Saxena N*, Tiwari N**, Amin K***, Chauhan AR****.
(* Previous ** Third Year Resident, *** Assisstant Professor, **** Additional Professor. Department of Obstetrics and Gynaecology, Seth GS Medical College and KEM Hospital, Mumbai, India.)
There is an underestimation of the prevalence of uterine fibroids in pregnancy, however the complications are primarily attributed to their presence. We report a case of a 33 year old G2P0A1 who went into spontaneous labour and expelled the fetus at 26 weeks of gestation, however the trapped placenta failed to deliver even after attempting its manual removal under general anaesthesia due to mechanical obstruction by large fibroids. Successful expectant management of the retained placenta was done using multi dose regimen of methotrexate and serial monitoring of β-HCG levels; patient subsequently underwent abdominal myomectomy.
Most pregnancies are unaffected by the presence of fibroids and in a majority, small fibroids are incidentally seen intraoperatively during cesarean section. Complications such as pain, vaginal bleeding, placental abruption, preterm labor, intra uterine growth restriction and retained placenta are mainly attributed to large fibroids more than 5 cm in diameter, especially submucosal and intramural fibroids. We observed that administration of methotrexate resulted in decreased uteroplacental blood flow and placental size, eventually resulting in disappearance of the entire placenta.
A 33 year old P1L0A1 was referred to our emergency department on day 2 of preterm vaginal delivery with postpartum hemorrhage and retained placenta. She had registered antenatally at 24 weeks of gestation at a peripheral hospital. Normal intrauterine pregnancy along with multiple uterine fibroids was diagnosed on routine antenatal ultrasonography. She went into spontaneous inevitable preterm labour at 26 weeks of gestation and delivered a male baby of 800 g. The baby died immediately after birth. A decision for manual removal of placenta was taken when the placenta failed to separate and deliver spontaneously 30 minutes after delivery. However, under general anesthesia, the placenta could not be removed due to mechanical obstruction from the fibroids. At this time, the patient had a mild postpartum hemorrhage, hence the vagina was packed and the patient was referred to our tertiary care centre for further management.
On admission, her general condition was fair, vital parameters were normal, there was no tachycardia or pallor. Abdominal examination revealed uterus corresponding to 22 weeks' size, well contracted. On speculum examination, the vaginal pack was removed; the cervical os was partially open, but there was no evidence of placental tissue seen through cervical os nor was there any active bleeding.
All routine blood investigations and coagulation profile were normal (hemoglobin was 13.1 g/dl, INR was 1.08), β-HCG was 3395 mIU/L, and liver and renal function tests were normal. Ultrasound of pelvis revealed a well-defined hyperechoic lesion in upper uterine segment suggestive of retained placenta, with a volume of approximately 200 ml, along with multiple uterine fibroids in the anterior and right lateral walls measuring 7.5 x 7 cm and 6.8 x 5.8 cm respectively. Magnetic resonance imaging (MRI) revealed multiple large intramural fibroids in antero-inferior and postero-lateral wall measuring approximately 10 x 8 x 8 cm and 7.5 x 5.3 x 5.7 cm respectively. Placental tissue of size 8.3 x 4 x 5 cm was seen attached to the posterior wall in the fundal area without any evidence of myometrial invasion.
In view of stable general condition and the above reports, a decision to manage the patient conservatively was taken. She received alternate day regimen of 3 doses of methotrexate (1 mg/kg body weight) and 3 doses of leucovorin (0.1 mg/kg body weight) and was discharged after 7 days. The patient was followed up regularly with serial measurements of serum β-HCG and placental volume, which fell rapidly initially and gradually disappeared till β-HCG levels fell to less than 2 mIU/L and no evidence of placenta seen on follow up ultrasonography (USG) after 6 months. However, 6 months postpartum, the uterus was approximately 22 weeks size, firm, and mobile. In view of these findings and her previous poor obstetric outcome, abdominal myomectomy was done. Three large fibroids were enucleated, the largest of those indenting the endometrial cavity which was opened during myomectomy. Further hospital course was uneventful and the patient was discharged.
Figure 2. After enucleation of fibroids.
Fibroids have been documented to be a common cause of retained placenta. However, other independent risk factors for retained placenta include preterm delivery owing to a smaller placenta with a thin cord, history of retained placenta in the previous pregnancy and history of abortions in the past..  It is associated with many complications like bleeding, infection and intrauterine adhesions, thereby increasing the overall rate of maternal morbidity and mortality in developing countries. Diagnosis is made when the placenta fails to deliver after 30 minutes of delivery of baby. However USG and MRI are frequently used imaging modalities for confirmation. We report a combination of factors that caused placenta to be trapped in our case - inevitable preterm labor where after the fetus was spontaneously expelled, the cervix closed down promptly, extreme prematurity with thin cord and small placenta, and location of the fibroids which obstructed the tract. In fact if this patient had reached term, it is unlikely that she would have delivered vaginally due to the location of the fibroids and distortion of the cavity.
There are a variety of treatment options available nowadays, however conservative line of management offers the potential to preserve future fertility in women of child bearing age.
Methotrexate has emerged with promising results to cure persistent retained placental tissue. It acts on the dividing trophoblastic cells of the placental tissue and also reduces the neovascularization thus resulting in reduction and resorption of the retained placental tissue over a course of time. However serial monitoring with serum β-HCG levels and periodic USG examination for placental volume are required during the treatment.
Other treatment modalities include internal iliac artery ligation, uterine artery embolization and cesarean hysterectomy. Literature has also documented studies regarding the efficacy of carbetocin, intra umbilical administration of oxytocin and use of prostaglandins; however the data regarding the safety profile is limited. However, abdominal myomectomy in such patients offers the potential for future fertility as fibroids were considered to the be the main culprit for their poor obstetric outcome.
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Saxena N, Tiwari N, Amin K, Chauhan AR.Successful Expectant Management Of Retained Placenta In A Patient With Multiple Fibroids. JPGO 2015. Volume 2 Number 10. Available from: http://www.jpgo.org/2015/10/successful-expectant-management-of.html