Conservative treatment of placenta accreta with subsequent normal pregnancy

Abstract

I T IS generally accepted, and most textbooks recommend, that a retained placenta be removed surgically or manually. It is also generally believed that a placenta accreta or increta must be treated by hysterectomy. Greenhill, in the ninth edition of DeLee-Greenhill, states that, in spite of fourteen reported cases where the placenta was allowed to remain and all the women survived, he believes that abdominal hysterectomy is the treatment of choice. The following is a case report of placenta accreta or increta that was treated conservatively with no harmful effects, One year subsequently the patient had a normal delivery with a normal third stage. D. M., aged 31 years, who had been under treatment for infertility, was examined on June 11, 1946. Her last normal menses was April 5, 1946, but she reported having had a scant one-day period on May 10, and another on June 1. Examination at this time revealed a slightly enlarged, soft uterus with a known previously existing cystic tumor in the right adnexa. A presumptive diagnosis of pregnancy was made. She was not seen again until August 16, 1946, because she had not kept her scheduled appointment, nor made a new one. She came in at this time because of lower abdominal cramps and slight bleeding, both of a week’s duration. Examination revealed a uterus the approximate size of a four months’ pregnancy. The cervix was effaced, dilated 2 cm., and the amniotic sac was visible. She was sent directly to the hospital and treated with absolute bed rest, sedation, and progesterone. Twenty-four hours later, she was delivered of a 22 cm. fetus that showed no gross abnormalities. All efforts to express the placenta failed. Since there was very little bleeding, she was returned to bed and put on an Ergotrate regime. The next morning she was taken to the operating room where, under deep anesthesia, an attempt was made to remove the placenta manually. Palpation of the uterine cavity by both the operator and his assistant revealed no line of cleavage of the placenta. It was impossible to determine where the placenta ended and the uterine wall began. Because there was pra.ctically no bleeding, it was decided to follow a conservative course, and the patient again was returned to bed, She was kept in the hospital one week under treatment with Ergotrate, penicillin, and sulfadiazine. No serious bleeding nor evidence of infection developed so she was transferred home. She remained in bed at home for three weeks, during which time the uterus drained a bloody purulent lochia. Her only complaint was of cramps and pains in the legs, especially at night. Two weeks after the delivery, the fundus was not palpable abdominally. From the fourth to eighth week post partum the uterine drainage was of a bright bloody character and very moderate in amount. All discharge stopped on October 10, 1946. On the 19th of October the uterus was found to be of normal size, anterior, firm, an.d mobile. The right adnexal mass was still present. She had a one-day menses on November 7, and a scant three-day period on December 15. On February 1, 1947, a presumptive diagnosis of six weeks’ pregnancy was made and treatment for habitual abortion instituted. Her pregnancy was essentially normal throughout and she was delivered of a normal ‘i-pound infant on September 24, 1947, after an elevenhour labor. A grossly normal placenta was delivered two minutes later by simple expression. Postpartum bleeding and the entire puerperium were normal. It may be concluded from this case that placenta aecreta, in the absence of unusual bleeding, can be treated conservatively without risk and that subsequent pregnancy may be entirely normal.