Hysteroscopic Approach to a Morbidly Adherent Placenta in the Postpartum Period

Abstract

<h3>Study Objective</h3> Morbidly adherent placenta (MAP) is associated with major maternal morbidity and mortality with risk factors most frequently related to previous uterine surgery. In rare occasions, retained products of conception (RPOC) could complicate low risk births or first trimester termination of pregnancy, resulting in abnormal bleeding patterns or infectious morbidity. We present a case of unsuspected focal (MAP) that was diagnosed two months after a cesarean delivery. Uterine Sparing treatment was accomplished by a 2-stage hysteroscopic resection without complications. <h3>Design</h3> Case Report Video. <h3>Setting</h3> Surgical Suite. <h3>Patients or Participants</h3> A 35-year-old G1 P0 woman had a cesarean delivery at 37 weeks and 4 days due to persistent fetal breech presentation and premature rupture of the membranes. The cesarean delivery was complicated by estimated blood loss of 1019mL with no mention of any precipitating factors. The patient presented with history of prolonged vaginal spotting while on Depot Provera. Office hysteroscopy and Pelvic MRI were utilized for diagnosis and evaluation. Uterine Sparing treatment was accomplished by a 2-stage hysteroscopic resection without complications. <h3>Interventions</h3> 2-stage hysteroscopic resection was performed. The first stage was approached by a mechanical morcellation device that resolved the main bulk of the RPOC. The second stage was approached with a Resectoscopic approach to the deep myometrial nodule that persisted on follow up imaging after the index procedure. <h3>Measurements and Main Results</h3> Complete resection of the RPOC and deep myometrial nodule was accomplished without complication. <h3>Conclusion</h3> Retained products of conception should be considered in the differential diagnosis of patients who present with abnormal uterine bleeding after birth. Treatment can be accomplished with hysteroscopic resection. Resectoscopic approach is more challenging and has a higher risk of uterine perforation yet has the ability to reach the deep-seated lesions. Provider's understanding of the limitations of each method and appropriate referral to an expert surgeon is key for optimal results.