The detection of a morbidly adherent placenta (MAP) in early pregnancy is rare. Routine first trimester transvaginal ultrasounds (TVUS) usually do not focus on localization and implantation of the placenta [
A 25-year-old G4P3003 at 7 weeks and 1 day by last menstrual period with a medical history of 3 previously documented low transverse cesarean deliveries and obesity (BMI: 34) presented for management at a county hospital for a missed abortion diagnosed at an outlying rural clinic. The patient reported that this was a planned pregnancy and desired future pregnancies; she denied any spotting, cramping, or passage of any tissue. The formal TVUS report at the outside clinic showed an intrauterine pregnancy with a 27.8 mm mean sac diameter consistent with 8 weeks and no fetal cardiac activity seen; no evidence of a MAP was noted in the report. A repeat bedside TVUS in clinic by a resident physician showed an irregular shaped gestational sac with a crown rump length of 1.5 cm.
After thoroughly counseling the patient on expectant, medical, and surgical management, she elected for medical management. The patient was uninsured and declined surgical management as she did not want to incur the expense of the procedure. The patient received 800 mcg of misoprostol per vagina (PV) in clinic and she was sent home with a prescription to take two additional doses of 800 mcg buccally every 24–48 hours if needed until she noted passage of clots or tissue. She was instructed to return to clinic in one week unless she developed heavy bleeding soaking greater than two pads an hour for two hours or fever greater than 100.4 degrees Fahrenheit [
She was Rh positive with a hemoglobin of 12.7 g/dL. During her procedure, the cervix was dilated followed by insertion of the suction curette; some products of conception were evacuated but the canister filled quickly with bright red blood. Upon removing the curette, she continued to bleed heavily. Methergine was administered intramuscularly which helped decrease the amount of bleeding. The estimated blood loss (EBL) was 1200 cc; two units of packed red blood cells (PRBC) were given and the main operating room (OR) and hospital were notified for her immediate transfer since the ambulatory surgery center was not sufficiently equipped for this level of care. A foley balloon was placed into the uterus and inflated to 60 cc. This was able to tamponade and minimize the bleeding.
The patient was transferred to the main hospital by ambulance. A TVUS was performed which showed products of conception versus a 5 cm hematometra. Given that the patient had refractory abdominal pain unrelieved by intravenous morphine and a concern for an expanding hematometra, the patient was taken back to the OR for an exploratory laparotomy. The patient was consented for a possible total abdominal hysterectomy versus evacuation of hematometra. Upon entry into the abdomen, dense abdominal adhesions were noted; there was approximately 200 cc of hemoperitoneum in the rectouterine pouch. It was noted that there was a 7-8 cm portion of the lower uterine segment that displayed placental tissue overlying the uterine serosa by 1 mm. The decision was made to proceed with a hysterectomy. She received 1 unit each of fresh frozen plasma and PRBC intraoperatively. The EBL intraoperatively was 500 cc bringing the total blood loss to 1900 cc. A cystoscopy was performed and bladder involvement was ruled out. The patient met all postoperative milestones and recovered well.
Final pathology showed a placenta percreta. Sectioning through the patient’s myometrium showed extensive hemorrhage dissecting through the entire myometrial thickness at the level of the lower uterine segment (Figure
Necrotic myometrium (arrow) with degenerating chorionic villi (arrowhead) transecting through the entire myometrial thickness to the serosal surface with extensive hemorrhage (H&E stain, 20x magnification).
