It is important to be aware of the risk of abnormally invasive placenta in patients with a history of Asherman syndrome and uterine scarring. A prenatal diagnosis by ultrasonography is useful when planning of mode of delivery

Engelbrechtsen, L.

Istre, O.

Kjer, J. J.

Langhoff-Roos, J.

Clinical Case Reports

PubMed

Syddansk Universitets Forskerportal

       University of Southern DenmarkPlacenta accretaadherent placenta due to Asherman syndromeEngelbrechtsen, L.; Langhoff-Roos, J.; Kjer, J. J.; Istre, O.Published in:Clinical Case ReportsDOI:10.1002/ccr3.194Publication date:2015Document version:Final published versionDocument license:CC BY-NCCitation for pulished version (APA):Engelbrechtsen, L., Langhoff-Roos, J., Kjer, J. J., & Istre, O. (2015). Placenta accreta: adherent placenta due toAsherman syndrome. Clinical Case Reports, 3(3), 175-178. https://doi.org/10.1002/ccr3.194Go to publication entry in University of Southern Denmark's Research PortalTerms of useThis work is brought to you by the University of Southern Denmark.Unless otherwise specified it has been shared according to the terms for self-archiving.If no other license is stated, these terms apply:            • You may download this work for personal use only.            • You may not further distribute the material or use it for any profit-making activity or commercial gain            • You may freely distribute the URL identifying this open access versionIf you believe that this document breaches copyright please contact us providing details and we will investigate your claim.Please direct all enquiries to puresupport@bib.sdu.dkDownload date: 23. Oct. 2025CASE REPORTPlacenta accreta: adherent placenta due to AshermansyndromeLine Engelbrechtsen1, Jens Langhoff-Roos2, Jens Joergen Kjer1 & Olav Istre31Department of Gynaecology, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark2Department of Obstetrics, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark3Department of Obstetrics and Gynaecology, Odense University Hospital Odense, 5000, DenmarkCorrespondenceLine Engelbrechtsen, Department ofGynaecology, Rigshospitalet, Blegdamsvej 9,Copenhagen, 2100, Denmark. E-mail:line@engelbrechtsen.infoFunding InformationNo funding information provided.Received: 8 May 2014; Revised: 15 October2014; Accepted: 25 October 2014Clinical Case Reports 2015; 3(3): 175–178doi: 10.1002/ccr3.194Key Clinical MessageIt is important to be aware of the risk of abnormally invasive placenta inpatients with a history of Asherman syndrome and uterine scarring. A prenataldiagnosis by ultrasonography is useful when planning of mode of delivery.Keywordsabnormally invasive placenta, antenatal ultrasonography, Asherman syndrome,intrauterine adhesions, postpartum hemorrhage.IntroductionAsherman syndrome was first reported in 1894 by Hein-rich Fritz [1]. Asherman syndrome is also known as uter-ine atresia, amenorrhea traumatica, endometrial sclerosis,and intrauterine adhesions or synechiae [2]. The preva-lence of Asherman syndrome varies from 1.55 to 20%[3–6] according to population, mainly due to differentdiagnostic criteria, the number of abortions in the popu-lation, choice of management, awareness of clinicians,and incidence of infections (genital tuberculosis and puer-peral infections) [4].Asherman syndrome arises due to trauma of the endo-metrium and produces partial or complete obliteration ofthe uterine cavity or/and cervical canal [1, 4, 7, 8].Trauma of the uterine cavity results in dysfunction of theendometrium which presents in conditions such as men-strual abnormalities, dysmenorrhea, infertility, and recur-rent pregnancy loss [8].Asherman syndrome can occur due to uterine andintrauterine surgery such as cesarean section, curettage,myomectomy involving the uterine cavity, endometrialablation, and hysteroscopic removal of fibroids and pol-yps [4, 7–11]. However, intrauterine adhesions are alsoseen as a consequence of endometritis, congenital uterineabnormalities, and genetic predisposition [2]. It is well-known that the endometrium is more susceptible totrauma in a pregnant uterus and the incidence of intra-uterine adhesions following curettage for retained placen-tal tissue is reported up to 40% 3 months after curettage[5]. In patients who develop Asherman syndrome, curet-tage of a pregnant uterus has been shown as the cause in64% of the cases. Hysteroscopic adhesiolysis can be aneffective treatment of Asherman syndrome, with an over-all conception rate of 40% following surgery [12].Trauma of the endometrium can cause defects in thebasal decidua (Nitabuchs layer) which in a gravid uteruscan give rise to abnormal placentation. Placenta accretaarises when the anchoring villi of the placenta adheres tothe surface of the myometrium [11, 13].Placenta accreta is associated with complications duringdelivery including life-threatening maternal hemorrhage,blood transfusions, and subsequent peripartum hysterec-tomy [9, 10, 14]. Over the last decades an increase in inci-dence has been reported with a rise from 0.04% to 0.9%,possibly due to increased rate of uterine surgery [14–17].We describe a case of placenta accreta in a patient witha history of Asherman syndrome due to uterine scarringª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use,distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.175after evacuation of retained tissue from a missed abor-tion.Case DescriptionA 38-year-old woman, gravida 3, para 1 presented with aspontaneous pregnancy. Her previous surgical historyincluded a cesarean section and a hysteroscopic removalof uterine synechiae secondary to Asherman syndrome.One year prior to this pregnancy, the patient had amissed abortion at 7 weeks of gestational age. Medicalinduction with misoprostol was unsuccessful in twoattempts. Due to retained tissue, a surgical evacuation ofthe uterus with dilatation and curettage was performed.In the following months, the patient experienced second-ary amenorrhea, and the patient was referred for gynecol-ogist due to suspicion of Asherman syndrome.A transvaginal ultrasound at day 17 in menstrual cycleshowed thick endometrium disrupted by defects, mostlikely due to strictures in the uterus.Hysterosalpingography was attempted, but not com-pleted due to the fact that it was not possible to injectcontrast into the uterine cavity. The patient was sched-uled for hysteroscopic surgery.Hysteroscopic surgery revealed a wide adherence acrossthe uterine cavity, just above the internal orifice. A smalldefect in the adherence was resected and incisions weremade at position 3, 6, 9, and 12 according to myometrialscoring [18]. The adhesion was removed and revealed auterine cavity covered by endometrium in approximately50% of the cavity (Figure 1). The uterine scarring wasclassified as Asherman syndrome stadium II (rangingfrom I to III) according to The American Society forReproductive Medicine classification [19]. The patientreceived treatment with Progynova (Estradiol valerate)2 mg twice daily in 4 weeks postoperatively to preventrecurrence of intrauterine adhesions.The patient attended postoperatively follow-up 4 weeksafter surgery. A transvaginal ultrasound showed a uteruswith visible endometrium along the whole cavity. A sono-hysterography was performed to evaluate uterine cavityand tubal patency and revealed a normal cavity with flowof saline through both tubes.The present pregnancy was conceived 2 months afterfollow-up. The patient attended first trimester screeningat 12 weeks of gestation. A singleton fetus with normalnuchal translucency thickness and risk assessment wasfound. A routine scan was performed at 22 weeks of ges-tation and showed no sign of congenital abnormalities.Placenta was seen on the posterior uterine wall, lowinserted approx. 18 mm from internal ostium (Figure 2).The myometrium underlying placenta had normalappearance. The anterior uterine wall was found thinbehind the bladder, measuring 4 mm.The patient was monitored with ultrasonography every3–4 weeks due to the previous history of Asherman syn-drome.The patient underwent an ultrasound scan at 35 weeksof gestation where the uterine wall was found thin at theanterior uterine wall (site of previous cesarean scar) with amyometrium of 2 mm (Figure 3). Due to risk of uterinerupture during vaginal delivery, the patient was planned forcesarean section. The woman had future childbearingwishes, and was informed that excessive bleeding at deliverymight lead to extensive uterine surgery and possibly hyster-ectomy.A cesarean section was performed at 38 weeks of gesta-tion. During surgery the lower anterior uterine wall wasfound very thin, however, without dehiscence. Placentawas found partly abnormally adherent on the posterioruterine wall with the appearance of a placenta accreta.Figure 1. Hysteroscopic image. Uterine cavity with uterine scarringdue to Asherman syndrome.Figure 2. Transabdominal ultrasound scan at 22 weeks of gestation.Placenta on posterior wall located 18 mm from internal ostium.176 ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.Adherent placenta due to Asherman syndrome L. Engelbrechtsen et al.Manual removal of placenta was performed and bleedingwas measured to approximately 1 liter intraoperatively. ABakri balloon was inserted and the bleeding subsided.There was no need for uterine sutures or hysterectomy.The Bakri ballon was removed 24 h after the cesarean sec-tion and the woman was discharged in good condition2 days postoperatively.DiscussionAsherman syndrome is seen in women with previoustrauma of the endometrium. The syndrome is well-known, however, evidence-based guidelines on preventionand management are lacking.Dilatation and curettage are known risk factors fordevelopment of Asherman syndrome. Curettage is oftenperformed due to retained tissue after abortion or deliv-ery and with the focus entirely on emptying the uterus,and not on the prognosis for future fertility. Therefore,curettage is often too coarse and even with preventivemeans, such as hormonal treatment or cobber IUD post-operatively, formation of intrauterine adhesions can stilloccur. Therefore, emptying of the uterine cavity afterabortion or delivery should be gentle and performedunder ultrasonic guidance or by hysteroscopy [20].Following diagnose and treatment of Asherman syn-drome it is important to prevent formation of new adhe-sions. Treatment with estrogen has shown good results inpreventing reformation of adhesions following hystero-scopic surgery for Asherman syndrome. Use of peroralestrogen gives better fertility and menstrual outcomewhen given in combination with ancillary treatment(IUD, balloon or hyaluronic acid) [21].A recent study by Roy et al. reported conception ratesof 58% in mild Asherman, 30% in moderate Asherman,and 33.3% in severe cases of Asherman syndrome follow-ing hysteroscopic adhesiolysis. Furthermore, the live birthrate reported was 86.1%, the miscarriage rate 11.1% andthe cumulative pregnancy rate showed that 97.2% of thepatients conceived within 24 months postoperatively [12].Studies evaluating obstetric complications in pregnantwomen with previous Asherman syndrome are sparse. Anumber of cases have been reported but large observa-tional studies are lacking. In 1982, Schenker and Margali-oth [4] found an incidence of placenta accreta in 13–14%of patients with previous Asherman syndrome. Roy et al.[12] reported an incidence of postpartum hemorrhagedue to adherent placenta in 12.5% of the 89 women whohad undergone hysteroscopic adhesiolysis due to Asher-man syndrome. These numbers present a remarkably lowincidence of abnormal placentation in a group of women,who all had known trauma of the endometrium (i.e.,87.5% did not have an adherent placenta and subsequentpostpartum hemorrhage).This case report describes a patient with a placenta ac-creta on posterior uterine wall in a pregnancy followinghysteroscopic removal of adhesions due to Asherman syn-drome. The finding of an adherent placenta intraopera-tively was unexpected, as the patient had been thoroughlyexamined with sonography during pregnancy.Conventional 2 dimensional ultrasonography is cur-rently the best screening tool for detecting placenta accre-ta with a sensitivity of 77–90.7%, a specificity of 96–98%,a positive predictive value of 65–93%, and a negative pre-dictive value of 98% [22–24]. Another diagnostic tool fordetection of abnormal placentation is Magnetic ResonanceImaging (MRI). MRI has a sensitivity of 80–85% and aspecificity of 65–100% [25]. MRI can be