Sonographic Diagnosis and Management With Delayed Hysterectomy of Two Cesarean Scar Pregnancies That Developed Into Placenta Percreta: Two Case Reports

Approximately two-thirds of the patients with a cesarean scar pregnancy (CSP) will develop placenta accreta spectrum (PAS). PAS occurs when the placenta attaches too deeply to the uterine wall, and sometimes, the placenta can extend beyond the uterus, invading surrounding organs. PAS is commonly managed with a cesarean hysterectomy, and these deliveries are often complicated by maternal and fetal morbidity and mortality. However, delaying hysterectomy and using chemotherapeutic agents may be a safe and beneficial alternative. We describe the case of a 32 -year-old G3P2002 with a history of two prior cesarean sections (CS) who was referred to our Maternal Fetal Medicine department due to the concern of a gestational sac embedded in the anterior uterine wall in the cesarean scar. Magnetic resonance imaging (MRI) findings at 33 weeks confirmed that the patient had developed placenta percreta extending into the sigmoid colon. We also describe the case of a 30-year-old G6P4104 with a history of four prior CS who was referred to our department for concern of a pregnancy complicated by CSP. This patient had an MRI performed at 23 weeks that showed placenta percreta invading the bladder. Patients one and two were managed with a staged procedure, with CS followed by a delayed laparoscopic and abdominal hysterectomy, respectively, to minimize bowel and bladder injury. After the CS, the patients subsequently received a five-day course of intravenous (IV) etoposide 100mg/m2, and at six weeks postpartum, the patients had a hysterectomy, both showing resolution of the placenta invasion into the surrounding organs on postpartum MRI and confirmed by tissue pathology reports. Our cases present the challenge in diagnosis and management of the most severe presentation of PAS that varies from the generally accepted management recommendations. Delayed hysterectomy with chemotherapy can be a reasonable, conservative surgical approach in the most severe types of PAS. As in our cases, this management could improve maternal and fetal morbidity and mortality.