Staged management of an extensive placenta percreta: a case report

Placenta percreta is a rare, but serious condition associated with significant maternal morbidity and mortality. Standard of care includes multidisciplinary delivery planning with cesarean hysterectomy; however, extensive pelvic sidewall invasion and neovascularization may preclude immediate safe hysterectomy. Alternative strategies, including intentional placental retention, uterine artery embolization, methotrexate therapy, and interval hysterectomy have been described in select cases. We report a case of an extensive placenta percreta with a staged approach. A 41-year-old Hispanic female, G10P2072, was diagnosed antenatally with a placenta percreta with suspected bladder, retroperitoneum, and right pelvic sidewall involvement. At cesarean delivery at 34 weeks’ gestation, extensive extrauterine invasion was encountered. Given the extreme hemorrhagic and urologic risks of immediate resection, the placenta was intentionally left in situ. The patient subsequently underwent three uterine artery embolizations and 9 weeks of methotrexate therapy. Rising β-hCG levels, coagulopathy, and worsening clinical symptoms prompted interval hysterectomy 70 days after delivery. Despite vascular involution, delayed surgery remained associated with significant complications, including a 4500 mL blood loss, disseminated intravascular coagulation, abdominal compartment syndrome, and massive transfusion with multiple washouts. The patient ultimately recovered without long-term sequelae. Intentional placental retention with adjuvant embolization and methotrexate therapy may serve as a bridge to delayed hysterectomy when immediate resection carries prohibitive risk. However, delayed hysterectomy still remains associated with appreciable morbidity despite vascular involution and should only be reserved for carefully selected patients managed in a multidisciplinary setting.