used in conjunc-tion with conventional ultrasonography [26], and can behelpful in some cases, especially if the placenta is locatedon the posterior uterine wall. Though it is important tonotice, that for cases of placenta accreta, MRI is not agood prognostic tool for changing of surgical manage-ment [27]. Retrospective studies have shown that womenwith an antenatal diagnosis of placenta accreta have lessblood loss and requirement for blood transfusion thanwomen in whom the abnormal placentation was diag-nosed during cesarean section [28, 29].Any patient with a previous history of intrauterine sur-gery or Asherman syndrome should be thoroughly exam-ined by a skilled sonographer for possible abnormalplacentation. In case of any suspicion of abnormal placen-tation, the patient should be scheduled for planned cesar-ean section with a set-up of skilled clinicians due to riskof severe postpartum hemorrhage.In conclusion, it is important to be aware of the risk ofa placenta accreta in patients with a previous history ofAsherman syndrome and uterine scarring. AntenatalFigure 3. Transabdominal ultrasound scan at 35 weeks of gestation.Anterior uterine wall is measuring 2 mm at the site of previouscesarean section.ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd. 177L. Engelbrechtsen et al. Adherent placenta due to Asherman syndromediagnosis is important to counsel the pregnant womanand to plan mode of delivery.Conflict of InterestNone declared.References1. Asherman, J. G. 1948. Amenorrhoea traumatica (atretica).J. Obstet. Gynaecol. Br. Emp. 55:23–30.2. March, C. M. 2011. Management of Asherman’s syndrome.Reprod. Biomed. Online 23:63–76.3. Dmowski, W. P., and R. B. Greenblatt. 1969. Asherman’ssyndrome and risk of placenta accreta. Obstet. Gynecol.34:288–299.4. Schenker, J. G., and E. J. Margalioth. 1982. Intrauterineadhesions: an updated appraisal. Fertil. Steril. 37:593–610.5. Westendorp, I. C., W. M. Ankum, B. W. Mol, and J. Vonk.1998. Prevalence of Asherman’s syndrome after secondaryremoval of placental remnants or a repeat curettage forincomplete abortion. Hum. Reprod. 13:3347–3350.6. Friedler, S., E. J. Margalioth, I. Kafka, and H. Yaffe. 1993.Incidence of post-abortion intra-uterine adhesionsevaluated by hysteroscopy–a prospective study. Hum.Reprod. 8:442–444.7. March, C. M. 1995. Intrauterine adhesions. Obstet.Gynecol. Clin. North Am. 22:491–505.8. March, C. M. 2011. Asherman’s syndrome. Semin. Reprod.Med. 29:83–94.9. Bauer, S. T., and C. Bonanno. 2009. Abnormalplacentation. Semin. Perinatol. 33:88–96.10. Eshkoli, T., A. Y. Weintraub, R. Sergienko, and E. Sheiner.2013. Placenta accreta: risk factors, perinatal outcomes,and consequences for subsequent births. Am. J. Obstet.Gynecol. 208:219.e1-7.11. Tantbirojn, P., C. P. Crum, and M. M. Parast. 2008.Pathophysiology of placenta accreta: the role of deciduaand extravillous trophoblast. Placenta 29:639–645.12. Roy, K. K., J. Baruah, J. B. Sharma, S. Kumar, G.Kachawa, and N. Singh. 2010. Reproductive outcomefollowing hysteroscopic adhesiolysis in patients withinfertility due to Asherman’s syndrome. Arch. Gynecol.Obstet. 281:355–361.13. Strickland, S., and W. G. Richards. 1992. Invasion of thetrophoblasts. Cell 71:355–357.14. Belfort, M. A. 2010. Placenta accreta. Am. J. Obstet.Gynecol. 203:430–439.15. Hull, A. D., and R. Resnik. 2010. Placenta accreta andpostpartum hemorrhage. Clin. Obstet. Gynecol. 53:228–236.16. Silver, R. M., M. B. Landon, D. J. Rouse, K. J. Leveno, C.Y. Spong, E. A. Thom, et al. 2006. Maternal morbidityassociated with multiple repeat cesarean deliveries. Obstet.Gynecol. 107:1226–1232.17. Esh-Broder, E., I. Ariel, N. Bashir, Y. Bdolah, and D. H.Celnikier. 2011. Placenta accreta is associated with IVFpregnancies: a retrospective chart review. BJOG 118:1084–1089.18. Protopapas, A., A. Shushan, and A. Magos. 1998.Myometrial scoring: a new technique for themanagement of severe Asherman’s syndrome. Fertil.Steril. 69:860–864.19. The American Fertility Society. 1988. The AmericanFertility Society classifications of adnexal adhesions, distaltubal occlusion, tubal occlusion secondary to tuballigation, tubal pregnancies, mullerian anomalies andintrauterine adhesions. Fertil. Steril. 49:944–955.20. Kjer, J. J. 2014. Asherman syndrome in a Danishpopulation. Acta Obstet. Gynecol. Scand. 93:425–427.21. Johary, J., M. Xue, X. Zhu, D. Xu, and P. P. Velu. 2014.Efficacy of estrogen therapy in patients with intrauterineadhesions: systematic review. J. Minim. Invasive Gynecol.21:44–54.22. D’Antonio, F., C. Iacovella, and A. Bhide. 2013. Prenatalidentification of invasive placentation using ultrasound:systematic review and meta-analysis. Ultrasound Obstet.Gynecol. 42:509–517.23. Warshak, C. R., R. Eskander, A. D. Hull, A. L. Scioscia, R.F. Mattrey, K. Benirschke, et al. 2006. Accuracy ofultrasonography and magnetic resonance imaging in thediagnosis of placenta accreta. Obstet. Gynecol. 108(3 Pt1):573–581.24. Comstock, C. H., J. J. Love Jr, R. A. Bronsteen, W. Lee, I. M.Vettraino, R. R. Huang, et al. 2004. Sonographic detectionof placenta accreta in the second and third trimesters ofpregnancy. Am. J. Obstet. Gynecol. 190:1135–1140.25. Gielchinsky, Y., D. Mankuta, N. Rojansky, N. Laufer, I.Gielchinsky, and Y. Ezra. 2004. Perinatal outcome ofpregnancies complicated by placenta accreta. Obstet.Gynecol. 104:527–530.26. Levine, D., C. A. Hulka, J. Ludmir, W. Li, and R. R.Edelman. 1997. Placenta accreta: evaluation with colorDoppler US, power Doppler US, and MR imaging.Radiology 205:773–776.27. McLean, L. A., M. E. Heilbrun, A. G. Eller, A. M.Kennedy, and P. J. Woodward. 2011. Assessing the role ofmagnetic resonance imaging in the management of gravidpatients at risk for placenta accreta. Acad. Radiol. 18:1175–1180.28. Warshak, C. R., G. A. Ramos, R. Eskander, K. Benirschke,C. C. Saenz, T. F. Kelly, et al. 2010. Effect of predeliverydiagnosis in 99 consecutive cases of placenta accreta.Obstet. Gynecol. 115:65–69.29. Tikkanen, M., J. Paavonen, M. Loukovaara, and V.Stefanovic. 2011. Antenatal diagnosis of placenta accretaleads to reduced blood loss. Acta Obstet. Gynecol. Scand.90:1140–6.178 ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.Adherent placenta due to Asherman syndrome L. Engelbrechtsen et al.

English

Placenta accreta:adherent placenta due to Asherman syndrome

Engelbrechtsen, Line

Langhoff-Roos, Jens

Kjer, Jens Jørgen

Istre, Olav

Copenhagen University Research Information System

Placenta accreta: adherent placenta due to Asherman syndrome

       University of Southern DenmarkPlacenta accretaadherent placenta due to Asherman syndromeEngelbrechtsen, L.; Langhoff-Roos, J.; Kjer, J. J.; Istre, O.Published in:Clinical Case ReportsDOI:10.1002/ccr3.194Publication date:2015Document version:Final published versionDocument license:CC BY-NCCitation for pulished version (APA):Engelbrechtsen, L., Langhoff-Roos, J., Kjer, J. J., & Istre, O. (2015). Placenta accreta: adherent placenta due toAsherman syndrome. Clinical Case Reports, 3(3), 175-178. https://doi.org/10.1002/ccr3.194Go to publication entry in University of Southern Denmark's Research PortalTerms of useThis work is brought to you by the University of Southern Denmark.Unless otherwise specified it has been shared according to the terms for self-archiving.If no other license is stated, these terms apply:            • You may download this work for personal use only.            • You may not further distribute the material or use it for any profit-making activity or commercial gain            • You may freely distribute the URL identifying this open access versionIf you believe that this document breaches copyright please contact us providing details and we will investigate your claim.Please direct all enquiries to puresupport@bib.sdu.dkDownload date: 25. Oct. 2025CASE REPORTPlacenta accreta: adherent placenta due to AshermansyndromeLine Engelbrechtsen1, Jens Langhoff-Roos2, Jens Joergen Kjer1 & Olav Istre31Department of Gynaecology, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark2Department of Obstetrics, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark3Department of Obstetrics and Gynaecology, Odense University Hospital Odense, 5000, DenmarkCorrespondenceLine Engelbrechtsen, Department ofGynaecology, Rigshospitalet, Blegdamsvej 9,Copenhagen, 2100, Denmark. E-mail:line@engelbrechtsen.infoFunding InformationNo funding information provided.Received: 8 May 2014; Revised: 15 October2014; Accepted: 25 October 2014Clinical Case Reports 2015; 3(3): 175–178doi: 10.1002/ccr3.194Key Clinical MessageIt is important to be aware of the risk of abnormally invasive placenta inpatients with a history of Asherman syndrome and uterine scarring. A prenataldiagnosis by ultrasonography is useful when planning of mode of delivery.Keywordsabnormally invasive placenta, antenatal ultrasonography, Asherman syndrome,intrauterine adhesions, postpartum hemorrhage.IntroductionAsherman syndrome was first reported in 1894 by Hein-rich Fritz [1]. Asherman syndrome is also known as uter-ine atresia, amenorrhea traumatica, endometrial sclerosis,and intrauterine adhesions or synechiae [2]. The preva-lence of Asherman syndrome varies from 1.55 to 20%[3–6] according to population, mainly due to differentdiagnostic criteria, the number of abortions in the popu-lation, choice of management, awareness of clinicians,and incidence of infections (genital tuberculosis and puer-peral infections) [4].Asherman syndrome arises due to trauma of the endo-metrium and produces partial or complete obliteration ofthe uterine cavity or/and cervical canal [1, 4, 7, 8].Trauma of the uterine cavity results in dysfunction of theendometrium which presents in conditions such as men-strual abnormalities, dysmenorrhea, infertility, and recur-rent pregnancy loss [8].Asherman syndrome can occur due to uterine andintrauterine surgery such as cesarean section, curettage,myomectomy involving the uterine cavity, endometrialablation, and hysteroscopic removal of fibroids and pol-yps [4, 7–11]. However, intrauterine adhesions are alsoseen as a consequence of endometritis, congenital uterineabnormalities, and genetic predisposition [2]. It is well-known that the endometrium is more susceptible totrauma in a pregnant uterus and the incidence of intra-uterine adhesions following curettage for retained placen-tal tissue is reported up to 40% 3 months after curettage[5]. In patients who develop Asherman syndrome, curet-tage of a pregnant uterus has been shown as the cause in64% of the cases. Hysteroscopic adhesiolysis can be aneffective treatment of Asherman syndrome, with an over-all conception rate of 40% following surgery [12].Trauma of the endometrium can cause defects in thebasal decidua (Nitabuchs layer) which in a gravid uteruscan give rise to abnormal placentation. Placenta accretaarises when the anchoring villi of the placenta adheres tothe surface of the myometrium [11, 13].Placenta accreta is associated with complications duringdelivery including life-threatening maternal hemorrhage,blood transfusions, and subsequent peripartum hysterec-tomy [9, 10, 14]. Over the last decades an increase in inci-dence has been reported with a rise from 0.04% to 0.9%,possibly due to increased rate of uterine surgery [14–17].We describe a case of placenta accreta in a patient witha history of Asherman syndrome due to uterine scarringª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use,distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.175after evacuation of retained tissue from a missed abor-tion.Case DescriptionA 38-year-old woman, gravida 3, para 1 presented with aspontaneous pregnancy. Her previous surgical historyincluded a cesarean section and a hysteroscopic removalof uterine synechiae secondary to Asherman syndrome.One year prior to this pregnancy, the patient had amissed abortion at 7 weeks of gestational age. Medicalinduction with misoprostol was unsuccessful in twoattempts. Due to retained tissue, a surgical evacuation ofthe uterus with dilatation and curettage was performed.In the following months, the patient experienced second-ary amenorrhea, and the patient was referred for gynecol-ogist due to suspicion of Asherman syndrome.A transvaginal ultrasound at day 17 in menstrual cycleshowed thick endometrium disrupted by defects, mostlikely due to strictures in the uterus.Hysterosalpingography was attempted, but not com-pleted due to the fact that it was not possible to injectcontrast into the uterine cavity. The patient was sched-uled for hysteroscopic surgery.Hysteroscopic surgery revealed a wide adherence acrossthe uterine cavity, just above the internal orifice. A smalldefect in the adherence was resected and incisions weremade at position 3, 6, 9, and 12 according to myometrialscoring [18]. The adhesion was removed and revealed auterine cavity covered by endometrium in approximately50% of the cavity (Figure 1). The uterine scarring wasclassified as Asherman syndrome stadium II (rangingfrom I to III) according to The American Society forReproductive Medicine classification [19]. The patientreceived treatment with Progynova (Estradiol valerate)2 mg twice daily in 4 weeks postoperatively to preventrecurrence of intrauterine adhesions.The patient attended postoperatively follow-up 4 weeksafter surgery. A transvaginal ultrasound showed a uteruswith visible endometrium along the whole cavity. A sono-hysterography was performed to evaluate uterine cavityand tubal patency and revealed a normal cavity with flowof saline through both tubes.The present pregnancy was conceived 2 months afterfollow-up. The patient attended first trimester screeningat 12 weeks of gestation. A singleton fetus with normalnuchal translucency thickness and risk assessment wasfound. A routine scan was performed at 22 weeks of ges-tation and showed no sign of congenital abnormalities.Placenta was seen on the posterior uterine wall, lowinserted approx. 18 mm from internal ostium (Figure 2).The myometrium underlying placenta had normalappearance. The anterior uterine wall was found thinbehind the bladder, measuring 4 mm.The patient was monitored with ultrasonography every3–4 weeks due to the previous history of Asherman syn-drome.The patient underwent an ultrasound scan at 35 weeksof gestation where the uterine wall was found thin at theanterior uterine wall (site of previous cesarean scar) with amyometrium of 2 mm (Figure 3). Due to risk of uterinerupture during vaginal delivery, the patient was planned forcesarean section. The woman had future childbearingwishes, and was informed that excessive bleeding at deliverymight lead to extensive uterine surgery and possibly hyster-ectomy.A cesarean section was performed at 38 weeks of gesta-tion. During surgery the lower anterior uterine wall wasfound very thin, however, without dehiscence. Placentawas found partly abnormally adherent on the posterioruterine wall with the appearance of a placenta accreta.Figure 1. Hysteroscopic image. Uterine cavity with uterine scarringdue to Asherman syndrome.Figure 2. Transabdominal ultrasound scan at 22 weeks of gestation.Placenta on posterior wall located 18 mm from internal ostium.176 ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.Adherent placenta due to Asherman syndrome L. Engelbrechtsen et al.Manual removal of placenta was performed and bleedingwas measured to approximately 1 liter intraoperatively. ABakri balloon was inserted and the bleeding subsided.There was no need for uterine sutures or hysterectomy.The Bakri ballon was removed 24 h after the cesarean sec-tion and the woman was discharged in good condition2 days postoperatively.DiscussionAsherman syndrome is seen in women with previoustrauma of the endometrium. The syndrome is well-known, however, evidence-based guidelines on preventionand management are lacking.Dilatation and curettage are known risk factors fordevelopment of Asherman syndrome. Curettage is oftenperformed due to retained tissue after abortion or deliv-ery and with the focus entirely on emptying the uterus,and not on the prognosis for future fertility. Therefore,curettage is often too coarse and even with preventivemeans, such as hormonal treatment or cobber IUD post-operatively, formation of intrauterine adhesions can stilloccur. Therefore, emptying of the uterine cavity afterabortion or delivery should be gentle and performedunder ultrasonic guidance or by hysteroscopy [20].Following diagnose and treatment of Asherman syn-drome it is important to prevent formation of new adhe-sions. Treatment with estrogen has shown good results inpreventing reformation of adhesions following hystero-scopic surgery for Asherman syndrome. Use of peroralestrogen gives better fertility and menstrual outcomewhen given in combination with ancillary treatment(IUD, balloon or hyaluronic acid) [21].A recent study by Roy et al. reported conception ratesof 58% in mild Asherman, 30% in moderate Asherman,and 33.3% in severe cases of Asherman syndrome follow-ing hysteroscopic adhesiolysis. Furthermore, the live birthrate reported was 86.1%, the miscarriage rate 11.1% andthe cumulative pregnancy rate showed that 97.2% of thepatients conceived within 24 months postoperatively [12].Studies evaluating obstetric complications in pregnantwomen with previous Asherman syndrome are sparse. Anumber of cases have been reported but large observa-tional studies are lacking. In 1982, Schenker and Margali-oth [4] found an incidence of placenta accreta in 13–14%of patients with previous Asherman syndrome. Roy et al.[12] reported an incidence of postpartum hemorrhagedue to adherent placenta in 12.5% of the 89 women whohad undergone hysteroscopic adhesiolysis due to Asher-man syndrome. These numbers present a remarkably lowincidence of abnormal placentation in a group of women,who all had known trauma of the endometrium (i.e.,87.5% did not have an adherent placenta and subsequentpostpartum hemorrhage).This case report describes a patient with a placenta ac-creta on posterior uterine wall in a pregnancy followinghysteroscopic removal of adhesions due to Asherman syn-drome. The finding of an adherent placenta intraopera-tively was unexpected, as the patient had been thoroughlyexamined with sonography during pregnancy.Conventional 2 dimensional ultrasonography is cur-rently the best screening tool for detecting placenta accre-ta with a sensitivity of 77–90.7%, a specificity of 96–98%,a positive predictive value of 65–93%, and a negative pre-dictive value of 98% [22–24]. Another diagnostic tool fordetection of abnormal placentation is Magnetic ResonanceImaging (MRI). MRI has a sensitivity of 80–85% and aspecificity of 65–100% [25]. MRI can be used in conjunc-tion with conventional ultrasonography [26], and can behelpful in some cases, especially if the placenta is locatedon the posterior uterine wall. Though it is important tonotice, that for cases of placenta accreta, MRI is not agood prognostic tool for changing of surgical manage-ment [27]. Retrospective studies have shown that womenwith an antenatal diagnosis of placenta accreta have lessblood loss and requirement for blood transfusion thanwomen in whom the abnormal placentation was diag-nosed during cesarean section [28, 29].Any patient with a previous history of intrauterine sur-gery or Asherman syndrome should be thoroughly exam-ined by a skilled sonographer for possible abnormalplacentation. In case of any suspicion of abnormal placen-tation, the patient should be scheduled for planned cesar-ean section with a set-up of skilled clinicians due to riskof severe postpartum hemorrhage.In conclusion, it is important to be aware of the risk ofa placenta accreta in patients with a previous history ofAsherman syndrome and uterine scarring. AntenatalFigure 3. Transabdominal ultrasound scan at 35 weeks of gestation.Anterior uterine wall is measuring 2 mm at the site of previouscesarean section.ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd. 177L. Engelbrechtsen et al. Adherent placenta due to Asherman syndromediagnosis is important to counsel the pregnant womanand to plan mode of delivery.Conflict of InterestNone declared.References1. Asherman, J. G. 1948. Amenorrhoea traumatica (atretica).J. Obstet. Gynaecol. Br. Emp. 55:23–30.2. March, C. M. 2011. Management of Asherman’s syndrome.Reprod. Biomed. Online 23:63–76.3. Dmowski, W. P., and R. B. Greenblatt. 1969. Asherman’ssyndrome and risk of placenta accreta. Obstet. Gynecol.34:288–299.4. Schenker, J. G., and E. J. Margalioth. 1982. Intrauterineadhesions: an updated appraisal. Fertil. Steril. 37:593–610.5. Westendorp, I. C., W. M. Ankum, B. W. Mol, and J. Vonk.1998. Prevalence of Asherman’s syndrome after secondaryremoval of placental remnants or a repeat curettage forincomplete abortion. Hum. Reprod. 13:3347–3350.6. Friedler, S., E. J. Margalioth, I. Kafka, and H. Yaffe. 1993.Incidence of post-abortion intra-uterine adhesionsevaluated by hysteroscopy–a prospective study. Hum.Reprod. 8:442–444.7. March, C. M. 1995. Intrauterine adhesions. Obstet.Gynecol. Clin. North Am. 22:491–505.8. March, C. M. 2011. Asherman’s syndrome. Semin. Reprod.Med. 29:83–94.9. Bauer, S. T., and C. Bonanno. 2009. Abnormalplacentation. Semin. Perinatol. 33:88–96.10. Eshkoli, T., A. Y. Weintraub, R. Sergienko, and E. Sheiner.2013. Placenta accreta: risk factors, perinatal outcomes,and consequences for subsequent births. Am. J. Obstet.Gynecol. 208:219.e1-7.11. Tantbirojn, P., C. P. Crum, and M. M. Parast. 2008.Pathophysiology of placenta accreta: the role of deciduaand extravillous trophoblast. Placenta 29:639–645.12. Roy, K. K., J. Baruah, J. B. Sharma, S. Kumar, G.Kachawa, and N. Singh. 2010. Reproductive outcomefollowing hysteroscopic adhesiolysis in patients withinfertility due to Asherman’s syndrome. Arch. Gynecol.Obstet. 281:355–361.13. Strickland, S., and W. G. Richards. 1992. Invasion of thetrophoblasts. Cell 71:355–357.14. Belfort, M. A. 2010. Placenta accreta. Am. J. Obstet.Gynecol. 203:430–439.15. Hull, A. D., and R. Resnik. 2010. Placenta accreta andpostpartum hemorrhage. Clin. Obstet. Gynecol. 53:228–236.16. Silver, R. M., M. B. Landon, D. J. Rouse, K. J. Leveno, C.Y. Spong, E. A. Thom, et al. 2006. Maternal morbidityassociated with multiple repeat cesarean deliveries. Obstet.Gynecol. 107:1226–1232.17. Esh-Broder, E., I. Ariel, N. Bashir, Y. Bdolah, and D. H.Celnikier. 2011. Placenta accreta is associated with IVFpregnancies: a retrospective chart review. BJOG 118:1084–1089.18. Protopapas, A., A. Shushan, and A. Magos. 1998.Myometrial scoring: a new technique for themanagement of severe Asherman’s syndrome. Fertil.Steril. 69:860–864.19. The American Fertility Society. 1988. The AmericanFertility Society classifications of adnexal adhesions, distaltubal occlusion, tubal occlusion secondary to tuballigation, tubal pregnancies, mullerian anomalies andintrauterine adhesions. Fertil. Steril. 49:944–955.20. Kjer, J. J. 2014. Asherman syndrome in a Danishpopulation. Acta Obstet. Gynecol. Scand. 93:425–427.21. Johary, J., M. Xue, X. Zhu, D. Xu, and P. P. Velu. 2014.Efficacy of estrogen therapy in patients with intrauterineadhesions: systematic review. J. Minim. Invasive Gynecol.21:44–54.22. D’Antonio, F., C. Iacovella, and A. Bhide. 2013. Prenatalidentification of invasive placentation using ultrasound:systematic review and meta-analysis. Ultrasound Obstet.Gynecol. 42:509–517.23. Warshak, C. R., R. Eskander, A. D. Hull, A. L. Scioscia, R.F. Mattrey, K. Benirschke, et al. 2006. Accuracy ofultrasonography and magnetic resonance imaging in thediagnosis of placenta accreta. Obstet. Gynecol. 108(3 Pt1):573–581.24. Comstock, C. H., J. J. Love Jr, R. A. Bronsteen, W. Lee, I. M.Vettraino, R. R. Huang, et al. 2004. Sonographic detectionof placenta accreta in the second and third trimesters ofpregnancy. Am. J. Obstet. Gynecol. 190:1135–1140.25. Gielchinsky, Y., D. Mankuta, N. Rojansky, N. Laufer, I.Gielchinsky, and Y. Ezra. 2004. Perinatal outcome ofpregnancies complicated by placenta accreta. Obstet.Gynecol. 104:527–530.26. Levine, D., C. A. Hulka, J. Ludmir, W. Li, and R. R.Edelman. 1997. Placenta accreta: evaluation with colorDoppler US, power Doppler US, and MR imaging.Radiology 205:773–776.27. McLean, L. A., M. E. Heilbrun, A. G. Eller, A. M.Kennedy, and P. J. Woodward. 2011. Assessing the role ofmagnetic resonance imaging in the management of gravidpatients at risk for placenta accreta. Acad. Radiol. 18:1175–1180.28. Warshak, C. R., G. A. Ramos, R. Eskander, K. Benirschke,C. C. Saenz, T. F. Kelly, et al. 2010. Effect of predeliverydiagnosis in 99 consecutive cases of placenta accreta.Obstet. Gynecol. 115:65–69.29. Tikkanen, M., J. Paavonen, M. Loukovaara, and V.Stefanovic. 2011. Antenatal diagnosis of placenta accretaleads to reduced blood loss. Acta Obstet. Gynecol. Scand.90:1140–6.178 ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.Adherent placenta due to Asherman syndrome L. Engelbrechtsen et al.

