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Successful Use Of Uterine Artery Embolisation To Treat Placenta Increta In The First Trimester

Hooman Soleymani Majd · Maithili Srikantha ·
Subrata Majumdar · Christopher B-Lynch ·
Kiyoshi Choji · Manivannan Canthaboo · Lamiese Ismail
Received: 31 May 2008 / Accepted: 25 August 2008
© Springer-Verlag 2008
Abstract A 39-year-old Asian woman was admitted to hospital with persistent, heavy vaginal bleeding following an uncomplicated Wrst trimester surgical termination of pregnancy (STOP). Her heavy bleeding continued after the STOP and she had recurrent hospital admissions which included two procedures to evacuate presumed retained products of conception. She eventually had a MRI scan performed which suggested placental tissue in the fundal region, extended into the uterine wall. The Wndings were consistent with placenta increta and the patient had a bilateral uterine artery embolisation (UAE), following which her symptoms rapidly subsided. We describe the First successfully managed case of persistent vaginal bleeding secondary to abnormal placentation. It would seem to substantiate the eYcacy of UAE as a therapeutic modality for the conservative management of invasive placentation
in the Wrst trimester of pregnancy.

Keywords Uterine artery embolisation · Placenta increta ·
ERPOC · First trimester · Bleeding · Treatment

CASE REPORT

A 39-year-old Asian woman elected to have a surgical terminationof pregnancy (STOP) at 11 weeks gestation for an unplanned pregnancy. She was an obese, nonsmoker who had three previous normal vaginal deliveries and no prior uterine surgery. The termination was an uneventful day case procedure, however, following this she developed persistent vaginal bleeding which lasted several weeks. During this time she was treated empirically with oral antibiotics
by her GP.

She also had two hospital admissions when pelvic ultrasound scans were performed. The reports suggested retained products of conception. Thus, she had two uterine evacuations at which time, the cavity was double checked with curettage to completely evacuate the uterus but her bleeding continued. Oral contraception and other hormonal treatments were not considered at this time because of the patient’s age, raised BMI and as yet undiagnosed vaginal bleeding.

Seven weeks after her initial STOP, she presented for a third time to hospital. She was haemodynamically stable. Despite having commenced ferrous sulphate a few weeks previously, she still only had haemoglobin of 8.5 g/dL. Her pregnancy test was now negative, thus the possibility of gestational trophoblastic disease was dismissed.

She had another pelvic ultrasound scan which showed a bulky anteverted uterus with a heterogenous ndometrium, thickened to 22 mm in the AP diameter at the fundal end (Fig. 1). The Wndings were completely unchanged from her previous two ultrasound scans. Thus magnetic resonance imaging (MRI) was requested. This demonstrated a bulky uterus containing placental tissue in the fundal region, which extended into the uterine wall without involving the serosa of the bladder. The Wndings were consistent with a placenta increta (Fig. 2).

The patient was counselled regarding the various treatment options and informed of their implication for her
future fertility. As her family was complete, she was not particularly concerned by this but she was rather keen to avoid surgery because of the associated potential morbidity and prolonged convalescence period. However, in light of the real possibility of hysterectomy, she was advised to have a two unit blood transfusion, to which she agreed.

The patient decided to proceed with bilateral uterine artery embolisation (UAE). It was a straight forward procedure, performed under conscious sedation by a highly experienced interventional radiologist and took approximately 60 min. Both uterine arteries were super selectively cannulated via a femoral approach. Embolisation was performed using grated gelatin sponge particles, which were soaked in 5% ethanolamine oleate. Five millilitres in total were infused and a satisfactory embolisation eVect was confirmed bilaterally.

Following the procedure, she remained an inpatient as given her previous repeated admissions, close follow up was deemed appropriate. Her bleeding subsided rapidly over the next 2 days and she was discharged without further complications. Appropriate follow-up appointments were made to ensure no intervening problems had occurred and the patient is doing very well.

Discussion
UAE is an extremely effective treatment modality for controlling intractable gynaecological and obstetric haemorrhage, which has failed to respond to conservative treatment [1]. UAE may be associated with morbidity and has an estimated 11% complication rate, with the commonest being post procedural pain [2]. Occasionally, inadvertent or unintended arterial embolisation of important blood vessels may occur but it should be noted that this risk is rare and can be minimised in the hands of an experienced operator. UAE is
also generally associated with a short hospital stay [3].

Most studies concur that women should expect a return to normal menses after UAE [4, 5]. However, the issue of fertility preservation is a less clear. In the vast majority of cases, UAE allows uterine preservation in young women who would otherwise have faced therapeutic hysterectomy before completing their families. Whilst there are many studies which suggest that UAE is eVective when treating women who wish to preserve their fertility [6]. There are still some concerns that the effects of UAE on fertility remain uncertain [7]. Furthermore, the impact of UAE on ovarian function is a long-term issue which warrants further
research [8].

UAE has been widely used in the gynaecological setting even though it was firstt mainly employed in the obstetric management of postpartum haemorrhage [9]. There is limited experience of its use in the first trimester. It has been used in consultation with good effect to control haemorrhage in the first trimester of pregnancy, after therapeutic or induced abortion and after incomplete, spontaneous miscarriage [10].

One series described the selective use of UAE for women at risk of severe haemorrhage from placenta accreta [11]. UAE has also been successfully used to treat severe haemorrhage after induced abortion in the firstt trimester, in patients who developed lower uterine segment pregnancy, following previous caesarean section [12]. Indicating that, previous caesarean section is a risk factor for subsequent abnormal placentation.

Fig. 1 Pelvic Ultrasound Scan Showing Heterogenous, Thickened Endometrium

Fig. 2 Sagittal MRI Image Of Placenta Increta

But there is no evidence in the literature to suggest endogenous increta in the firstt trimester, or following
ERPOC/curettage. Our patient had three normal deliveries and had no apparent risk factors for abnormal placentation.
However, she had a fundal placenta increta on MRI, accounting for her ongoing vaginal bleeding.
MRI appears to be an accurate modality for the assessment and diagnosis of abnormal placentation as compared to ultrasonography, especially in cases where the abnormality is located on the posterior wall or the fundus [13]. A number of recent studies, most notably a large Canadian study by Warshak et al. [14] have further supported the superiority and reliability of MRI in diagnosing abnormal placentation, especially where ultrasound features have been inconclusive. Proposing that MRI has a sensitivity of 0.88 and speciWcity of 1.0.

To our knowledge, there has only been one other reported case of abnormal placentation in the first trimester where there were no risk factors. In that case report, the patient had failed UAE (twice) and required a hysterectomy [15].

Our case describes the firstt successful use of UAE in the firstt trimester, to cure persistent vaginal bleeding secondary to abnormal placentation. It seems to substantiate the efficacy of UAE as a therapeutic modality for the conservative management of invasive placentation in the firstt trimester of pregnancy.

Conflict of interest statement There is no confict of interest in submitting this paper for publication.

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