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Uterine Artery Embolization Prior to Gravid Hysterectomy

CASE PRESENTATION A 32-year-old woman who is 20 weeks and 6 days pregnant presents to our service with abnormal placentation and suspected placenta accreta. The condition was diagnosed on a routine anatomic survey ultrasound at another facility. She is gravida 4 with one prior term delivery, one preterm delivery, one abortion, and three living children (TPAL: 1-1-1-3). Before being seen at the outside facility, she complained only of achy pelvic pain for 8 weeks and on-and-off painless vaginal spotting. The transvaginal sonogram showed that the placenta had a moth-eaten appearance and increased vascularity. There were no clear borders between the uterus and the bladder. The imaging displayed vascular extensions into the serosa of the bladder. Our physician team discussed the images as well as management options. We ordered an MRI for better delineation of the anatomy, which confirmed the diagnosis of placenta percreta (Figure 1). After extensive counseling, the patient and her husband decide to have an in situ hysterectomy. A multidisciplinary team is assembled consisting of urology, interventional radiology, anesthesia, obstetrics and gynecology, and the ethics department. The night before surgery, to help with the anticipated severe blood loss, interventional radiology performs bilateral uterine artery embolization after fetacidal digoxin (Figure 2), and both uterine arteries are successfully embolized. The next day, the patient undergoes a gravid hysterectomy, cystoscopy, bilateral ureteral stent placement, and bladder dome repair. The postoperative gravid hysterectomy specimen shows complete placental erosion of the serosal surface of the uterus (Figure 3). Despite embolization, the patient has a large volume blood loss of 5.7 L during the operation. The patient is admitted to the intensive care unit for 24 hours and is Uterine Artery Embolization Prior to Gravid Hysterectomy