Placenta percreta: report of two cases and review of the literature

Placenta percreta is a serious complication of pregnancy. Two cases of placenta percreta confirmed histologically were treated by supravaginal hysterectomy. Case 1: A case of uterine rupture secondary to placenta percreta was diagnosed in a 29-year-old term primigravida during an elective abdominal delivery of a healthy fetus. Spontaneous rupture of the primigravid uterus due to placenta percreta without a history of trauma or infection is a very rare occurrence. Case 2: A 33-year-old previously healthy G4P2 woman was admitted at 29 weeks of gestation with acute abdominal pain and hemorrhagic shock. There was a history of one induced abortion and two cesarean section deliveries. A review of risk factors, diagnostic tools and treatment possibilities are given.

First-trimester uterine rupture from a placenta percreta. A case report

BACKGROUND

Cesarean scar pregnancy complicated by placenta percreta and uterine rupture is an uncommon gynecologic emergency.

CASE

A woman presenting with abdominal pain and shock was found to have a cesarean scar pregnancy complicated by placenta percreta and uterine rupture.

CONCLUSION

Implantation within a cesarean scar may cause placenta percreta, leading to uterine rupture in the first trimester and mimicking other gynecologic emergencies.

Treatment of obstetric hemorrhage with recombinant activated factor VII (rFVIIa)

Recombinant activated factor VII (rFVIIa, NovoSeven) was used in three patients with massive obstetric hemorrhage due to placenta previa accreta, rupture of the uterus and pre-eclampsia with HELLP. Administration of the drug markedly decreased the bleeding and enabled control of the hemorrhage. rFVIIa seems to be an adjunctive hemostatic measure for the treatment of severe obstetric hemorrhage.

[Acute puerperal uterine inversion: two cases]

Acute puerperal inversion is both rare and serious (1/20000 deliveries in France) and may lead to significant morbidity and mortality. Outcome depends on the degree of uterine bleeding and the presence or not of a state of shock. Acute puerperal inversion occurs at the time of placental delivery. Four stages are usually described by degree of exteriorization of the uterus. The diagnosis is essentially clinical. The predisposing factors are hypotonic uterus, fundal implantation of the placenta and placental acretas. 60% of all cases are caused by precipitous manoeuvres including traction on the cord or improper fundal pressure. Once a diagnosis is made immediate measures must be undertaken to assure clinical stability of the mother. Manuel reinversion of the uterus must be done quickly to avoid a cervical stricture that may form within thirty minutes of the inversion making successful manipulation very difficult. Failure or reoccurrence requires surgical treatment either by abdominal or vaginal approach. We report on two cases: one of complete inversion leading to a hysterectomy in order to control bleeding and a second case of incomplete inversion where repositioning was successful.

Placenta percreta with painless uterine rupture at the 2nd trimester

A pregnant lady at 27 weeks and 2 days gestation with a known placenta previa major and a history of previous lower segment cesarean section had a sudden severe painless vaginal bleeding. At laparotomy a uterine rupture was noted, no hemoperitoneum found and placenta percreta was diagnosed. This is the first case reported in the Kingdom of Saudi Arabia, it is rare, only 3 cases of silent or asymptomatic uterine rupture secondary to placenta percreta were reported in the literature in the last 30-years. Non-invasive methods could help in the diagnosis or increase suspicion of placenta percreta, therefore, proper management could be arranged through a multi-disciplinary team.

Urologic complications of placenta percreta invading the urinary bladder: a case report and review of the literature

INTRODUCTION

Placenta percreta invading the urinary bladder may cause hemorrhagic shock, hematuria and urologic complications at parturition. This retrospective survey of 54 patients reviews maternal characteristics, presentations, urologic complications, and management.

METHODS

The first reported case of placenta percreta with urinary bladder invasion in Hawaii is presented. Medline search and literature review identified an additional 53 patients. A meta-analysis of all 54 cases was performed.

RESULTS

Hematuria was present initially in 31% (17/54) patients. Of these, 9 of 17 required transfusion support. A preoperative diagnosis was established by ultrasound or MRI in 33% of patients. Cystoscopy was performed in 12 patients and did not make a preoperative diagnosis in any patient. 39 urologic complications included bladder laceration 26%, urinary fistula 13%, gross hematuria 9%, ureteral transection 6%, and small capacity bladder 4%. Partial cystectomy was performed in 44% (24/54). Three maternal deaths and 14 fetal deaths occurred. Only 1 patient subsequently had a delivery.

