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CASE REPORT
Year : 2022  |  Volume : 49  |  Issue : 2  |  Page : 210-212

Placenta increta manifesting as unusual cervical mass after first trimester dilatation and curettage, managed by laparoscopy


1 Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, KAHER, Belagavi, Karnataka, India
2 Department of Pathology, Jawaharlal Nehru Medical College, KAHER, Belagavi, Karnataka, India
3 Department of General Surgery, Dr. Prabhakar Kore Hospital, Belagavi, Karnataka, India

Date of Submission08-Feb-2022
Date of Acceptance22-Jun-2022
Date of Web Publication23-Aug-2022

Correspondence Address:
Mrityunjay Metgud
Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, KAHER, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.jss_22_22

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  Abstract 


Placenta accreta spectrum, is characterized by abnormal placental adherence to the myometrium. Depending on the depth of trophoblastic growth, it is classified into placenta accreta, placenta increta, and placenta percreta. This condition is associated with life-threatening hemorrhage, resulting in high maternal and neonatal morbidity and mortality. Placenta accreta usually presents with vaginal bleeding during difficult placental removal in the third trimester. Placenta accreta spectrum is very rarely present in the first trimester. Severe forms may complicate first-trimester pregnancy losses, causing profuse postcurettage hemorrhage. A 28-year-old lady with one living issue by cesarean section who had undergone a dilatation and curettage (D&C) 2 months ago for missed abortion, came with the complaints of prolonged vaginal bleeding following the procedure. On pelvic examination, the uterus was bulky, partly firm on one side, and soft on the other. Ultrasound examination revealed it to be a bicornuate uterus with retained products in one of the horns. Magnetic resonance imagining was suggestive of lateral cervical fibroid. Diagnostic laparoscopy revealed it to be a left lateral cervical mass. Total laparoscopic hysterectomy was performed. On histopathological examination, specimen revealed necrotic placenta infiltrating the endocervix and isthmus. Placenta accreta is a rare problem and difficult to diagnose in the first trimester. It can occur when there are risk factors or if there are ultrasound markers of the first trimester suspicious of the adherent placenta. A diagnosis of placenta accreta spectrum needs to be considered when there is post-D&C prolonged or heavy vaginal bleeding.

Keywords: Cervical mass, first-trimester miscarriage, placenta increta


How to cite this article:
Metgud M, Alimilla S, Patil KP, Savanur M, Malli R, Sanikop A, Kenawadekar R. Placenta increta manifesting as unusual cervical mass after first trimester dilatation and curettage, managed by laparoscopy. J Sci Soc 2022;49:210-2

How to cite this URL:
Metgud M, Alimilla S, Patil KP, Savanur M, Malli R, Sanikop A, Kenawadekar R. Placenta increta manifesting as unusual cervical mass after first trimester dilatation and curettage, managed by laparoscopy. J Sci Soc [serial online] 2022 [cited 2022 Sep 27];49:210-2. Available from: https://www.jscisociety.com/text.asp?2022/49/2/210/354266




  Introduction Top


Placenta accreta spectrum is characterized by abnormal placental adherence to the myometrium.[1] Depending on the depth of trophoblastic growth, it is classified into placenta accreta (villi attached to the myometrium), placenta increta (villi invading the myometrium), and placenta percreta (villi penetrate through the myometrium and to or through the serosa).[2] Although the presentation of a placenta accreta after a dilatation and curettage (D&C) procedure is extremely rare, it is clinically significant in that it can cause postevacuation profuse and prolonged bleeding, making clinical management difficult.[1] Furthermore, the retained trophoblastic tissue and an accompanying hematoma can get entrapped in the myometrium and mimic an unusual uterine mass lesion.[1]

This report describes a case of placenta increta that caused prolonged bleeding after first-trimester abortion, and was identified by magnetic resonance imagining (MRI) as a heterogeneous mass in the cervical region.