Line Engelbrechtsen

Jens Langhoff-Roos

Jens Joergen Kjer

Olav Istre

Crossref

       University of Southern DenmarkPlacenta accretaadherent placenta due to Asherman syndromeEngelbrechtsen, L.; Langhoff-Roos, J.; Kjer, J. J.; Istre, O.Published in:Clinical Case ReportsDOI:10.1002/ccr3.194Publication date:2015Document version:Final published versionDocument license:CC BY-NCCitation for pulished version (APA):Engelbrechtsen, L., Langhoff-Roos, J., Kjer, J. J., & Istre, O. (2015). Placenta accreta: adherent placenta due toAsherman syndrome. Clinical Case Reports, 3(3), 175-178. https://doi.org/10.1002/ccr3.194Go to publication entry in University of Southern Denmark's Research PortalTerms of useThis work is brought to you by the University of Southern Denmark.Unless otherwise specified it has been shared according to the terms for self-archiving.If no other license is stated, these terms apply:            • You may download this work for personal use only.            • You may not further distribute the material or use it for any profit-making activity or commercial gain            • You may freely distribute the URL identifying this open access versionIf you believe that this document breaches copyright please contact us providing details and we will investigate your claim.Please direct all enquiries to puresupport@bib.sdu.dkDownload date: 21. Oct. 2025CASE REPORTPlacenta accreta: adherent placenta due to AshermansyndromeLine Engelbrechtsen1, Jens Langhoff-Roos2, Jens Joergen Kjer1 & Olav Istre31Department of Gynaecology, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark2Department of Obstetrics, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark3Department of Obstetrics and Gynaecology, Odense University Hospital Odense, 5000, DenmarkCorrespondenceLine Engelbrechtsen, Department ofGynaecology, Rigshospitalet, Blegdamsvej 9,Copenhagen, 2100, Denmark. E-mail:line@engelbrechtsen.infoFunding InformationNo funding information provided.Received: 8 May 2014; Revised: 15 October2014; Accepted: 25 October 2014Clinical Case Reports 2015; 3(3): 175–178doi: 10.1002/ccr3.194Key Clinical MessageIt is important to be aware of the risk of abnormally invasive placenta inpatients with a history of Asherman syndrome and uterine scarring. A prenataldiagnosis by ultrasonography is useful when planning of mode of delivery.Keywordsabnormally invasive placenta, antenatal ultrasonography, Asherman syndrome,intrauterine adhesions, postpartum hemorrhage.IntroductionAsherman syndrome was first reported in 1894 by Hein-rich Fritz [1]. Asherman syndrome is also known as uter-ine atresia, amenorrhea traumatica, endometrial sclerosis,and intrauterine adhesions or synechiae [2]. The preva-lence of Asherman syndrome varies from 1.55 to 20%[3–6] according to population, mainly due to differentdiagnostic criteria, the number of abortions in the popu-lation, choice of management, awareness of clinicians,and incidence of infections (genital tuberculosis and puer-peral infections) [4].Asherman syndrome arises due to trauma of the endo-metrium and produces partial or complete obliteration ofthe uterine cavity or/and cervical canal [1, 4, 7, 8].Trauma of the uterine cavity results in dysfunction of theendometrium which presents in conditions such as men-strual abnormalities, dysmenorrhea, infertility, and recur-rent pregnancy loss [8].Asherman syndrome can occur due to uterine andintrauterine surgery such as cesarean section, curettage,myomectomy involving the uterine cavity, endometrialablation, and hysteroscopic removal of fibroids and pol-yps [4, 7–11]. However, intrauterine adhesions are alsoseen as a consequence of endometritis, congenital uterineabnormalities, and genetic predisposition [2]. It is well-known that the endometrium is more susceptible totrauma in a pregnant uterus and the incidence of intra-uterine adhesions following curettage for retained placen-tal tissue is reported up to 40% 3 months after curettage[5]. In patients who develop Asherman syndrome, curet-tage of a pregnant uterus has been shown as the cause in64% of the cases. Hysteroscopic adhesiolysis can be aneffective treatment of Asherman syndrome, with an over-all conception rate of 40% following surgery [12].Trauma of the endometrium can cause defects in thebasal decidua (Nitabuchs layer) which in a gravid uteruscan give rise to abnormal placentation. Placenta accretaarises when the anchoring villi of the placenta adheres tothe surface of the myometrium [11, 13].Placenta accreta is associated with complications duringdelivery including life-threatening maternal hemorrhage,blood transfusions, and subsequent peripartum hysterec-tomy [9, 10, 14]. Over the last decades an increase in inci-dence has been reported with a rise from 0.04% to 0.9%,possibly due to increased rate of uterine surgery [14–17].We describe a case of placenta accreta in a patient witha history of Asherman syndrome due to uterine scarringª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use,distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.175after evacuation of retained tissue from a missed abor-tion.Case DescriptionA 38-year-old woman, gravida 3, para 1 presented with aspontaneous pregnancy. Her previous surgical historyincluded a cesarean section and a hysteroscopic removalof uterine synechiae secondary to Asherman syndrome.One year prior to this pregnancy, the patient had amissed abortion at 7 weeks of gestational age. Medicalinduction with misoprostol was unsuccessful in twoattempts. Due to retained tissue, a surgical evacuation ofthe uterus with dilatation and curettage was performed.In the following months, the patient experienced second-ary amenorrhea, and the patient was referred for gynecol-ogist due to suspicion of Asherman syndrome.A transvaginal ultrasound at day 17 in menstrual cycleshowed thick endometrium disrupted by defects, mostlikely due to strictures in the uterus.Hysterosalpingography was attempted, but not com-pleted due to the fact that it was not possible to injectcontrast into the uterine cavity. The patient was sched-uled for hysteroscopic surgery.Hysteroscopic surgery revealed a wide adherence acrossthe uterine cavity, just above the internal orifice. A smalldefect in the adherence was resected and incisions weremade at position 3, 6, 9, and 12 according to myometrialscoring [18]. The adhesion was removed and revealed auterine cavity covered by endometrium in approximately50% of the cavity (Figure 1). The uterine scarring wasclassified as Asherman syndrome stadium II (rangingfrom I to III) according to The American Society forReproductive Medicine classification [19]. The patientreceived treatment with Progynova (Estradiol valerate)2 mg twice daily in 4 weeks postoperatively to preventrecurrence of intrauterine adhesions.The patient attended postoperatively follow-up 4 weeksafter surgery. A transvaginal ultrasound showed a uteruswith visible endometrium along the whole cavity. A sono-hysterography was performed to evaluate uterine cavityand tubal patency and revealed a normal cavity with flowof saline through both tubes.The present pregnancy was conceived 2 months afterfollow-up. The patient attended first trimester screeningat 12 weeks of gestation. A singleton fetus with normalnuchal translucency thickness and risk assessment wasfound. A routine scan was performed at 22 weeks of ges-tation and showed no sign of congenital abnormalities.Placenta was seen on the posterior uterine wall, lowinserted approx. 18 mm from internal ostium (Figure 2).The myometrium underlying placenta had normalappearance. The anterior uterine wall was found thinbehind the bladder, measuring 4 mm.The patient was monitored with ultrasonography every3–4 weeks due to the previous history of Asherman syn-drome.The patient underwent an ultrasound scan at 35 weeksof gestation where the uterine wall was found thin at theanterior uterine wall (site of previous cesarean scar) with amyometrium of 2 mm (Figure 3). Due to risk of uterinerupture during vaginal delivery, the patient was planned forcesarean section. The woman had future childbearingwishes, and was informed that excessive bleeding at deliverymight lead to extensive uterine surgery and possibly hyster-ectomy.A cesarean section was performed at 38 weeks of gesta-tion. During surgery the lower anterior uterine wall wasfound very thin, however, without dehiscence. Placentawas found partly abnormally adherent on the posterioruterine wall with the appearance of a placenta accreta.Figure 1. Hysteroscopic image. Uterine cavity with uterine scarringdue to Asherman syndrome.Figure 2. Transabdominal ultrasound scan at 22 weeks of gestation.Placenta on posterior wall located 18 mm from internal ostium.176 ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.Adherent placenta due to Asherman syndrome L. Engelbrechtsen et al.Manual removal of placenta was performed and bleedingwas measured to approximately 1 liter intraoperatively. ABakri balloon was inserted and the bleeding subsided.There was no need for uterine sutures or hysterectomy.The Bakri ballon was removed 24 h after the cesarean sec-tion and the woman was discharged in good condition2 days postoperatively.DiscussionAsherman syndrome is seen in women with previoustrauma of the