CONCLUSION

Readily identifiable risk factors by history are important to suggest placenta percreta in pregnant patients with gross hematuria. Ultrasound and/or MRI can establish a preoperative diagnosis. Cystoscopy did not identify any patient preoperatively. Partial cystectomy is commonly required for extensive or deep bladder invasion.

Arterial embolization for haemorrhage in the obstetric patient

Arterial embolization is a safe and effective treatment for persistent post-partum haemorrhage that is unresponsive to conservative management. Embolization should be the treatment of choice in these patients provided that suitable radiological skills and equipment are available. Embolization is potentially useful in patients with antepartum haemorrhage in the last trimester or in patients at high risk for antepartum haemorrhage.

Disseminated intravascular coagulation

Healthy pregnancy is accompanied by changes in the haemostatic system which convert it into a hypercoagulable state vulnerable to a spectrum of disorders ranging from venous thromboembolism to disseminated intravascular coagulation (DIC). This latter is always a secondary phenomenon triggered by specific disorders such as abruptio placentae and amniotic fluid embolism due to release of thromboplastin intravascularly or endothelial damage resulting from pre-eclampsia and sepsis. In modern obstetric practice the most common cause is haemorrhagic shock with delay in resuscitation leading to endothelial damage. The initial management of massive obstetric haemorrhage is the same whether associated with coagulopathy initially or not. Low-grade DIC, associated with pre-eclampsia, is monitored haematologically by serial platelet counts and serum fibrin degradation products (FDPs). Supportive measures and removal of the triggering mechanism are the key to successful management. Outcome depends primarily on our ability to deal with the trigger and not on direct attempts to correct the coagulation deficit.

Placenta accreta associated with a ruptured pregnant rudimentary uterine horn. Case report and review of the literature

Pregnancy in a rudimentary uterine horn is rare and is usually associated with fetal death and serious maternal morbidity and mortality. A case of pregnancy in a rudimentary uterine horn with rupture 14 weeks after last menstrual period and is complicated with placenta accreta is presented. The patient had signs and symptoms of massive hemoperitoneum. An emergency exploratory laparotomy revealed rupture of the gravid rudimentary horn of a bicornuate uterus. Histologic examination of the specimen showed that placenta was accreta. The relative literature is reviewed and the association of placenta accreta in such situations is pointed out.

Identification of mtDNA mutation in a pedigree with gestational diabetes, deafness, Wolff-Parkinson-White syndrome and placenta accreta

Mitochondrial DNA (mtDNA) defects are associated with a number of human disorders. Although many occur sporadically, maternal transmission is the hallmark of diseases due to mtDNA point mutations. The same mutation may manifest strikingly different phenotypes; for example, the A to G substitution at np 3243 was first reported in patients with mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (the MELAS syndrome), but is also found in patients with diabetes and deafness. Here we present a case of gestational diabetes, deafness, premature greying, placenta accreta and Wolff-Parkinson-White (WPW) syndrome associated with a mtDNA mutation. Although this is the first report of such an association, study of 27 other patients with WPW syndrome failed to confirm that this mtDNA mutation is a common cause of such pre-excitation disorders.

Transient myocardial ischemia may occur following subendometrial vasopressin infiltration

A case of transient myocardial ischemia following subendometrial vasopressin infiltration in intractable intra-operative postpartum bleeding due to placenta accreta is described. In our experience, the rate of this side effect is one in 14 patients (rate of 7.1%). We believe that the benefits of the treatment outweigh the risks, since the uterus was saved in all 14 patients. Nevertheless, this case emphasises that extreme precaution is needed with subendometrial vasopressin infiltration. It should be emphasised that the needle must not be within a blood vessel because intravascular injection of vasopressin solution can precipitate acute arterial hypertension, bradycardia and even death. We suggest that local vasopressin infiltration into the placental site is indicated in cases of intractable bleeding at cesarean section after other conventional obstetric and pharmacological maneuvers have failed.

Placenta accreta and methotrexate therapy: three case reports

Placenta accreta is a complication that is rising in incidence. The reported experience of methotrexate treatment in the conservative management of placenta accreta is scant. Three cases of placenta accreta managed with methotrexate are presented. Case 1: A woman had an antenatal diagnosis of placenta percreta. A successful manual placental removal occurred on post-cesarean day 16. Case 2: A woman had retention of a placenta accreta after a term vaginal delivery. Successful dilation and curettage were performed on postpartum day 37. Case 3: A woman had an antenatal diagnosis of placenta previa-percreta with bladder invasion. A simple hysterectomy was performed on post-cesarean day 46. Conservative management and methotrexate treatment resulted in uterine preservation in two of our three patients; however, this treatment did not prevent significant delayed hemorrhage. In view of the rapid resolution of vascular invasion of the bladder, methotrexate may have an important role in the management of placenta percreta with bladder invasion. The utility of methotrexate treatment with the conservative management of placenta accreta requires further evaluation.

