CONSERVATIVE MANAGEMENT OF PLACENTA PREVIA PRECRETA

Abstract

Placenta accrete is a potentially life threatening obstetric condition. The incidence of placenta previa has  increased and seems to parallel the increasing cesarean delivery rate. Treatment strategies range from cesarean          hysterectomy to leaving the placenta in situ with or without internal iliac artery ligation or uterine artery embolisation and or methotrexate therapy. Maternal morbidity and mortality associated with placenta accreta is mainly caused by massive hemorrhage and emergency hysterectomy. Conservative management of this condition allows the women to retain her fertility and avoid the complications associated with massive hemorrhage. We are presenting a case of placenta percreta which has been managed conservatively. A 30 years old multigravida with 38 weeks of gestation with previous history of two lower segment cesarean section was diagnosed by ultrasound as a case of central placenta previa. Her Magnetic Resonance Imaging showed invasion of placenta into the bladder, hence found to be placenta percreta. She was planned for elective classical cesarean section. After     delivering the baby, bilateral uterine artery ligation done. There was no signs of placental separation and placenta was found to be densely adherent with invasion into the          myometrium, through the serosa into the bladder with ongoing hemodynamic stability, placenta was left in situ.        Postoperatively broad spectrum antibiotics, oxytocics were administered during initial 72 hours. Ultrasound including uterine artery Doppler and serum beta human chorionic           gonadotrophin hormone was performed daily for initial three days. Human chorionic gonadotrophic hormone was in            increasing trend and ultrasound showed increased vascularity with low pulsatiliy index of uterine arteries. So, on fourth   postoperative day injection Methotrexate 1milligram per              kilogram body weight and injection Folinic acid 0.1                   micrograms per kilogram body weight 4 doses were given on alternative days. Serial monitoring of serum Beta human Chorionic Gonadotrophin and Ultra Sound was done on weekly basis. Placental site infection was monitored using high vaginal swab weekly. The Beta human Chorionic            Gonadotrophin values were in decreasing trend and the  placental tissue showed decrease in volume and vascularity over 60 days.