Conservative Management of Placenta Previa-Accreta in a First Trimester Missed Abortion

Abstract

The incidence of placenta accreta has been increasing along with the incidence of caesarean sections. There have only been a few case reports of placenta accreta diagnosed in the first trimester, and none in association with a missed abortion in a woman without risk factors. At a routine prenatal visit, a 33 year old G2P0101 at 12+6 weeks had an ultrasound demonstrating a fetus with a crown-rump length of 8+0 weeks, no fetal heart tones, a placenta previa, and a morbidly adherent placenta. The patient requested conservative management to help preserve her fertility. Imaging demonstrated an anterior placenta previa with extension of the placenta past the inner endometrium into the superficial myometrium wall and the myometrium adjacent to the superior surface of the bladder. Consultation with Maternal Fetal Medicine (MFM) at another institution similarly demonstrated a suspicion of vascular invasion of the uterine wall with no increased vascularity extending to the maternal bladder using color flow Doppler. The opinion from this second MFM team recommended expectant management with serial beta-hCG, ultrasounds, and serial physician visits as well. Her beta-hCG levels declined serially from 55262 to 4874 mIU/mL over eight weeks. Her serial ultrasounds showed involution of the placenta and reasborption of the fetus during that time. After nine weeks of conservative management, the patient underwent an uncomplicated suction dilation and curettage. Postoperatively, the patient did well and did not have any complications. A first trimester missed abortion with a placenta previa and accreta can be managed conservatively in the attempt to preserve future fertility.