Authors: Megaly, Kenyon, Anthony, & Robins

Authors: Megaly, Kenyon, Anthony, & Robins

1wk: 4th July 2005

3wk: 20th July 2005

6wk: 17th August 2005

8wk: 31st August 2005

Case Report:

Our Case is 43 years old nulliparous who had a missed miscarriage at 11 weeks gestational age. Ultrasound scan on 21/06/05 showed early fetal demise , Crown Rump Length 55 mm = 12 weeks, no fetal heart, large placenta with cystic changes raising the possibility of partial molar pregnancy.

The patient is keen to preserve fertility and to minimise the risk of damage to her uterus. She opted to have medical treatment of miscarriage. Mifepristone (Anti Progesterone) 200 mg was given on 21/06/05, 48 hours later she was admitted to the Hospital for Misoprostol (Prostaglandin). However the patient did not respond to medical treatment of miscarriage despite additional dose of mifepristone on 24/06/05.

The patient had surgical evacuation of the uterus on 24/06/05 for missed miscarriage with possible molar component at 12 weeks sized uterus. The patient had significant bleeding and the estimated blood loss was 3.5 Litres associated with coagulation defects

-  Prothrombin time 16.6 Seconds (Normal 11.0 – 14.0).

-  Activated Partial Thromboplastin Time 76.9 Seconds (Normal 24 – 35).

The Haematologist was involved in the management of our case. The patient received 6 units red cell concentrate and 4 units of Fresh Frozen Plasma (Containing coagulation factors essential for breaking the vicious circle of DIC). Ecbolic medications were given to make the uterus contract in the form of intra venous Syntocinon infusion and prostaglandin per rectum. Intra uterine compression using SOS Bakery Temponade Balloon was inflated for 24 hours.

N.B. SOS Bakery Temponade Balloon used for control of post partum haemorrhage. Should not be left indwelling for more than 24 hours. Used as a temporary mean of establishing haemostasis in cases requiring conservative management of post partum bleeding.

The coagulopathy was corrected and the patient condition became stable, however the patient continues to have mild bleeding per vagina. Ultrasound Scan 3 days post operative was performed on 27/06/05 to exclude retained products of conception. The Ultrasound Scan showed: Fundus of uterus empty, mid uterus appears full 8 X 4 cm, requires further investigation by Magnetic Resonance Imaging (MRI) for suspected abnormal placental implantation.

Histology results reported on 27/06/05 showed partially necrotic inflamed deciduas, blood clot, chorionic villi and macerated fetal remains. The villi have a basically normal structure, although there are degenerative features in the form of calcification and some necrosis in places. A few of the villi show trophoblastic inclusions but there is no abnormal trophoblast proliferation and no evidence of any cystic degeneration. Lying within the villi are a few large laminated thrombi.

The MRI on 28/06/05 showed: Appearance and histology suggest that this is a placenta increta in a low lying position over the cervical os. Thinning of the myometrium with probable infiltration of the placenta suggesting a placenta increta.

The patient received methotrexate to try to prevent placental tissue from invading the myometrium. The dose was calculated according to the patient’s surface area (1.74 metre square), Height (1.7 metre), Weight (64 Kg). The dose was calculated in a similar way of calculating the dose of methotrexate used for medical treatment of ectopic pregnancy.

The patient had a follow up by serum Beta Human Chorionic Gonadotrophin Hormone (Serum B HCG) and Ultrasound Scans.

Ultrasound Scan on 20/07/05 showed empty uterus with disorders of uterine architecture in the lower two thirds. No evidence of retained products of conception. Serum B HCG continues to fall until it reached 2 i.u./ Litre on 04/08/05 suggesting that no active placental tissue remains.

Conclusion:

Morbidly adherent placenta is a serious cause of haemorrhage in first trimester miscarriage. Most of previous reported cases of morbidly adherent placenta in first trimester happened after a previous Caesarean Section. In one study, it was suggested that in a patient with a previous Caesarean delivery, a sac lying in the lower uterine segment on a scan at 10 weeks or earlier suggest the possibility of placenta accrete.

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