Conservative multidisciplinary management of placenta percreta following in vitro fertilization
A 35-year-old nulliparous woman was referred at 24 weeks' gestation to our clinic with regular uterine contractions. She had a history of primary infertility due to bilateral occlusion of the fallopian tubes, and had undergone 10 cycles of IVF. She had no relevant family or medical history. Pelvic examination on admission revealed that the membranes were intact and that the uterine cervix was 90% effaced and 3 cm dilated. Vital signs were stable and microbiological examination revealed no abnormalities of the urine sample or vaginal swab.\nSonographic examination showed a vertex presentation, fetal biometry compatible with 24 weeks' gestation, an estimated fetal weight of 603 g, and location of the placenta in the right fundus with thinning of the myometrium. MRI of the pelvis was performed to confirm placental invasion. Axial and coronal T2-weighted MRI showed that placental tissue occupied the superolateral aspect of the fundus, and that the full thickness of both the myometrium and the uterine serosa was involved. There were no signs of placental invasion of adjacent organs ().\nOn admission, tocolytics were commenced to suppress the regular uterine contractions. Betamethasone was also administered to facilitate fetal pulmonary maturation. Despite these measures, the uterine contractions intensified and progressive changes in the uterine cervix were observed; thus, tocolytic therapy was discontinued 6 hours post-admission. The parents were fully informed of the potential complications associated with preterm birth and placenta percreta, and they decided that vaginal delivery should be attempted. Intrapartum fetal heart rate monitoring showed a reassuring pattern. A female newborn weighing 669 g was delivered 30 minutes after stopping tocolytics by spontaneous vaginal delivery, with Apgar scores of 2 and 4 at 1 and 5 minutes, respectively. The newborn was transferred immediately to the neonatal intensive care unit.\nSpontaneous delivery of placental tissue did not occur, and a decision was made to leave the placenta in situ. No significant hemorrhage occurred in the 1 hour period post-delivery. Pelvic arterial embolization was performed at the 1 hour post-delivery to prevent hemorrhage at the time of placental separation. Under fluoroscopic guidance, the bilateral uterine arteries were selectively catheterized and embolized with absorbable gelatin sponge pledgets.\nSix hours after delivery, maternal tachycardia and vaginal bleeding occurred, and placental detachment or uterine rupture was suspected. Therefore, a decision was made to remove the placenta in the operating room under general anesthesia. Most of the intrauterine placenta was removed vaginally using placental forceps under transabdominal sonography guidance. Emergency laparoscopy was performed, which revealed a ruptured placenta percreta with hemoperitoneum. Exploratory laparotomy was done immediately and primary resection of the remaining placental tissues and closure of the uterine wall was then performed (). The postoperative course was uneventful and the woman was discharged home 5 days postoperatively.