Abstract
BackgroundsPregnancy termination during the second trimester in patients with placenta previa and placenta accreta spectrum (PAS) is a complex and challenging clinical problem. Based on our literature review, there has been a relative increase in the number of such cases being treated by hysterotomy and/or local uterine lesion resection and repair. In the present study, a retrospective analysis was conducted to compare the clinical outcomes when different management strategies were used to terminate pregnancy in the patients with placenta previa and PAS.MethodsA total of 51 patients who underwent pregnancy termination in the second trimester in Beijing Obstetrics and Gynecology Hospital between June 2013 and December 2018 were retrospectively analyzed in this study. All patients having previous caesarean delivery (CD) were diagnosed with placenta previa status and PAS.Results① Among the 51 patients, 16 cases received mifepristone and misoprostol medical termination, 15 cases received mifepristone and Rivanol medical termination, but 1 of them was transferred to hysterotomy due to failed labor induction, another 20 cases were performed planned hysterotomy. There was no placenta percreta cases and uterine artery embolization (UAE) was all performed before surgery.② There were 31 cases who underwent medical termination and 30 cases were vaginal delivery. Dilation and evacuation (D&E) were used in 20 cases of medical abortion failure and in all 30 cases of difficult manual removal of placental tissue. ③ A statistically significant difference was found among the three different strategies in terms of gestational weeks, the type of placenta previa status, main operative success rate and β-HCG regression time (P < 0.05). ④ There were 4(7.8%) cases who were taken up for hysterectomy because of life-threatening bleeding or severe bacteremia during or after delivery and hysterotomy. The uterus was preserved with the implanted placenta partly or completely left in situ in 47(92.2%) cases. Combined medical and/or surgical management were used for the residual placenta and the time of menstrual recovery was 52(range: 33 to 86) days after pregnancy termination.ConclusionsTerminating a pregnancy by vaginal delivery through medical induction of labor may be feasible if clinicians have an overall understanding of gestational age, the type of placenta previa status, the type of placenta accreta, and patients concerns about preserving fertility. A collaborative team effort in tertiary medical centers with a very experience MDT and combined application of multiple methods is required to optimize patient outcomes.
Highlights
Caesarean scar pregnancy (CSP) is a rare ectopic pregnancy where the conceptus is implanted on the fibrous tissue of a previous cesarean scar defect [1, 2]
The uterus was preserved with the implanted placenta partly or completely left in situ in 47(92.2%) cases
Terminating a pregnancy by vaginal delivery through medical induction of labor may be feasible if clinicians have an overall understanding of gestational age, the type of placenta previa status, the type of placenta accreta, and patients concerns about preserving fertility
Summary
Caesarean scar pregnancy (CSP) is a rare ectopic pregnancy where the conceptus is implanted on the fibrous tissue of a previous cesarean scar defect [1, 2]. The incidence of CSP is increasing as the rate of cesarean delivery (CD) increases, and in response to the secondchild policy in China [3]. The majority of CSP patients promptly terminate the pregnancy in the first trimester. CSPs progress to the second or third trimester and develop into placenta previa and placenta accreta spectrum (PAS) which may cause a life-threatening condition because of the high risk of uncontrolled hemorrhage, disseminated intravascular coagulation, uterine rupture, hysterectomy, and even death [4,5,6]. Terminating pregnancy in the second trimester for pregnant women with placenta previa and PAS and who have had a previous CD is both controversial and rarely reported. There are still difficult challenges in the clinical management of these complex cases and few studies have reported on such cases, especially regarding vaginal delivery
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