed with pregnancy termination,
and termination options
were reviewed. The diagnosis of
placenta previa with a history of
both endometrial ablation and
cesarean delivery conferred a
high risk of placenta accreta. The
couple wanted to avoid a potentially
catastrophic hemorrhage,
and chose hysterectomy as
opposed to dilation and evacuation,
as second-trimester dilation
and evacuation in the setting of
placenta accreta poses a significant
risk of hemorrhage requiring
emergency hysterectomy.
A total abdominal hysterectomy was performed in the standard fashion
and without complication. Estimated blood loss was 350 mL. The uterus
grossly appeared to be 22 weeks' gestational size. Clots and placenta
were found to be covering the cervix after amputation of the specimen.
The patient's recovery was unremarkable, and no transfusion of blood
products was required. She was discharged on postoperative day 3
without complication.
Pathologic diagnosis was consistent with diffuse placenta accreta
and increta, with no intervening decidua between the chorionic villi
(or extravillous trophoblast) and uterine wall (Figure
1). There was also an accessory placental lobe occluding
the internal cervical os (Figure 2).
Estimated gestational age by fetal foot length was 22 to 23 weeks.
|
Figure not available online
|
FIGURE
1.Slices of uterine wall with placenta invading the myometrium
and approaching
the serosal surface; large arrow indicates placenta, small arrow
indicates
serosal surface
Courtesy of Marta C. Kolthoff, MD; and Harold C. Wiesenfeld,
MD, CM.
|
|
Figure not available online
|
FIGURE
2. Coronal section through uterus; large arrow
indicates cervix, small arrow indicates clotting
and placenta.
Courtesy of Marta C. Kolthoff, MD; and Harold C.
Wiesenfeld, MD, CM.
|
back to top
DISCUSSION
To the authors' knowledge, this is the third reported case
of placenta accreta in a patient with a prior endometrial ablation
who required a hysterectomy due to a lifethreatening complication.
This case was remarkable in that emergent surgical intervention
was required. Furthermore, this case also demonstrates the consequences
of inadequate contraceptive counseling following endometrial ablation.
This poor reproductive outcome may have been avoided had this patient
received proper counseling regarding possible postprocedure fertility.
The overall pregnancy rate after endometrial ablation has been
estimated at approximately 0.7%.1
As of 2005, 70 cases of postablation pregnancy had been reported
in the literature.3
Of the 32 cases that reached over 20 weeks' gestation, eight were
consistent with abnormalities of placental adherence.3
This is the fifth reported case in the English literature specifically
involving placenta accreta/increta in a postablation pregnancy.
A similar case reported in 2004 also demonstrated a morbid reproductive
outcome following ablation and ultimately requiring hysterectomy
for placenta accreta.4
Postablation pregnancy risks include (but are not limited to) placenta
accreta, hemorrhage, fetal demise, preterm delivery, and emergency
hysterectomy. These complications are likely due to postablation
uterine changes including intrauterine adhesions, contracture of
the endometrial cavity, and deficient endometrium (similar to Asherman
syndrome).2 The
Table shows comparative estimates
of placenta accreta with and without endometrial ablation.1,2,5
|
Table not available online |
TABLE.
Estimates of Placenta Accreta/Increta With and Without Ablation
*Fifty-five of 590 (9.3%) patients
with previa had accreta versus seven of 155,080 (0.005%) patients
without previa that had accreta. |
back to top
CONCLUSION
The current report underscores
the importance of communicating
to patients the risks associated
with pregnancy after endometrial
ablation, which predisposes
to abnormalities of placental
development and adherence. It
is essential that patients be
informed of these potential risks,
and that effective contraception
is required following endometrial
ablation.
back to top
Marta C. Kolthoff, MD, is a fellow
in clinical genetics. Harold C. Wiesenfeld, MD, CM,
is associate professor. Both are in the Department of Obstetrics,
Gynecology, and Reproductive Sciences, University of Pittsburgh
School of Medicine, Pa.
References
- Pugh CP, Crane JM, Hogan TG. Successful intrauterine
pregnancy after endometrial ablation. J Am Assoc Gynecol Laparosc.
2000;7(3): 391-394.
- Cook JR, Seman EI. Pregnancy following endometrial
ablation: case history and literature review. Obstet Gynecol
Surv. 2003;58(8): 551-556.
- Hare AA, Olah KS. Pregnancy following endometrial
ablation: a review article. J Obstet Gynaecol. 2005;25(2):108-114.
- Hoffman MK, Sciscione AC. Placenta accreta and
intrauterine fetal death in a woman with prior endometrial ablation:
a case report. J Reprod Med. 2004;49(5):384-386.
- Miller DA, Chollet JA, Goodwin TM. Clinical
risk factors for placenta previa-placenta accreta. Am J Obstet
Gynecol. 1997;177(1):210-214.
back to top
|
