Hypervascular placental polypoid mass is a possible source of acute hemorrhage after pregnancy. We present a case report and literature review of a rare case after spontaneous miscarriage. We describe the diagnosis, imaging, and management of placental polyps, which includes the use of iliac artery occlusion catheters with concomitant hysteroscopic resection.
A placental polypoid mass is a fragment of retained placental tissue in the uterus that has undergone neovascularization after resolution of gestation. Most commonly, placental polypoid masses occur after therapeutic abortion and spontaneous delivery. It is extremely rare after spontaneous abortion (SAB).
The most clinically significant placental polypoid mass is the hypervascular type. A hypervascular placental polypoid mass (HPPM) may cause profuse hemorrhage that requires blood transfusions, interventional radiology procedures, hysteroscopic resection, and even hysterectomy to control bleeding. Therefore, high clinical suspicion and prompt diagnosis are essential. HPPM can be diagnosed and differentiated from other vascular uterine pathologic events with various imaging techniques. Typically, pelvic ultrasound with Doppler imaging is a useful initial test for a suspected hypervascular uterine lesion. However, more specific imaging modalities to diagnosis of HPPM include computed tomographic angiography and magnetic resonance imaging.
Profuse hemorrhage and hypovolemic shock are the most feared complications of an HPPM. Thus, prompt resuscitation, control of bleeding, and complete removal are paramount. Uterine artery embolization (UAE) followed by hysteroscopic resection has been described. Because of the risks of uterine wall ischemia and infection, UAE may not be an ideal option in patients desiring future fertility. Without UAE, complete hysteroscopic resection is challenging because bleeding obscures visualization. We describe a case of HPPM that was associated with acute hemorrhage after SAB that was managed successfully with temporary internal iliac balloon occlusion followed by complete hysteroscopic resection.
Case Report
A 28-year-old gravida 2, para 0 was treated in the Emergency Department with syncope from profuse uterine bleeding. Her history was significant for an SAB at 7 weeks gestation, which was 4 months before the bleeding episode. She had mild, intermittent uterine bleeding after her SAB; however, on the day she was examined she noticed continuous, profuse bleeding. Initially, she had a normal decline in human chorionic gonadotropin levels. However, a few weeks before the bleeding episode, it plateaued in the 20 mIU/mL range. On admission, her human chorionic gonadotropin level was 6 mIU/mL. The patient’s hematocrit level was 36.5%; however, after extensive vaginal bleeding, her immediate preoperative hematocrit level was 25.3%. Transvaginal ultrasound with power Doppler imaging showed a hypervascular mass that extended in to the myometrium, which was suspicious for arteriovenous malformation or arteriovenous fistula ( Figure 1 , A and B ). A conventional arteriogram confirmed a hypervascular lesion with bilateral uterine artery supply that was consistent with an HPPM ( Figure 1 , C and D). The patient was treated further with bilateral balloon occlusion catheter placement in the internal iliac arteries and complete hysteroscopic resection of HPPM.
The balloons were inflated intraoperatively to control bleeding. Good visualization and hemostasis were maintained throughout the procedure ( Figure 2 ). Complete resection of the polypoid mass from the myometrium was performed with a hysteroscopic loop resectoscope ( Figure 3 ). The balloons were deflated, and the catheters were removed shortly after the surgery. Her postoperative hematocrit level was 23.1%. The patient recovered from the procedure well and was discharged home. Histologic evaluation of the polypoid mass revealed decidualized tissue with partially hyalinized chorionic villi that was consistent with hypervascular polypoid mass.
