A 27-year-old woman, gravida 2 para 1, at 37 weeks gestation is admitted to the labor and delivery unit in active labor. The patient has had no vaginal bleeding or leakage of fluid. She has no chronic medical conditions but has not received prenatal care during this pregnancy. Her only surgery was a prior cesarean delivery for an uncomplicated twin gestation at term. Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, and pulse is 88/min. Ultrasound reveals an anterior placenta and a breech fetus with a heart rate of 140/min. The patient undergoes a repeat cesarean delivery. After delivery of the infant, there is moderate bleeding from the uterine hysterotomy site. The uterine fundus is firm, and the placenta cannot be removed due to dense adhesions to the anterior uterine wall. Vital signs are repeated, and temperature is 36.7 C (98 F), blood pressure is 114/66 mm Hg, and pulse is 83/min. Which of the following is the best next step in management for this patient?

Question

A 27-year-old woman, gravida 2 para 1, at 37 weeks gestation is admitted to the labor and delivery unit in active labor.  The patient has had no vaginal bleeding or leakage of fluid.  She has no chronic medical conditions but has not received prenatal care during this pregnancy.  Her only surgery was a prior cesarean delivery for an uncomplicated twin gestation at term.  Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, and pulse is 88/min.  Ultrasound reveals an anterior placenta and a breech fetus with a heart rate of 140/min.  The patient undergoes a repeat cesarean delivery.  After delivery of the infant, there is moderate bleeding from the uterine hysterotomy site.  The uterine fundus is firm, and the placenta cannot be removed due to dense adhesions to the anterior uterine wall.  Vital signs are repeated, and temperature is 36.7 C (98 F), blood pressure is 114/66 mm Hg, and pulse is 83/min.  Which of the following is the best next step in management for this patient?

Quizplus · Accepted Answer

11ec25c8_da59_d555_bc81_d1242f064b1d_MD0003_00 This patient with dense placental adhesions to the anterior uterine wall has placenta accreta, the pathologic attachment of placental villi directly onto the uterine myometrium rather than the uterine decidua. This abnormal placentation likely occurs due to defective or absent endometrial decidualization in areas with scarring from prior uterine surgery (eg, cesarean delivery, dilation and curettage). The lack of normal decidua in these areas allows the chorionic villi to attach to the myometrium and become morbidly adherent. Placenta accreta is typically diagnosed on routine second-trimester ultrasound, and management is usually with a planned cesarean hysterectomy (prior to the onset of spontaneous labor) due to the significant risk of postpartum hemorrhage. However, in some cases (eg, limited prenatal care), the diagnosis of placenta accreta is only made after fetal delivery when there is significant difficulty detaching the placenta from the uterine wall. Attempts to remove the placenta (eg, manual placental extraction, sharp uterine curettage) are usually unsuccessful (due to dense adhesions between the placenta and uterus) and can significantly increase bleeding; therefore, removal of the placenta is contraindicated (Choices D and E). Without emergency management, placenta accreta can lead to severe postpartum hemorrhage, hemorrhagic shock, consumptive coagulopathy, and maternal death. Therefore, the best next step in management is surgical removal of the uterus (ie, hysterectomy) with the placenta in situ (ie, remaining attached to the uterine wall), which minimizes further maternal blood loss. (Choices A and C) Bimanual uterine massage and intrauterine balloon tamponade are treatment options for postpartum hemorrhage due to uterine atony (ie, inadequate contractility). In contrast, this patient has a firm uterine fundus. In addition, neither intervention treats the underlying etiology of placenta accreta, which is a morbidly adherent placenta. intrauterine balloon tamponade Educational objective: Placenta accreta occurs due to direct placental villi attachment to the uterine myometrium. Patients typically have difficulty with placental detachment following fetal delivery and continued placental bleeding due to dense adhesions to the uterine wall. Treatment is with hysterectomy (with the placenta left in situ) to prevent life-threatening maternal hemorrhage. References: Epidemiology, etiology, diagnosis, and management of placenta accreta. (http://www.ncbi.nlm.nih.gov/pubmed/22645616) Placenta accreta: diagnosis, management and the molecular biology of the morbidly adherent placenta. (http://www.ncbi.nlm.nih.gov/pubmed/26135782) The morbidly adherent placenta: an overview of management options. (http://www.ncbi.nlm.nih.gov/pubmed/20804337)

A 27-Year-Old Woman, Gravida 2 Para 1, at 37 Weeks