Placenta Percreta and Incomplete Uterine Rupture after Endometrial Ablation and Tubal Occlusion

Abstract

Endometrial ablation offers symptomatic relief for menorrhagia. Pregnancy after ablation is rare but is often complicated due to pregnancy loss, growth restriction, preterm premature rupture of membranes, preterm delivery, and morbidly adherent placentation, a dangerous complication that can result in hemorrhage, intensive care unit admission, and cesarean hysterectomy. We report a case of pregnancy conceived contemporaneously with endometrial ablation and tubal occlusion. Diagnosis of pregnancy was delayed due to low suspicion. Complications included cervical implantation and placenta percreta, necessitating hysterectomy with the fetus in situ. Intraoperatively, incomplete uterine rupture was noted. Abnormal neovascularization, fibrous adhesions, and anatomical distortion necessitated a complex surgical approach. Women undergoing endometrial ablation must be thoroughly counseled about the serious risks of postablation pregnancy, the need for contraception, and the risk of sterilization failure. Pregnancy should remain in the differential diagnosis for women of reproductive age, regardless of tubal occlusion. Cases of placenta percreta should be referred early to centers of excellence with multidisciplinary teams.

Placenta accreta after postpartum tubal sterilisation and Novasure® endometrial ablation

“…Generally, the pregnancy rate after ablation is 0.25%‐5.2% depending on the ablative procedure used 10 . In all, 85% of such pregnancies end as ectopic pregnancy, miscarriage, or termination 11 .…”

Uterus preservation after placenta percreta and uterine rupture: A case report

“…Decisive hysterectomy should be performed in patients with serious intraoperative bleeding, shock, a coagulation dysfunction or blood shortage, a large area of placenta percreta, a thin uterine wall, and poor uterine contractions. Kohn et al (2016) reported the case of a pregnant woman in whom hysterectomy was performed because of placenta percreta and incomplete uterine rupture after endometrial ablation was performed at 18 weeks of pregnancy. However, removal of the uterus would cause the patient to lose fertility, resulting in physical and psychological damage, and some patients cannot accept this outcome.…”

Uterine rupture in patients with a history of laparoscopy or hysteroscopy procedures

“…[12] B-Lynch suture and Shirodkar cerclage [13,14] may cause UR in the pregnancy, and endometrial ablation may be another cause of placenta percreta and UR. [15] Smid et al [16] presented a case of posterior UR in the setting of rapidly developing twin–twin transfusion syndrome (TTTS) with the rapid development of polyhydramnios of the uterus, resulting in uterine overdistension. Rarer is a spontaneous UR at 14 weeks of gestation in a Turner patient as reported by Masia et al, [17] where the pregnancy was produced from oocyte donation and in vitro fertilization.…”