P03.09: Management dilemma of complete placenta previa with Breus' mole

Abstract

Prenatal diagnosis of massive subchorionic thromobohematoma (Breus' mole) is inconsistently reported in the literature. Management of poor prognosis type Breus' mole can be of challenge if combined with potentially life threatening obstetric condition such as placenta previa. We report a 28 year old healthy primigravida of African descent was referred at 19 weeks gestation with ultrasound finding of large placenta. Detailed ultrasound examination revealed posterior placenta away from the cervical os with 4 cm thick, laminated sub-chorionic hematoma extending over the whole length of the placenta “Breus' mole”, severe IUGR fetus with absent end diastolic flow in the umbilical artery. Patient had no history of vaginal bleeding, abdominal pain, trauma and no history of blood disorder. Repeated ultrasound examinations showed enlarged subchorionic hematoma and a complete placenta previa. Given the poor pregnancy outcome, at 28 weeks fetocide using intracardiac KCL was done aiming to devascularise the placenta. Two days later the patient presented to ER with massive antepartum hemorrhage. Emergency Caesarean section was performed. Delivery of a dead male fetus weight 400 gm, the placenta weight 365 gm. Placenta appeared thick, cylindrical with complete circumvallation. A subchorionic hematoma was seen extending from chorionic plate down to decidua basalis. We conclude that despite rare occurrence of Breus' mole; it should be considered a risk factor for placenta previa. There are few case reports indicating less maternal blood loss and decreased morbidity after fetocide through decreased uteroplacental blood flow in cases of complete placenta previa; this does not prove to be the rule with Breus' mole placentas. It's unclear why there would be a tendency to massively bleed after fetocide in cases of placenta previa with Breus' mole. Alternative option of uterine artery embolisation might be considered. Further research on this topic is recommended.