Spontaneous uterine rupture at the 21st week of gestation caused by placenta percreta

Uterine rupture with massive hemoperitoneum due to placenta percreta in a second trimester: A case report

Introduction

Uterine rupture due to placenta percreta is very rare. It often occurs in patients with a history of Cesarean section.

Quick diagnosis, management and intervention improves survival rate and decreases maternal and foetal morbidity.

Observation

Patient, 36 years old, mother of three children delivered by cesarean section, admitted for acute abdominal pain in the context of a poorly monitored pregnancy estimated at 25 weeks of amenorrhea.

Pelvic ultrasound showed a large peritoneal effusion with the presence of an evolving intrauterine pregnancy with cardiac activity present, the placenta was with anterior coverage.

An emergency laparotomy revealed uterine rupture with active hemorrhage localized on the anterior uterine scar with placental protrusion was noted. A cesarean section was quickly performed to save the fetus. The placenta was left in place and a difficult hysterectomy was then undertaken.

Discussion

Uterine rupture in second trimester caused by placental percreta is a rare event that can be life threatening for both mother and fetus.

Placenta percreta should be considered when diagnosing internal bleeding in a patient during the first trimester of pregnancy.

Conclusion

Placenta percreta is a rare but severe obstetric complication that is potentially life threatening for both the mother and fetus.

It is important to maintain a high level of clinical suspicion for this disease in pregnant women with acute abdomen, especially those with specific risk factors.

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Uterine rupture in second trimester caused by placental percreta is a rare event that can be life threatening for both mother and fetus.

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The clinical presentation of this complication ranges from mild abdominal pain to hemorrhagic shock.

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Quick diagnosis, management and intervention improves survival rate and decreases maternal and foetal morbidity.

Uterine body placenta accreta spectrum: A detailed literature review

Placenta accreta spectrum (PAS) is a major obstetrical problem whose incidence is rising. Current guidelines recommend screening of all women with placenta previa and risk factors for PAS between 20 and 24 weeks. Risk factors, diagnosis, and management of previa PAS are well established, but an apparently normal location of the placenta does not exclude PAS. Literature data are scarce on uterine body PAS, which carries a high risk of maternal and neonatal adverse outcome, but is still easily missed on prenatal ultrasound. We conducted a comprehensive review to identify possible risk factors, clinical presentations, and diagnostic modalities of uterine PAS. A total of 133 cases were found during a 70-year period (1949-2019). The vast majority of them presented with signs of uterine rupture, even prior to the viability threshold of 24 weeks (up to 45%). Major risk factors included previous cesarean delivery, uterine curettage, uterine surgery, Asherman's syndrome, manual removal of the placenta, endometritis, high parity, young maternal age, in vitro fertilization, radiotherapy, uterine artery embolization, and uterine leiomyoma. Diagnosis was pre-symptomatic in only 3% of cases. Future studies should differentiate between previa PAS and uterine body PAS.

A Literature Review of Placenta Accreta Spectrum Disorder: The Place of Expectant Management in Ethiopian Setup

In the last three to four decades, the increasing caesarean delivery rate has contributed to several fold increment in the incidence of placenta accreta spectrum disorders globally. Placenta accreta spectrum with its subtypes (accreta, increta and percreta) is one of the devastating obstetric complications. As a result, it is the commonest indication for peripartum hysterectomy and common cause of severe maternal morbidity. However, in recent years, there is a growing interest in and practice of expectant management either to minimize emergency hysterectomy related maternal complications or to preserve the fertility potential of a woman with an intact uterus. A large body of observational research findings has demonstrated the success rate of expectant management in many of well selected cases. Similarly, the experience on delayed hysterectomy was encouraging in order to have less hemorrhage. For the best success of placenta accreta spectrum management, multidisciplinary team approach, antenatal diagnosis and managing such cases in a hospital with center of excellence has been strongly recommended. This literature review provides a robust synthesis of up-to-date knowledge and practice on the challenges and successes of placenta accreta spectrum disorders management. The currently practiced management options in the high and middle income countries are also summarized under seven categories. Therefore, the purpose of this review was to shed light on the applicability of the PAS disorder management modalities in our setup.

Laparoscopic hysterectomy to manage uterine rupture due to placenta percreta in the first trimester: A case report

Placenta percreta causing uterine rupture is a rare complication of pregnancy. It is most commonly diagnosed after the second trimester and can lead to significant morbidity necessitating abdominal hysterectomy of a gravid or immediately postpartum uterus. We describe a patient who presented with abdominal pain at 13 weeks of gestation and was diagnosed with placenta percreta during laparoscopy for presumed appendicitis. Intraoperatively, placenta was seen perforating the uterine fundus and 1 l of hemoperitoneum was evacuated. However, the uterus was hemostatic and the patient was stable, so the procedure was terminated. The patient was then transferred to a tertiary care center, where she ultimately underwent an uncomplicated laparoscopic gravid hysterectomy. We conclude that placenta percreta can occur in the first trimester even in patients without traditional risk factors. In stable patients, it is appropriate to consider minimally invasive hysterectomy with utilization of specific techniques to minimize intraoperative blood loss.

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Uterine rupture due to placenta percreta can present in the first trimester.