Upon review of the literature, a MAP is a rare finding to detect in the first trimester. Of the MAPs, placenta accreta occurs 75%, placenta increta 18%, and placenta percreta 7% of the time [
Morbidly adherent placentas (MAPs) diagnosed in the first trimester and treated before 15 weeks’ gestation [
Author and year | Type of MAP | Prior CS§ | Prior D&C† | GA at Diagnosis# | Presenting symptoms | US diagnostic of MAP | Management & |
---|---|---|---|---|---|---|---|
Helkjaer et al., 1982 | n/ |
1 | 0 | 11 wks | VB |
n/a | Laparotomy, |
Woolcott et al., 1987 | Percreta | 2 | 0 | 10 wks | VB | No; missed abortion | Laparotomy, |
Haider, 1990 | Percreta | 1 | 0 | 10 wks | VB | No; missed abortion | Laparotomy, |
Ecker et al., 1992 | Increta | n/a | n/a | 1st trimester | n/a | n/a | Laparotomy, |
Arredondo et al., 1995 | Accreta | 0 | 3 | 1st trimester | None | No; missed abortion | Laparotomy, |
Gherman et al., 1999 | Increta | 1 | 1 | 8 wks | VB/abd pain | Yes; suspected MAP | Laparoscopy/laparotomy, hysterectomy |
Walter et al., 1999 | Increta | 1 | 0 | 11 wks | VB | n/a | D&C/laparotomy, hysterectomy |
Marcus et al., 1999 | Percreta | 2 | 0 | 13 wks | VB | n/a | UAE |
Chanrachakul et al., 2001 | Increta | 1 | 0 | 7 wks | VB | No; missed abortion | D&C/laparotomy, hysterectomy |
Hopker et al., 2002 | Percreta | 1 | 1 | 10 wks | Abd pain | Yes; suspected MAP versus invasive mole | Laparotomy, |
Shih et al., 2002 | Accreta | 0 | 0 | 8 wks | VB | Yes; suspected MAP | Elective laparotomy at 15 wks, hysterectomy |
Buetow, 2002 | Percreta | 1 | 0 | 1st trimester | VB/pelvic pain | Yes; suspected MAP | Laparotomy, |
Chen et al., 2002 | Accreta | 2 | 1 | 9 wks | VB | Yes; suspected MAP | Laparotomy, |
Liang et al., 2003 | Percreta | 2 | n/a | 1st trimester | Abd pain/shock | n/a | Laparotomy, |
Liu et al., 2003 | Increta | 1 | 0 | 1st trimester | n/a | n/a | UAE/laparotomy, hysterectomy |
Coniglio and Dickinson, 2004 | Accreta | 2 | 0 | 8 wks | Abd pain/shock | Yes; suspected Cesarean scar pregnancy | Laparotomy, repair |
Dabulis and McGuirk, 2007 | Percreta | 3 | 1 | 9 wks | Abd pain | Yes; suspected MAP | Laparotomy, |
Son et al., 2007 | Increta | 0 | 3 | 8 wks | Abd pain/syncope | Abd/pelvis computed tomography | Laparotomy, |
Tanyi et al., 2008 | Percreta | 1 | 1 | 7 wks | VB/abd pain | No; threatened abortion | D&C/laparotomy, hysterectomy |
Papadaskis et al., 2008†† | Percreta | 2 | 1 | 11 wks | VB | No; missed abortion | D&C/laparotomy, hysterectomy |
Soleymani et al., 2009 | Increta | 0 | 0 | 11 wks | VB | Yes; suspected MAP | D&C/UAE, resolved |
Yang et al., 2009 | Increta | 2 | 3 | 12 wks | VB | Yes; suspected MAP | UAE, resolved |
Pont et al., 2010 | Percreta | 1 | 1 | 13 wks | Abd pain | n/a | Laparotomy, |
Hanif et al., 2011 | Percreta | 2 | 2 | 12 wks | Abd pain/syncope | No; ectopic pregnancy | Laparotomy, |
Shojai et al., 2012†† | Increta | 2 | 0 | 7 wks | n/a | No; missed abortion | D&C/laparotomy, hysterectomy |
Shaamash et al., 2014 | Accreta | 2 | 0 | 11 wks | VB/abd pain | Yes; suspected MAP versus molar changes | D&C/laparotomy, hysterectomy |
However, failed medical management raises concern, especially in patients with risk factors for a MAP. This should trigger further evaluation with a thorough repeat formal TVUS to rule out a MAP and have radiology look closer at the placenta to myometrial interaction and morphology. Relaying identifiable risk factors and pertinent clinical findings to radiology is important to assist in their assessment. Ultrasound is the primary modality for diagnosing a MAP [
Vascular findings have also been described in a MAP. Placental lacunae and indistinct intraplacental channels with turbulent flow have the highest sensitivity for a MAP [
Longitudinal grayscale and color Doppler image of the lower uterine segment and cervix demonstrates endometrial fluid (red arrow) and an irregular, heterogeneously hypoechoic placenta (orange arrow) with blood supply from cervical vessels (yellow arrow) extending into the anterior myometrial wall and over the internal cervical os (white arrow).
Magnetic resonance imaging (MRI) may be used when an ultrasound is not definitive or if the placenta is posterior [
In patients with a concern for a first trimester MAP, their management needs to entail extensive counseling regarding therapeutic options with a definitive (hysterectomy) or conservative (leave placenta in situ) management depending on patients fertility goals [
Being adequately prepared in the OR with appropriate hospital resources is essential. Our patient was scheduled for a routine minor procedure in an outpatient ambulatory surgical center but necessitated transfer to the main hospital for higher level of care. In patients with risk factors and possible concern for a MAP, it is critical that these surgeries be performed in a tertiary hospital setting where sufficient resources are available if any complications arise [
MAPs represent a life-threatening concern and pose additional risk when patients are not diagnosed until the time of surgery. In patients with failed medical management for a missed abortion, assessment of MAP risk factors is critical and considered to further guide management. Communicating pertinent information to radiology better equips them in their ultrasound investigation and may place additional focus on detecting MAPs earlier and prevent unanticipated discoveries peripartum [
Written consent was obtained from the patient.
The authors declare no conflicts of interest.