endometrium. The syndrome is well-known, however, evidence-based guidelines on preventionand management are lacking.Dilatation and curettage are known risk factors fordevelopment of Asherman syndrome. Curettage is oftenperformed due to retained tissue after abortion or deliv-ery and with the focus entirely on emptying the uterus,and not on the prognosis for future fertility. Therefore,curettage is often too coarse and even with preventivemeans, such as hormonal treatment or cobber IUD post-operatively, formation of intrauterine adhesions can stilloccur. Therefore, emptying of the uterine cavity afterabortion or delivery should be gentle and performedunder ultrasonic guidance or by hysteroscopy [20].Following diagnose and treatment of Asherman syn-drome it is important to prevent formation of new adhe-sions. Treatment with estrogen has shown good results inpreventing reformation of adhesions following hystero-scopic surgery for Asherman syndrome. Use of peroralestrogen gives better fertility and menstrual outcomewhen given in combination with ancillary treatment(IUD, balloon or hyaluronic acid) [21].A recent study by Roy et al. reported conception ratesof 58% in mild Asherman, 30% in moderate Asherman,and 33.3% in severe cases of Asherman syndrome follow-ing hysteroscopic adhesiolysis. Furthermore, the live birthrate reported was 86.1%, the miscarriage rate 11.1% andthe cumulative pregnancy rate showed that 97.2% of thepatients conceived within 24 months postoperatively [12].Studies evaluating obstetric complications in pregnantwomen with previous Asherman syndrome are sparse. Anumber of cases have been reported but large observa-tional studies are lacking. In 1982, Schenker and Margali-oth [4] found an incidence of placenta accreta in 13–14%of patients with previous Asherman syndrome. Roy et al.[12] reported an incidence of postpartum hemorrhagedue to adherent placenta in 12.5% of the 89 women whohad undergone hysteroscopic adhesiolysis due to Asher-man syndrome. These numbers present a remarkably lowincidence of abnormal placentation in a group of women,who all had known trauma of the endometrium (i.e.,87.5% did not have an adherent placenta and subsequentpostpartum hemorrhage).This case report describes a patient with a placenta ac-creta on posterior uterine wall in a pregnancy followinghysteroscopic removal of adhesions due to Asherman syn-drome. The finding of an adherent placenta intraopera-tively was unexpected, as the patient had been thoroughlyexamined with sonography during pregnancy.Conventional 2 dimensional ultrasonography is cur-rently the best screening tool for detecting placenta accre-ta with a sensitivity of 77–90.7%, a specificity of 96–98%,a positive predictive value of 65–93%, and a negative pre-dictive value of 98% [22–24]. Another diagnostic tool fordetection of abnormal placentation is Magnetic ResonanceImaging (MRI). MRI has a sensitivity of 80–85% and aspecificity of 65–100% [25]. MRI can be used in conjunc-tion with conventional ultrasonography [26], and can behelpful in some cases, especially if the placenta is locatedon the posterior uterine wall. Though it is important tonotice, that for cases of placenta accreta, MRI is not agood prognostic tool for changing of surgical manage-ment [27]. Retrospective studies have shown that womenwith an antenatal diagnosis of placenta accreta have lessblood loss and requirement for blood transfusion thanwomen in whom the abnormal placentation was diag-nosed during cesarean section [28, 29].Any patient with a previous history of intrauterine sur-gery or Asherman syndrome should be thoroughly exam-ined by a skilled sonographer for possible abnormalplacentation. In case of any suspicion of abnormal placen-tation, the patient should be scheduled for planned cesar-ean section with a set-up of skilled clinicians due to riskof severe postpartum hemorrhage.In conclusion, it is important to be aware of the risk ofa placenta accreta in patients with a previous history ofAsherman syndrome and uterine scarring. AntenatalFigure 3. Transabdominal ultrasound scan at 35 weeks of gestation.Anterior uterine wall is measuring 2 mm at the site of previouscesarean section.ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd. 177L. Engelbrechtsen et al. Adherent placenta due to Asherman syndromediagnosis is important to counsel the pregnant womanand to plan mode of delivery.Conflict of InterestNone declared.References1. Asherman, J. G. 1948. Amenorrhoea traumatica (atretica).J. Obstet. Gynaecol. Br. Emp. 55:23–30.2. March, C. M. 2011. Management of Asherman’s syndrome.Reprod. Biomed. Online 23:63–76.3. Dmowski, W. P., and R. B. Greenblatt. 1969. Asherman’ssyndrome and risk of placenta accreta. Obstet. Gynecol.34:288–299.4. Schenker, J. G., and E. J. Margalioth. 1982. Intrauterineadhesions: an updated appraisal. Fertil. Steril. 37:593–610.5. Westendorp, I. C., W. M. Ankum, B. W. Mol, and J. Vonk.1998. Prevalence of Asherman’s syndrome after secondaryremoval of placental remnants or a repeat curettage forincomplete abortion. Hum. Reprod. 13:3347–3350.6. Friedler, S., E. J. Margalioth, I. Kafka, and H. Yaffe. 1993.Incidence of post-abortion intra-uterine adhesionsevaluated by hysteroscopy–a prospective study. Hum.Reprod. 8:442–444.7. March, C. M. 1995. Intrauterine adhesions. Obstet.Gynecol. Clin. North Am. 22:491–505.8. March, C. M. 2011. Asherman’s syndrome. Semin. Reprod.Med. 29:83–94.9. Bauer, S. T., and C. Bonanno. 2009. Abnormalplacentation. Semin. Perinatol. 33:88–96.10. Eshkoli, T., A. Y. Weintraub, R. Sergienko, and E. Sheiner.2013. Placenta accreta: risk factors, perinatal outcomes,and consequences for subsequent births. Am. J. Obstet.Gynecol. 208:219.e1-7.11. Tantbirojn, P., C. P. Crum, and M. M. Parast. 2008.Pathophysiology of placenta accreta: the role of deciduaand extravillous trophoblast. Placenta 29:639–645.12. Roy, K. K., J. Baruah, J. B. Sharma, S. Kumar, G.Kachawa, and N. Singh. 2010. Reproductive outcomefollowing hysteroscopic adhesiolysis in patients withinfertility due to Asherman’s syndrome. Arch. Gynecol.Obstet. 281:355–361.13. Strickland, S., and W. G. Richards. 1992. Invasion of thetrophoblasts. Cell 71:355–357.14. Belfort, M. A. 2010. Placenta accreta. Am. J. Obstet.Gynecol. 203:430–439.15. Hull, A. D., and R. Resnik. 2010. Placenta accreta andpostpartum hemorrhage. Clin. Obstet. Gynecol. 53:228–236.16. Silver, R. M., M. B. Landon, D. J. Rouse, K. J. Leveno, C.Y. Spong, E. A. Thom, et al. 2006. Maternal morbidityassociated with multiple repeat cesarean deliveries. Obstet.Gynecol. 107:1226–1232.17. Esh-Broder, E., I. Ariel, N. Bashir, Y. Bdolah, and D. H.Celnikier. 2011. Placenta accreta is associated with IVFpregnancies: a retrospective chart review. BJOG 118:1084–1089.18. Protopapas, A., A. Shushan, and A. Magos. 1998.Myometrial scoring: a new technique for themanagement of severe Asherman’s syndrome. Fertil.Steril. 69:860–864.19. The American Fertility Society. 1988. The AmericanFertility Society classifications of adnexal adhesions, distaltubal occlusion, tubal occlusion secondary to tuballigation, tubal pregnancies, mullerian anomalies andintrauterine adhesions. Fertil. Steril. 49:944–955.20. Kjer, J. J. 2014. Asherman syndrome in a Danishpopulation. Acta Obstet. Gynecol. Scand. 93:425–427.21. Johary, J., M. Xue, X. Zhu, D. Xu, and P. P. Velu. 2014.Efficacy of estrogen therapy in patients with intrauterineadhesions: systematic review. J. Minim. Invasive Gynecol.21:44–54.22. D’Antonio, F., C. Iacovella, and A. Bhide. 2013. Prenatalidentification of invasive placentation using ultrasound:systematic review and meta-analysis. Ultrasound Obstet.Gynecol. 42:509–517.23. Warshak, C. R., R. Eskander, A. D. Hull, A. L. Scioscia, R.F. Mattrey, K. Benirschke, et al. 2006. Accuracy ofultrasonography and magnetic resonance imaging in thediagnosis of placenta accreta. Obstet. Gynecol. 108(3 Pt1):573–581.24. Comstock, C. H., J. J. Love Jr, R. A. Bronsteen, W. Lee, I. M.Vettraino, R. R. Huang, et al. 2004. Sonographic detectionof placenta accreta in the second and third trimesters ofpregnancy. Am. J. Obstet. Gynecol. 190:1135–1140.25. Gielchinsky, Y., D. Mankuta, N. Rojansky, N. Laufer, I.Gielchinsky, and Y. Ezra. 2004. Perinatal outcome ofpregnancies complicated by placenta accreta. Obstet.Gynecol. 104:527–530.26. Levine, D., C. A. Hulka, J. Ludmir, W. Li, and R. R.Edelman. 1997. Placenta accreta: evaluation with colorDoppler US, power Doppler US, and MR imaging.Radiology 205:773–776.27. McLean, L. A., M. E. Heilbrun, A. G. Eller, A. M.Kennedy, and P. J. Woodward. 2011. Assessing the role ofmagnetic resonance imaging in the management of gravidpatients at risk for placenta accreta. Acad. Radiol. 18:1175–1180.28. Warshak, C. R., G. A. Ramos, R. Eskander, K. Benirschke,C. C. Saenz, T. F. Kelly, et al. 2010. Effect of predeliverydiagnosis in 99 consecutive cases of placenta accreta.Obstet. Gynecol. 115:65–69.29. Tikkanen, M., J. Paavonen, M. Loukovaara, and V.Stefanovic. 2011. Antenatal diagnosis of placenta accretaleads to reduced blood loss. Acta Obstet. Gynecol. Scand.90:1140–6.178 ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.Adherent placenta due to Asherman syndrome L. Engelbrechtsen et al.

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