Placenta previa percreta managed conservatively with methotrexate and multiple bilateral uterine artery embolizations

A 35-year-old woman, para 4, with three previous transverse lower-segment Cesarean deliveries was noted sonographically at 22 weeks' gestation to have findings consistent with placenta previa percreta, and this was later confirmed by magnetic resonance imaging (Figure 1). Possible management plans were discussed with the patient and, given the potential morbidity associated with Cesarean hysterectomy in the presence of placenta previa percreta, she opted for conservative management (if possible). (a) Sagittal suprapubic transabdominal color Doppler image at 22 weeks' gestation depicting placenta previa percreta. Note the absence of myometrium and the placenta (pl.) abutting the bladder (bl.). Also note the abundant maternal vessels immediately under the bladder mucosa and numerous placental lacunae. (b) Sagittal magnetic resonance image confirming placenta previa percreta at 24 weeks' gestation. Note the complete absence of myometrium in the anterior aspect of the lower uterine segment. The arrow indicates the bladder mucosa immediately adjacent to placental tissue. At 30 weeks, following prolonged fetal bradycardia, an infant weighing 1510 g was delivered by Cesarean section through a classical uterine incision. The umbilical artery pH was 7.29 and the base excess was − 1. Placenta previa percreta was confirmed visually at surgery. No evidence of active hemorrhage was noted. The umbilical cord was ligated proximally and the placenta left in situ. Intraoperative blood loss was < 500 mL. Immediate postoperative bilateral uterine artery embolization was performed. The patient remained afebrile with no evidence of hemorrhage. Three weekly courses of intramuscular methotrexate 100 mg (1 mg/kg) were administered, with decreasing serum beta-human chorionic gonadotropin (β-hCG) levels. Color Doppler ultrasonography continued to show abundant vascular flow within the uterus and retained placenta. Three additional bilateral uterine artery embolizations, each following an angiogram with contrast depicting abundant vascularization of the retained placenta, were performed biweekly (Figure 2). Uterine size gradually decreased, and serum prothrombin time and partial thromboplastin time levels remained normal. The serum β-hCG level was 28 mIU/mL on postoperative day 60. To avoid potential ovulation/menstruation-associated hematometra while anticipating sloughing of the placenta, the patient received intramuscular Lupron Depot® (TAP Pharmaceuticals Inc., Lake Forest, IL, USA) every 4 weeks. She remained in good health 9 months postpartum with transvaginal ultrasonography depicting a uterus 10 × 8 × 8 cm in size, with no abnormal vascular activity. (a) Selective (left) uterine artery angiogram immediately before the fourth embolization. Note the abundant feeding placental vessels and faint cotyledon imprint highlighted in the background. (b) Postembolization angiogram showing complete obliteration of the vessels depicted in (a). Patients with placenta previa percreta are at significantly increased risk of life-threatening massive hemorrhage and other surgical complications including hysterectomy, and bladder and ureteral injury. Current imaging modalities have enabled detailed planning of conservative management of such cases1-6. Accordingly, various conservative management paradigms, including retention of the placenta in situ, methotrexate administration and bilateral uterine artery embolization, have been reported with varying degrees of success2, 4-6. However, failures of such conservative management measures are not uncommon, and the precise etiologies of these failures and optimal adjuvant therapy remain unclear6-9. The continued presence of abundant maternal vascularization of the retained placenta (depicted by angiography and color Doppler imaging) despite decreasing serum β-hCG levels, as in the present case, has been reported previously7. The continued vascularization, previously associated with failure of conservative treatment of placenta previa percreta, led us to perform multiple bilateral uterine artery embolization procedures during the postoperative course in the current case. A systematic English language literature search (PubMed and Medline) between 1966 and 2007 using the search terms ‘placenta previa’, ‘placenta percreta’, ‘previa percreta’, ‘uterine artery embolization’, ‘conservative management’ and ‘methotrexate’ has confirmed that this is the first report of multiple bilateral uterine artery embolizations in the conservative management of a patient with placenta previa percreta. This case suggests that multiple postoperative bilateral uterine artery embolizations may increase the success of conservative management of patients with this life-threatening condition. D. M. Sherer*, C. Gorelick , A. Zigalo*, S. Sclafani , H. L. Zinn , O. Abulafia , * Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, 445 Lenox Road, Box 24, Brooklyn, NY 11203-2098, USA, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA, Department of Radiology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA