**7. Conclusion**

*Induced Abortion and Spontaneous Early Pregnancy Loss - Focus on Management*

the placenta tissue having no atypical trophoblast cells [24].

embolisation that subsequently ended in hysterectomy [22].

**6. Recommendations for interruption of pregnancy in women with localisation of chorion/placenta in the uterine scar area after the** 

The optimal treatment of patients in the first trimester of pregnancy with sonographic diagnosis of suspected chorion increta into the uterine scar remains uncertain. The suggested options include one principal type of treatment or its combination with other methods, like curettage, systemic or local administration of Methotrexate, hysteroscopy, laparotomy and uterine artery embolisation [22, 40]. A review by Timor-Tritsch and Monteagudo [22] analyses the structure of surgical interferences in 44 patients with the given diagnosis: 5 of them (10.6%) underwent uterine arteries embolisation; 38 (78.7%) were subjected to laparotomy; 35 of the latter (74.4%) to hysterectomy; 1 patient of this group was diagnosed with arteriovenous malformation after the dilation and curettage and was subjected to

The sporadic, mainly individual, cases and their results are insufficient to draw a definite conclusion as to which of the performed interference methods is the most effective. It is almost impossible to identify what type of treatment entails maximum number of complications and should be avoided. Gynaecologists, as a rule, undertake curettage, laparoscopy and hysteroscopy, deeming them preferable as the

Nevertheless, the following recommendations were made on the basis of the

• If possible, dilation and curettage should be avoided because this might entail excessive bleeding, repeated curettage (for the haemostatic purpose) with no effect, blood transfusion, and in many cases—laparotomy and loss of uterus.

• Systemic administration of Methotrexate as the only method of treatment should be avoided. The argument: lengthy expectation of the effect or its absence results in further growth of the embryo and vascularisation of the

by the authors A. Esmans et al. [38].

**caesarean section**

"first-line" approach.

meta-analysis [22]:

was made during which the gestational tissue was completely removed. This did not entail any intra- or postoperative complications. The level of β-HCG in blood serum returned to normal 4 weeks after the operation. According to the authors, the hysteroscopic ectomy of ingrown chorion residues can be regarded as primary treatment, and as a secondary option-after an unsuccessful attempt of treatment with Methotrexate [39]. Histopathology of the placenta is shown in **Figure 7**, performed on a 40-year-old patient with a uterine rupture at 13 weeks of gestation, described

Lim et al. [24] give a clinical observation of placenta accreta and tardive haemorrhage in a patient aged 41 with five pregnancy episodes in the past medical history (1—confinement, 1—caesarean section for presentation of placenta and 3 curettage manipulations). Placenta accreta caused vaginal haemorrhage 3 years after the abortion, in the first trimester, 5 weeks' period. Originally the patient had regular menstruation, further the menses became irregular and heavy within the last year, which was the reason to seek medical attention. The level of serous β-HCG was 0.27 mIU/mL. The ultrasonography failed to visualize the endometrium line. Originally, endometrium cancer or uterine myoma with necrosis of the node was suspected. Actions taken: curettage; subsequently, in connection with the continuing haemorrhage-hysterectomy. The histopathological examination evidentiated

**96**

Interruption of pregnancy in case of a uterine scar can be effected at any pregnancy period using any method; at the same time, no additional risks for the mother are described if the ovum is localized beyond the scar zone.

Ultrasonic examination is an important method for viewing possible ovum presentation to the scar and possible chorion increta into the scar.

At suspicion on chorion ingrowth into the uterine scar, dilation and curettage, systemic administration of Methotrexate, uterine artery embolisation should be avoided, while it is recommended to give preference to combined methods surgical exsection of the impairment zone through hysteroscopic access and local administration of Methotrexate.

In all cases, patients with the uterine scar (irrespective of localisation of the ovum) are subject to hospitalisation for interruption of pregnancy at any period.
