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Retained Products of Conception After Cesarean Section and Occult Placenta Accreta

      A 30-year-old woman had a history of prior cesarean section complicated by occult placenta accreta. During her subsequent pregnancy, third trimester ultrasound identified findings concerning for recurrent accreta (Figure 1). Hysterectomy was recommended if, at delivery, there was clinical evidence of accreta and routine cesarean section if not. At 37 weeks, the patient underwent repeat cesarean section. The placenta delivered spontaneously and intact and hysterectomy was not required.
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      Figure 1Focal placenta accreta could not be excluded (arrow) by third trimester ultrasound.
      The patient had worsening abdominal pain and new onset nausea 3 days postpartum. She had normal lochia and was afebrile. Pelvic computed tomography identified a normal post-gravid uterus with a small amount of blood in the endometrial canal (Supplemental Figure 1). Transabdominal ultrasound showed avascular thickening of the endometrium in the lower uterine segment, likely normal postpartum (Supplemental Figure 2). Complete blood count and coagulation lab tests were normal. Subsequent pathologic examination of the placenta identified focal occult placenta accreta (Supplemental Figure 3).
      Twelve weeks following dismissal, the patient presented similar to her preceding pregnancy, with intermittent pelvic cramping and persistent vaginal bleeding after delivery. Ultrasound identified a fundal uterine lesion consistent with retained products of conception (POC) (Supplemental Figure 4) and the patient elected for hysteroscopic resection. At hysteroscopy, there was a 2 cm mass at the uterine fundus consistent with retained POC (Figure 2); the lesion was resected and the patient’s symptoms resolved.
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      Figure 2Hysteroscopic visualization of chronic retained products of conception at the uterine fundus.
      Retained POC often is placental tissue that persists in the uterus after delivery or evacuation. Abnormal placentation, such as placenta accreta, can increase risk of retained POC.
      • Mullen C.
      • Battarbee A.N.
      • Ernst L.M.
      • Peaceman A.M.
      Occult placenta accreta: risk factors, adverse obstetrical outcomes, and recurrence in subsequent pregnancies.
      Clinically, placenta accreta often leads to combined cesarean section and hysterectomy secondary to obvious placental attachment to the myometrium or hemorrhage after manually separating the placenta from the underlying myometrium.
      • Silver R.M.
      • Branch D.W.
      Placenta accreta spectrum.
      Occult accreta may not be clinically evident at the time of uncomplicated delivery but symptomatic retained POC after accreta may require surgical intervention.

      Supplemental Online Material

      Figure thumbnail figs1
      Supplemental Figure 1Avascular thickening of lower uterine endometrial stripe (arrow).
      Figure thumbnail figs2
      Supplemental Figure 2Blood within the endometrial canal (arrow) and normal 3-day postpartum uterus.
      Figure thumbnail figs3
      Supplemental Figure 3Photomicrograph of occult placenta accreta showing absent decidua between superficial myometrium (central to bottom right) and villi (upper left).
      Figure thumbnail figs4
      Supplemental Figure 4Twelve-week postpartum ultrasound suggesting retained products of conception at the fundus (arrow).

      References

        • Mullen C.
        • Battarbee A.N.
        • Ernst L.M.
        • Peaceman A.M.
        Occult placenta accreta: risk factors, adverse obstetrical outcomes, and recurrence in subsequent pregnancies.
        Am J Perinatol. 2019; 36: 472-475
        • Silver R.M.
        • Branch D.W.
        Placenta accreta spectrum.
        N Engl J Med. 2018; 378: 1529-1536