[Placenta accreta with placenta previa after previous cesarean sections--a growing danger in modern obstetrics]

The increased rate of cesarean sections in recent decades has brought with it an increase in the frequency of placenta accreta. There are direct correlations between previous cesarean deliveries and also maternal age, with the risk of placenta accreta. There is also a direct correlation between placenta accreta and placenta previa. The risk of placenta accreta in women who have had placenta previa is 2% for those younger than 35 years and with no history of uterine surgery. The risk increases to 39% for those over 35 who have had 2 or more cesarean sections. We present 3 cases of placenta accreta admitted in 15 months, all of whom had a history of cesarean sections. The frequency of placenta accreta in our hospital is 1:1,579 deliveries, in line with the 1:1,420 in the literature. We consider hysterectomy the treatment of choice for this serious complication. When performing a cesarean in cases of placenta previa with a history of cesarean sections, the possibility of placenta accreta should be considered.

Uterine inversion: a life-threatening obstetric emergency

BACKGROUND

Acute puerperal uterine inversion is a rare but potentially life-threatening complication in which the uterine fundus collapses within the endometrial cavity. Although the cause of uterine inversion is unclear, several predisposing factors have been described. Maternal mortality is extremely high unless the condition is recognized and corrected.

METHODS

MEDLINE was searched from 1966 to the present using the key phrase "uterine inversion." Nonpuerperal uterine inversion case reports were excluded from review except when providing information on classification and diagnostic techniques. A summarized case involving uterine inversion and a review of the classification, etiology, diagnosis, and management are reported.

RESULTS AND CONCLUSIONS

Although uncommon, if left unrecognized, uterine inversion will result in severe hemorrhage and shock, leading to maternal death. Manual manipulation should be attempted immediately to reverse the inversion. Tocolytics, such as magnesium sulfate and terbutaline, or halogenated anesthetics may be administered to relax the uterus to aid in reversal. Intravenous nitroglycerin provides an alternative to the tocolytics and offers several pharmacodynamic advantages. Treatment with hydrostatic pressure may be attempted while waiting for medications to be administered or for general anesthesia to be induced. In the most resistant of inversions, surgical correction might be required.

Prenatal diagnosis of placenta previa accreta by transabdominal color Doppler ultrasound

OBJECTIVE

The aim of this study was to evaluate the efficacy of transabdominal color Doppler ultrasound in diagnosing placenta previa accreta.

DESIGN

Eighty patients with persistent placenta previa underwent transabdominal B-mode and color Doppler ultrasound evaluation in the second and third trimesters because they had a high risk of placenta accreta. Color Doppler imaging criteria used included diffuse intraparenchymal placental lacunar flow; focal intraparenchymal placental lacunar flow; bladder-uterine serosa interphase hypervascularity; prominent subplacental venous complex; and loss of subplacental Doppler vascular signals. The color Doppler images were interpreted prospectively for signs of placenta previa accreta according to the exhibited color Doppler sonographic features.

RESULTS

Sixteen of the 80 patients exhibited characteristic color Doppler imaging patterns highly specific for placenta accreta according to the preceding criteria, and 14 of these had histopathological proof of placenta accreta. Two patients had false-positive color Doppler imaging evidence mistaken for interphase hypervascularity caused by bladder varices. Thirteen patients underwent hysterectomy in the group suspicious for accreta. Of the 64 patients with negative color Doppler imaging results, three had placenta accreta, while two required cesarean hysterectomy; the remaining patient underwent uterine artery ligation for bleeding from the lower uterine segment. The sensitivity of color Doppler imaging in the diagnosis of placenta previa accreta was 82.4% (14/17) and the specificity was 96.8% (61/63). The positive and negative predictive values were 87.5% (14/16) and 95.3% (61/64), respectively.

CONCLUSIONS

Variable vascular morphological patterns of placenta previa accreta were exhibited and categorized by transabdominal color Doppler sonography in the antenatal period. The identification of these specific vascular patterns had a positive impact on the peripartum clinical management of the affected patients.