Use of methotrexate (mxt) in medical management of invasive placenta remains a matter of speculation as a large randomized study is still awaited, although case reports from various parts of the world show some promising results [1]. To the authors’ knowledge, there are no reports evaluating the outcome of using mxt for residual adherent placenta in the presence of urinary tract injury. As we know, bladder injury is not very uncommon in women undergoing C-section for adherent placenta with previous C-section birth. We happened to be in such a clinical situation where the use of mxt seemed prudent, but the poor outcome of the concurrent bladder injury made us rethink the clinical scenario.
A full-term pregnant woman, with a previous C-section birth with placenta previa, had a repeat C-section at a peripheral hospital and was intraoperatively found to have bladder dome injury as attempts were made to remove the abnormally adherent placenta. The bladder looked otherwise healthy with no placental invasion. It was repaired in double layers and she was referred to a higher center. In the initial evaluation with us, she was stable with no active bleeding. USG showed a 4.2 9 6.9 cm-sized mass in the uterine cavity. We decided to treat her with mxt and folic acid on alternate days with prophylactic antibiotics [2]. At the end of the course, a repeat scan showed a reduction in the size of the placental mass to 3.2 9 3.9 cm. She developed a high grade fever with uterine tenderness on the 16th postoperative day, suggestive of endometritis, and was hence treated with second line antibiotics.
At the end of 21 days of continuous bladder drainage (CBD), a Cystogram showed a large dome defect. The urologist opined to retain the CBD for four more weeks. Repeated cystograms at regular intervals showed a continued leak from the bladder dome. After 4 months, when the CBD was removed, she complained of incontinence of urine and was diagnosed to have vesicouterine fistula.
We know that bladder dome injuries are particularly forgiving and heal with no consequences if cared for [3]. But, in this instance, the continued bladder catheterization after repair failed to heal the rent and ultimately resulted in a fistula. In the absence of any other reason to suggest otherwise, we propose that mxt interferes with the healing of bladder injury either directly or through increased infection or both factors in combination. Therefore, mxt should be considered contraindicated for medical management of residual adherent placenta in the presence of bladder injury awaiting further research.
Conflict of interest: The authors have no conflict of interest.
