Interstitial Pregnancy in the Third Trimester with Severe Pr
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A 41-year-old (4-gravida, 1-parous) woman was referred because of early-onset PE at 26 weeks of gestation. She had a history of two spontaneous abortions in the first trimester. She conceived naturally. Low-dose aspirin (100mg/day) was administered from 11 weeks of gestation because of recurrent abortion. She was diagnosed with a subchorionic hematoma that was mainly located in the uterine fundus at 11 weeks of gestation without bleeding or pain. The hematoma disappeared at 16 weeks of gestation.

At 26 weeks of gestation, her blood pressure (BP) was found to be elevated (162/101mmHg) with proteinuria, and thus, she was admitted to this hospital. Nifedipine (20 mg/day) was started with BP at 140-160/80-90 mmHg. At 272/7 weeks, proteinuria was 11 g/24 hours. Ultrasound revealed an estimated fetal weight of 940 g without growth arrest. The uterine artery and umbilical artery Dopplers were normal. A cardiotocogram also showed a reassuring pattern. The placental position was the right fundus and color Doppler showed subplacental hypervascularity at the back of the placenta, which led us to suspect PAS in the normal placental position (without previa).

She had severe edema of her legs and face. Chest X-ray also revealed lung edema; however, it was not severe and we administered betamethasone intramuscularly. Her blood pressure was over 180/110 mmHg under antihypertensives, and she also had severe headache. After a comprehensive analysis of all findings, an emergency cesarean section was conducted. The procedure was performed at 281/7 weeks, yielding a female infant (926 g, Apgar score: 3/6 at 1/5 min, umbilical artery pH 7.44, B.E. -7.1 mmol/L). With the uterus exteriorized, the right tubal horn to isthmus of the fallopian tube showed bulging. A part of the fallopian tube (together with the adjacent uterus) had ruptured, with the omentum adhering over the rupture.

Considering that preserving the uterus was impossible, performed a hysterectomy. The intraoperative blood loss was 3,800 mL: 10 units of red blood cells and 8 units of fresh frozen plasma were transfused. The mother was discharged on the 10th postoperative day with normal blood pressure (126/78mmHg) without proteinuria or sequelae. The macroscopic findings revealed that the placenta had adhered to a thin interstitial and isthmic part on the right fallopian tube with uterine rupture. The pathological finding was interstitial pregnancy with placenta accreta. Interstitial and tubal isthmic pregnancy with uterine rupture was diagnosed. The infant was discharged at 3 months without sequelae.