  Case Report Top


A 28-year-old lady with one living issue by cesarean section who had undergone a D&C 2 months ago for missed abortion, came with the complaints of prolonged vaginal bleeding. There was no pain abdomen, fever, or vaginal discharge. Her past cycles were normal. She was a known case of diabetes on oral hypoglycemic drugs. Clinically, her vitals were stable at the time of presentation to the hospital. Pelvic examination showed bleeding from the cervical os. On bimanual examination, the uterus was bulky, partly firm on one side, and soft on the other. Ultrasound revealed it to be a bicornuate uterus with retained products in one of the horns. Human chorionic gonadotropin (HCG) titer was 52 mIU/ml. A lateral cervical mass approximately measuring 7.6 cm × 8.2 cm × 7.4 cm was detected on MRI suggestive of fibroid. Diagnostic laparoscopy revealed it to be a left lateral cervical mass. Total laparoscopic hysterectomy was performed. A mass at the uterocervical junction extending to the entire cervix more so on the left side was seen on gross examination of the hysterectomy specimen. The cut section showed a small area of necrotic tissue in the endocervical canal near the isthmic region as shown in [Figure 1]a.
Figure 1: (a) Cut section of the cervix showing necrotic tissue and the mass. (b) Necrosed chorionic villi under a high-power field. 1: Uterus; 2: Isthmus; 3: Endocervical canal; 4: Cervical mass. (c) Gross view of hysterectomy specimen

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On histopathological examination, the specimen revealed necrotic placenta infiltrating the endocervix and isthmus as shown in [Figure 1]b. There were no further episodes of vaginal bleeding postoperatively and HCG titer returned to normal after 3 weeks.


  Discussion Top


Placenta accreta is an abnormality characterized by placental villi attaching to the uterine myometrium without intervening decidual membrane. Risk factors for placenta accreta include multiparity, placenta previa, prior cesarean section, prior D&C, and miscarriage.[3],[4] Placenta accreta spectrum is very rare before 20 weeks of gestation and still rare in the first trimester. Severe forms may complicate first and early second-trimester pregnancy losses, causing profuse postcurettage hemorrhage. Ultrasound markers of placenta accreta syndrome in the first trimester are: implantation of a gestational sac in the lower uterine segment, multiple irregular vascular spaces in and around the placenta, and cesarean scar implantation of the gestational sac.[5] The case being reported is a placenta increta in the first trimester. She presented with prolonged vaginal bleeding postdilatation and -evacuation. The elevated HCG titers with MRI suggestive of cervical fibroid made the diagnosis difficult. A diagnostic laparoscopy was performed which revealed a left lateral cervical mass. As per the insistence of the patient for hysterectomy before the planned operative procedure, a hysterectomy was performed. The intraoperative and postoperative periods were uneventful. A good dissection and clearance were possible laparoscopically evident by the symptoms subsiding and serum beta HCG titers being normal, 2 weeks posthysterectomy. A report showing necrotic placenta infiltrating the isthmus and the endocervix on histopathology, we could arrive at the diagnosis of placenta increta. Very few cases of first-trimester abortion complicated with placenta accreta are reported in the literature.[6] Majority of the cases in the literature presented as profuse hemorrhage during D&C or the immediate postoperative period. However, none of the cases had a cervical mass.


  Conclusion Top


Placenta accreta is a rare problem and difficult to diagnose in the first trimester, especially without ultrasound markers.[5] However, a diagnosis of placenta accreta needs to be considered when associated with risk factors and with the clinical presentation of prolonged or profuse vaginal bleeding following D&C.

Details of ethics approval

Institutional ethical approval was obtained for the study. Informed consent was also obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ju W, Kim SC. Placenta increta after first – Trimester dilatation and curettage manifesting as an unusual uterine mass: Magnetic resonance findings. Acta Radiol 2007;48:938-40.  Back to cited text no. 1
    
2.
Rouholamin S, Behnamfar F, Zafarbakhsh A. Placenta increta as an important cause of uterine mass after first-trimester Curettage (case report). Adv Biomed Res 2014;3:240.  Back to cited text no. 2
  [Full text]  
3.
American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Obstetric care consensus No. 7. Placenta accrete spectrum. Obstet Gynecol 2018;132:e259-75.  Back to cited text no. 3
    
4.
Read JA, Cotton DB, Miller FC. Placenta accrete: Changing clinical aspects and outcome. Obstet Gynecol 1980;56:31-4.  Back to cited text no. 4
    
5.
Silver RM, editor. Placenta Accreta Syndrome. 1st ed. University of Utah Health Sciences Center, Salt Lake City, Utah: Robert M. Silver; 2017.  Back to cited text no. 5
    
6.
Wang YL, Weng SS, Huang WC. First-trimester abortion complicated with placenta accreta: A systematic review. Taiwan J Obstet Gynaecol 2019;58:10-4.  Back to cited text no. 6
    


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