Conservative management of placenta previa percreta by leaving placental tissue in situ with arterial ligation and adjuvant methotrexate therapy

Abstract

Placenta percreta is one of the life-threatening conditions in modern obstetrics. The rising caesarean section rate means rising placenta percreta rate. Treatment strategies range from a caesarean hysterectomy to leaving the placenta in situ with or without internal iliac artery ligation/uterine artery embolisation and/or methotrexate therapy. We describe a case of placenta previa percreta which we managed successfully with conservative modalities. (J Turkish-German Gynecol Assoc 2011; 12: 127-9) Key words: Placenta percreta/accreta, methotrexate, conservative management Received: 15 May, 2010 Accepted: 3 August, 2010Plasenta perkreata modern obstetrideki hayatı tehdit eden patolojilerden biridir. Artan sezaryen doğum oranı artan plasenta perkreata oranı anlamına gelmektedir. Tedavi stratejileri sezaryen histerektomiden plasentanın içeride bırakılması veya internal iliak arter ligasyonu/uterin arter embolizasyonu ve/veya metotreksat tedavisine kadar uzanmaktadır. Bu yazıda konservatif yöntemler kullanarak başarılı şekilde yönettiğimiz bir plasenta previa perkreata tanılı olguyu takdim etmekteyiz. (J Turkish-German Gynecol Assoc 2011; 12: 127-9) Anahtar kelimeler: Plasenta perkreata/akreata, metotreksat, konservatif yönetim

Management of Abnormal Placenta Implantation with Methotrexate: A Review of Published Data

“…We identified 53 articles including one prospective cohort study, 2 retrospective cohort studies, 10 case series and 40 case reports with cumulative describing 121 patients [10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62]. Our inclusion criteria led to exclusion of 33 patients: 1 patient due to another diagnosis (un-ruptured interstitial corneal pregnancy) [32], 24 patients due to lack of exact reported data [17,51], 4 patients due to initial total hysterectomy [14,17,61], and finally another 4 patients due to other conservative modalities without MTX administration [14,23,42] (fig.…”

“…We found 19 cases with placenta accreta and percreta who received MTX along with other conservative modalities [13,18,24,32,34,37,38,42,45,51,53,54,55,59]. In these patients, other conservative managements including uterine arterial embolization and uterus preserving surgeries (arterial occlusion involving arterial ligation or balloon tamponade) were applied.…”

“…Outcomes of these patients showed that uterine preservation was achieved in 10 cases, while placenta removal was performed in 2 involved cases. And finally 5 cases have experienced subsequent menstruation [32,37,42,53,55]. Elective hysterectomy was done for preserving the bladder in 2 cases [45].…”

The Feasibility of Conservative Management for Morbidly Adherent Placenta Accidentally Encountered after Vaginal Delivery

“…The role of MTX in treating MAP remains controversial [21] . Although some researchers have used MTX as an adjunctive treatment for MAP and have suggested that MTX effectively inhibit trophoblast proliferation [20,22,23] , there is no convincing evidence to verify the benefits of MTX [10] . Tong et al [24] suggested that adjunctive MTX treatment may not be necessary for MAP because the placenta could pass spontaneously through the vagina once the vascular supply was interrupted.…”

Update on the Management of Morbid Adherent Placenta

“…It is dihydrofolate reductase inhibitor that targets rapidly developing cells, most commonly used for the treatment of an ectopic pregnancy & trophoblastic diseases. Some experts have used it as an adjunct to the conservative treatment of placenta accreta and also suggest that it helps rapid expulsion of placenta 24 . But methotrexate is contraindicated during breast feeding.…”