Vid Janša

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    Late termination of pregnancy because of fetal anomaly complicated by placenta praevia: case report

    Vid Janša, Nataša Tul Mandić Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia - vid.jansa@gmail.com

    Introduction: The presence of placenta praevia totalis is an important cause of postpartum bleeding and can be a challenge for obstetricians in cases of late termination of pregnancy (TOP). Case report: A 35-year old woman, G4, P3, was referred to our hospital due to fetal heart anomaly and intrauterine growth restriction (IUGR). The previous pregnancies and deliveries were uncomplicated. The patient’s first antenatal visit in this pregnancy was at 28th week of amenorrhoea and ultrasound at 29 weeks revealed IUGR, complex heart anomaly (ventricular septal defect, double outlet right ventricle, pulmonary atresia) and placenta praevia totalis. A patient request for TOP was approved by the ethical committee. We wanted to avoid caesarean section. The risk of bleeding during TOP because of placenta praevia totalis became an important issue. A decision was made to proceed with selective uterine arteries embolization (UAE), which was performed in the Radiology department. 18 hours after the procedure fetal heart activity was absent. After 5 days of waiting for spontaneous onset of labour, we decided to continue with misoprostol and she received 100mcg vaginally, 3 hours later 100mcg buccally, followed by 200mcg and 400mcg buccally in 3 hourly intervals. The patient was transferred to the delivery room and placenta and stillborn fetus (770 grams) in breech presentation were delivered vaginally 15 hours after first application of misoprostol. After delivery karboprost was applied for prevention of bleeding and overall blood loss was less than 300ml. The patient was discharged in good condition the day after delivery. Fetal autopsy confirmed prenatal diagnostic conclusions. Discussion: The risk of heavy bleeding with vaginal delivery in cases of late TOP complicated by placenta praevia totalis can be reduced by UAE which has low complication rates, shorter hospitalization and avoids surgical risks as published. Embolization can be followed by misoprostol. Care must be taken to prevent postpartum bleeding.