A 31-year-old woman with a previous history of 2 cesarean sections received dilatation and curettage under the diagnosis of missed abortion at 7 weeks of gestation. Although retrospective evaluation of the ultrasonographic image indicated the presence of a gestational sac in the previous cesarean section scar (Fig. 1A, arrow), such a diagnosis was not made at that time. Seven weeks later, she was transferred to our hospital due to hypovolemic shock status with massive vaginal hemorrhage. Prominent vascular flow was noted around the retained gestational products (Fig. 1B). On iodine-enhanced computerized tomographic image, active extravasation of contrast agent (Fig. 1C, arrow) originating from the left uterine artery (Fig. 1C, arrowhead) was identified. On emergent pelvic angiography, the occurrence of major bleeding was confirmed from the left uterine artery. After intra-arterial infusion of dactinomycin (Cosmegen, Merck & Co, Inc, Whitehouse Station, NJ, USA), arterial embolization was performed with Tornado platinum coils (Cook, Bloomington, IN, USA) for left uterine arterial occlusion (Fig. 1D, arrow) and with gelatin sponge particles (Gelpart, Nippon Kayaku, Tokyo, Japan) for right uterine arterial occlusion. With successful hemostasis, further conservative management was chosen and systemic intramuscular administration of MTX (50 mg/m2/day) was additionally performed 3 times. Subsequently, gestational products resolved without any further hemorrhagic complications, and first menstruation resumed 97 days after TACE.
The patient reported a missed period after 4 cycles of resumed menstruation and was diagnosed as having intrauterine pregnancy. At 8 weeks of gestation, normal fetal growth was identified (Fig. 2A). The lower segment of the placenta was attached to the cesarean section scar (Fig. 2A, arrow). Intermittent bleeding occurred from 16 weeks of gestation and was conservatively managed. To achieve more accurate diagnosis of the site of placental attachment, magnetic resonance imaging (MRI) was performed at 19 weeks of gestation. Attachment of the lower part of the placenta to the previous cesarean section scar was confirmed (Fig. 2B, arrow). After 21 weeks of gestation, uterine bleeding spontaneously ceased, and the pregnancy course was uneventful.
Elective cesarean section was scheduled at 37 weeks and 2 days of gestation. However, at 36 weeks and 5 days of pregnancy, the patient was transferred due to sudden massive bleeding. Since peritoneal fluid pooling was not evident on ultrasonography, uterine rupture was less likely. Regular fetal heartbeat was audible. Her hemoglobin value was 9.6 g/dL. Coagulation disorders were not identified. Emergency cesarean section was initiated under endotracheal general anesthesia. At laparotomy, the uterine scar from the previous cesarean section showed slight decompression, but scar dehiscence or rupture was not evident (Fig. 2C, arrow). When anterior transverse hysterotomy at 2 cm above previous cesarean section scar was performed, abruptio placentae was diagnosed with expulsion of substantial blood and clots. Since the placenta occupied the anterior wall of the uterus, manual removal of the placenta was initially performed, and then a healthy 2486 g girl was delivered. After confirming the absence of placental retention, the hysterotomy incision was closed with 2-layered sutures. Intraoperative blood loss was 1800 mL. The mother was admitted to the intensive care unit for cardiopulmonary management. Her hemoglobin value was 6.6 g/dL on postoperative day 1. Since her vital signs were well maintained, red blood cell transfusion was not performed. The postoperative course was uneventful.