Exploratory Laparotomy and Uterine Embolization in a Case of Missed Abortion Complicated by Placenta Accreta Spectrum Versus Cesarean Ectopic Pregnancy

Background Placenta accreta spectrum (PAS) is a term that describes a spectrum of diseases of placental attachment. PAS typically occurs in pregnancies with a maternal history of uterine surgery, including the non-exhaustive examples of cesarean section, myomectomy, and previous dilatation and curettage. As a result of such uterine interventions, a focal absence of the normal decidua basalis can result. This creates a situation that could later allow for a trophoblast to attach to the damaged area. Consequently, this can lead to abnormally deep placental anchoring villi and trophoblast infiltration. Such pathologies ultimately risk severe hemorrhage and resultant maternal morbidity and mortality. Objective To present a rare case of first-trimester placenta accreta spectrum versus cesarean ectopic pregnancy culminating in pregnancy loss managed by dilatation and curettage (d&c). Significant hemorrhage was experienced during the d&c. This was eventually controlled with assistance from our interventional radiology colleagues in a way that preserved the patient’s future fertility prospects. Through presenting this case, we hope to highlight the importance of multidisciplinary preparedness in dealing with pathologies of placental attachment – even in early gestation. Study Design This case report details the clinical presentation, intraoperative findings, and multidisciplinary management of a patient with suspected placenta accreta spectrum who experienced severe hemorrhage during a first-trimester dilatation and curettage. The patient’s clinical course, interventions performed, and recovery trajectory were retrospectively reviewed. Results A 31-year-old gravida 2 para 1 with a history of term cesarean section presented for elective dilatation and curettage following a diagnosis of missed abortion at approximately 13 weeks’ gestation. Prenatal imaging raised concern for abnormal placentation; several first-trimester ultrasounds prior to the abortion noted a 5-centimeter subchorionic hemorrhage versus involuting second gestational sac and concern for placenta accreta spectrum (PAS) versus cesarean scar ectopic. Given these concerns for placental pathology, shared decision-making between patient and provider concluded that surgical evacuation of the products of conception would be the safest way to manage the missed abortion. During the procedure, brisk hemorrhage occurred following initial suction curettage. Despite administration of intramuscular methergine and uterotonics, hemorrhage persisted. Intraprocedural ultrasound was used to evaluate the situation and revealed a possible clot in the lower uterine segment, as well as a uterine niche at the site of the prior cesarean scar. A Foley balloon was placed for attempted intrauterine tamponade, but bleeding continued around the catheter. With an estimated blood loss exceeding 1000cc, tranexamic acid and intrauterine methergine injections were administered and vaginal packing was placed. However, the patient became hemodynamically unstable and the decision to perform an emergent exploratory laparotomy was made to evaluate for injury of the uterus and surrounding structures. No uterine rupture or extrauterine bleeding was identified. The source of hemorrhage was determined to be intrauterine, likely related to focal placental invasion. The patient was stabilized and the abdomen was closed. She was transferred to interventional radiology for successful uterine artery embolization. Postoperative recovery was uneventful. Discussion This case illustrates the clinical challenges of managing an early PAS versus cesarean ectopic abortion. It also accentuates the importance of careful surgical coordination in all cases of suspected abnormal placentation – even first-trimester pregnancy losses – as the extent of placental invasion and resultant bleeding can be unpredictable. In this case, high clinical suspicion for placental pathology, timely recognition of bleeding complications, and access to multidisciplinary care were essential to preserving uterine integrity and preventing maternal morbidity. Conclusion First trimester dilation and curettage complicated by hemorrhage due to placental pathology is a rare but potentially devastating complication with profound risks of maternal morbidity and mortality. This case highlights the importance of preoperative risk assessment, interdepartmental planning, and provider preparedness to escalate care. Further research and clinical guidelines are needed to assist providers in managing early PAS in order to further improve maternal outcomes.