Diagnosis, treatment and application of color Doppler in conservative management of abnormally adherent placenta.

PURPOSE

Placenta ac-, in-, percreta is rare, but associated with high maternal morbidity. We report the results of diagnosis and management of patients with this condition at our institution. Serial color Doppler examinations were performed to investigate the pattern and duration of perfusion to abnormally adherent placenta after conservative treatment. The influence of these results on management decisions was evaluated.

MATERIALS AND METHODS

Women with placenta ac-, in-, percreta delivering within a three-year interval were included. Diagnosis was established by ultrasound, color Doppler, MRI, and histology specimen. B-mode ultrasound and color Doppler were applied post-operatively.

RESULTS

Fifteen cases of placenta ac-, in-, percreta occurred (0.29% of deliveries). 73.3% were associated with placenta previa, 66.6% had > or = 1 previous uterine surgery. Abnormal placentation was diagnosed antenatally in 5/15 cases; in these women complication rate (0/5 vs. 8/10, p = 0.12) and blood loss was significantly lower (mean 1.140 vs. 3.080 ml, p < 0.01). 8/15 women underwent Cesarean hysterectomy, 2 after embolization of uterine arteries. 7/15 women had conservative management. In 3 of these cases complete removal of the placenta was achieved; in the remaining 4 the entire (n = 2) or parts (n = 2) of the placenta were left in place, methotrexate was administered postoperatively, and close clinical and laboratory controls were performed. Serial color Doppler examinations revealed cessation of blood flow to the adherent tissue 9 - 13 weeks postoperatively, followed by complete resorption (n = 1)/expulsion (n = 1) of placental fragments. In two cases (placenta previa percreta) curettage was performed without major complications after negative blood flow.

CONCLUSION

The high maternal morbidity of placenta ac-, in-, percreta can be reduced with antenatal diagnosis and elective delivery. Conservative management of placenta percreta may be considered in selected cases, with embolization and/or methotrexate as an adjuvant therapy. Serial examinations of the perfusion in the retained placental tissue allow conclusions about the degree of involution and aid in determining the appropriate timing of curettage if necessary.