Conservative management of abnormally invasive placenta: Choriocarcinoma with uterine arteriovenous fistula from remnant invasive placenta

摘要

Sir We reviewed your article on the conservative management of abnormally invasive placenta (1). Placenta previa with invasion is a serious burden to obstetricians in terms of preserving the uterus. We would like to comment on a rare complication of the remnant placenta. A 36-year-old patient at 20 gestational weeks had total placenta previa with placenta accreta. She underwent a hysterotomy with bilateral uterine artery ligation because of intrauterine fetal death and uterine bleeding. We could not completely remove the placenta because of bladder invasion. Six months later, she presented with massive uterine bleeding. Color Doppler ultrasonography revealed a uterine arte-riovenous fistula (AVF). Her human chorionic gonadotropin (P-hCG) level was 223 600 mlU/mL. Packed red blood cells were administered to treat a hemoglobin level of 5.2 g/dL. The intrauterine mass removal was performed via laparotomy. Bilateral uterine artery embolization (UAE) was performed to preserve the uterus. Angiographic findings revealed multifocal AVF and multiple collaterals from both internal iliac arteries. The pathology results revealed choriocarcinoma (Figures 1 and 2). Combined chemotherapy (etoposide, methotrexate and actino-mycin-D) was initiated postoperatively. At follow-up 4 years later, the patient had a 28-day menstruation cycle, normal Pap smear, and normal uterine size.