Placenta accreta is defined as a placenta that in whole or in part invades the uterine wall and is inseparable from it . Placenta accreta is one of the most serious obstetric complications and is associated with an increased risk of massive hemorrhage during cesarean section. Peripartum emergency hysterectomy is often required to control massive hemorrhage. Risk factors include a history of a cesarean section, placenta previa, maternal age, and a history of curettage .
In recent years, ART treatments, especially IVF, have been reported as a new risk factor for placenta accreta [1, 2]. Esh-Broder et al. reported that the rate of placenta accreta in the IVF group was 13.2-fold higher than that in the spontaneous pregnancy group . FET in particular leads to a higher incidence of placenta accreta than fresh embryo transfer (0.27% and 0.09%, respectively) [7,8,9]. As our patient did not have conventional risk factors for placenta accreta, pregnancy achieved by FET may have been one of the risk factors for placenta accreta in this case. Anesthetic management for massive obstetric hemorrhage should be prepared for patients who underwent FET, even without a history of cesarean section or other uterine surgeries, because placenta accreta may only be diagnosed at the time of delivery. In our case, a preoperative definitive diagnosis of placenta accreta was unable to be made, although it was suggested by preoperative ultrasound imaging findings. Magnetic resonance imaging may have helped to confirm the diagnosis in this case. Also, measures to decrease intraoperative blood loss, e.g., intra-aortic balloon occlusion or iliac artery balloon catheter placement, should have been considered preoperatively.
This patient also had a background of SLE. In a study of 25 pregnant women with SLE complications, underdevelopment and dysfunction of the placental villi were observed and were likely caused by reduced blood flow in the intervillous space through the myometrium due to vascular abnormalities of the placenta . Similar to the present study, hysterectomy was performed during cesarean section because of placenta accreta and myometrial thinning in a pregnancy with SLE complications [3, 4]. The relationships among SLE, myometrial thinning, and placenta accreta have not been elucidated. A larger number of cases and more data are necessary to determine such a relationship.
In conclusion, we report the case of a primigravida with a background of SLE who became pregnant by FET. Massive hemorrhage developed following delivery and emergency total hysterectomy was performed due to placenta accreta. When performing cesarean section on patients who have undergone FET, preoperative examinations to assess for placenta accreta should be performed, and the anesthetic management should include sufficient planning for massive hemorrhage. Further cases and data are necessary to clarify the association between placenta accreta and SLE.