Fertility and Pregnancy Outcomes Following Conservative Treatment for Placenta Accreta

Loïc Sentilhes; Gilles Kayem; Clémence Ambroselli; Magali Provansal; Hervé Fernandez; Franck Perrotin; Norbert Winer; Fabrice Pierre; Alexandra Benachi; Michel Dreyfus; Estelle Bauville; Dominique Mahieu-Caputo; Loïc Marpeau; Philippe Descamps; Florence Bretelle; François Goffinet

Disclosures

Hum Reprod. 2010;25(11):2803-2810. 

In This Article

Discussion

Our results suggest that successful conservative treatment for placenta accreta does not appear to compromise women's subsequent fertility or obstetric outcome, but that the risk of recurrence of placenta accreta during future deliveries is high.

A major strength of this study is the number of pregnancies observed in this cohort (n = 34), especially since conservative treatment for placenta accreta is a rare event. An additional strength is the systematic follow-up of a relatively large cohort (n = 96), including evaluation of desire and attempts to conceive, in order to obtain information about women with presumed preserved fertility who either had no desire for pregnancy, or did desire pregnancy but have not become pregnant (Sentilhes et al., 2010c).

However, several limitations of our study must be underlined. The first is its retrospective design, common to all studies that have thus far assessed maternal outcome after placenta accreta. Accordingly, all the flaws of retrospective analyses apply. In particular, some eligible cases may not have been detected. Second, 26.7% of eligible women were lost to follow-up during this 15-year period study. Nevertheless, because their demographic and obstetric characteristics for the first conservative treatment did not differ from those of women who were included in the study, we can reasonably suppose that this is unlikely to have induced bias in our results. Third, it is possible that some women did not actually have placenta accreta; pathological confirmation is of course impossible after successful conservative treatment, i.e. in cases without a hysterectomy specimen (Sentilhes et al., 2010a). Nevertheless, our results reflect the long-term consequences in real life of conservative treatment for placenta accreta.

Placenta accreta is thought to be due to an absence or deficiency of Nitabuch's layer or the decidua spongiosa, following the failure of the endometrium/decidua basalis to re-form after trauma to the endometrium from surgical procedures (Benirschke and Kaufmann, 2000). The pathophysiology of placenta accreta is therefore similar to that of intrauterine synechiae, based as it is on endometrial alteration that might promote abnormal implantation, resulting in infertility, miscarriage or recurrent placenta accreta (Benirschke and Kaufmann, 2000). Hypothetically, conservative treatment might worsen the endometrial disease, due to more uterine scars (i.e. by cesarean), uterine devascularization procedures (i.e. embolization or surgical vessel ligation) or clinical or subclinical uterine infection. Our results are therefore reassuring in suggesting that successful conservative treatment for placenta accreta does not appear to compromise the patients' subsequent fertility or obstetrical outcome.

However, we found severe intrauterine synechiae, known to affect fertility adversely, in the 8 women who did not resume menstruation among the 96 women followed up after successful conservative treatment. Fertility was clearly altered in the two women for whom synechiae were not removed. This relatively high rate of synechiae following placenta accreta is consistent with a previous smaller and more limited study that suggested that placenta accreta might be a risk factor for synechiae (Sentilhes et al., 2010b). Moreover, the frequency of intrauterine synechia in the group presumed fertile is probably underestimated: mild or moderate synechiae are frequently asymptomatic, and hysteroscopy was not performed routinely for women after conservative treatment. Subclinical synechiae or endometrial diseases may be one of the factors responsible for the high number of miscarriages observed in our study (10 for 34 pregnancies) and may result in implantation failure.

The 21 subsequent third-trimester pregnancies resulted in 21 healthy babies, with normal birthweight for age, except for one whose mother had current and past pre-eclampsia. The absence of pregnancy complications observed in our study, except for abnormal placentation and post-partum hemorrhage, is consistent with the few previous reports on pregnancy after conservative treatment for placenta accreta (Kayem et al., 2002; Alanis et al., 2006; Bretelle et al., 2007).

Moreover, no adverse neonatal outcome was observed in women who underwent additional embolization or vessel ligation (n = 7) with the conservative treatment. This result is also consistent with the literature, as previous reports suggest that neither vessel ligation (Nizard et al., 2003; Sentilhes et al., 2008a) nor pelvic arterial embolization (Salomon et al., 2003; Sentilhes et al., 2010b) compromises subsequent obstetrical outcome.

Although the neonatal outcome was favorable for all the pregnancies, the recurrence rate of placenta accreta was high (28.6%). This result is consistent with the literature review performed by Alanis et al. (2006). The high rate of recurrence is not surprising, for all the women had acquired risk factors for abnormal placentation that resulted in the history of placenta accreta required for inclusion in this study. Furthermore, still other risk factors for placenta accreta (age >35 years, additional cesarean delivery, previous history of placenta accreta) were added to the previous ones. We cannot rule out the possibility that this high rate of recurrent placenta accreta was also related, at least in part, to the uterine devascularization procedures performed as part of the conservative treatment. It has been suggested that implantation and trophoblast invasion in subsequent pregnancies may be modified in a uterus previously devascularized, either by stepwise uterine devascularization (Sentilhes et al., 2008a) or pelvic arterial embolization (Salomon et al., 2003; Sentilhes et al., 2010b). Nevertheless, interestingly, in our study, placenta accreta recurred in only two of the seven women who had undergone an additional uterine devascularization procedure concomitantly with the previous conservative treatment.

We might speculate that relatively few parous women who have undergone conservative treatment and therefore also close monitoring for several months would want another child, especially in view of the potential risk of another episode of placenta accreta. Our study shows that this percentage is not that low (31.7%; 27/85). It is even higher (36.5%; 27/74) if we do not consider the women who reported that it was too soon after their last delivery to become pregnant again (n = 11). Interestingly, the primary reason that women decided against another pregnancy was that their obstetrician strongly recommended against it. Nevertheless, the second leading reason was the woman's own fear of a recurrence of placenta accreta. Four earlier studies report similar results: women with a history of severe post-partum hemorrhage requiring pelvic arterial embolization and/or uterine-sparing surgical procedures are likely to decide against another pregnancy because of their fear of another hemorrhage (Nizard et al., 2003; Salomon et al., 2003; Sentilhes et al., 2008a,2010b).

In conclusion, our study suggests that successful conservative treatment for placenta accreta does not appear to compromise the patients' subsequent fertility or obstetrical outcome. Women who want another pregnancy should, however, be advised that the risk of recurrence is high.

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