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Minimally invasive laparoscopic hysterectomy can provide definitive treatment with decreased surgical morbidity and shorter convalescence.

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Blood loss and allogenic transfusion can be minimized with appropriate hemostatic techniques and surgical planning.

Maternal and fetal death at 22 weeks following uterine rupture at the site of the placenta percreta in a C-section scar

Placenta percreta is the abnormal invasion of the placenta through the myometrium and serosa of the uterus. It is the most invasive of the placenta accreta spectrum followed by placenta increta. This paper presents a case of a maternal and fetal death in the second trimester due to rupture of the uterus at the site of placenta percreta in a C-section scar. Postmortem MRI showed a large hemoperitoneum and thinning of the anterolateral uterine wall. Internal examination revealed two liters of blood in the abdomen and rupture of the anterolateral uterine wall at the site of placenta percreta in a previous C-section scar. Placenta percreta is a rare complication of pregnancy, however, it is becoming more common with the increasing rate of C-section, the most common and significant risk factor.

Hysterectomy with Fetus In Situ for Uterine Rupture at 21-Week Gestation due to a Morbidly Adherent Placenta

Background

Uterine rupture due to a morbidly adherent placenta is a rare obstetrical cause of acute abdominal pain in the pregnant patient. We present a case to add to the small body of published literature describing this diagnosis.

Case

A 32-year-old G5T2P1A1L2 with multiple prior cesarean sections presented at 21⁺³ weeks' gestation with abdominal pain and presyncope. Ultrasound showed a large volume of complex intraabdominal free fluid and a heterogenous placenta with irregular lacunae and increased vascularity extending to the posterior bladder wall. Exploratory laparotomy identified a uterine defect and a hysterectomy was performed due to significant bleeding. Pathology confirmed a diagnosis of placenta percreta.

Conclusion

Early recognition and management of uterine rupture due to a morbidly adherent placenta are essential to prevent catastrophic hemorrhage.

Intrauterine Growth Restriction. Guideline of the German Society of Gynecology and Obstetrics (S2k-Level, AWMF Registry No. 015/080, October 2016)

AIMS

The aim of this official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG) was to provide consensus-based recommendations obtained by evaluating the relevant literature for the diagnostic treatment and management of women with fetal growth restriction.

METHODS

This S2k guideline represents the structured consensus of a representative panel of experts with a range of different professional backgrounds commissioned by the Guideline Committee of the DGGG.

RECOMMENDATIONS

Recommendations for diagnostic treatment, management, counselling, prophylaxis and screening are presented.

Placenta percreta with concomitant uterine didelphys at 18 weeks of pregnancy: a case report and review of the literature

AIM

The aim of this paper is to draw the attention of the clinicians on placenta percreta detected along with uterine anomalies in early second trimester.

CASE PRESENTATION

A 35-year-old, gravida 2 parity 1 woman at 18 weeks of pregnancy was admitted to our emergency unit with abdominal pain. In ultrasound exam, a live fetus compatible with 18 weeks of gestation, hemoperitoneum and a solid mass adjacent to the uterus were detected. An emergent laparotomy was decided because of hemorrhagic shock findings. In the operation, uterine didelphys and an active bleeding area from placenta percreta on the anterior wall of the uterus where pregnancy was settled were detected. In the simultaneous vaginal examination two cervixes and a longitudinal vaginal septum were seen. Supracervical hemihysterectomy was performed.

CONCLUSION

Placenta percreta is a rare clinical entity with an elevated perinatal mortality. Uterine anomalies are risk factors for placental adhesion anomalies. Clinical suspicion is vital for early diagnosis and timely management.

Asymptomatic expulsion of a fetus through cesarean section scar in the presence of invasive placenta previa

Spontaneous rupture of the uterus during the 2nd and 3rd trimester resulting from invasive placentation is a rare complication of pregnancy. We report a case of a 39-year-old G6P4, with four previous cesarean sections, who presented at mid-gestation with brown vaginal discharge. Invasive placenta previa was detected upon conducting abdominal ultrasound. The fetal head was seen trapped within the uterine scar, while the fetal body was visualized within the maternal abdominal cavity with intact membranes. In cases with invasive placentation, early attention to uterine rupture may reduce maternal morbidity.

Spontaneous uterine rupture at 15 weeks' gestation in a patient with a history of cesarean delivery after removal of shirodkar cerclage

A pregnant woman presented with acute upper abdominal pain and nausea at 15 weeks' gestation. She had a history of cesarean delivery for abruption after the removal of a Shirodkar cerclage that was placed because of cervical shortening caused by conization. She became pregnant again 14 months later. Ultrasonography revealed no significant findings, and a single intrauterine pregnancy with positive fetal heart activity was confirmed. An intestinal obstruction was suspected because abdominal radiography showed multiple air-fluid levels in the colon. Over the 3 hours following admission, her symptoms gradually worsened, and plain abdominal computed tomography (CT) showed a large hemorrhage in the abdominal cavity, but the uterine wall appeared intact at this time. Subsequently, dynamic CT revealed discontinuity of the uterine muscle layer. During laparotomy, uterine rupture with complete opening of the uterine wall at the site of the previous transverse scar was identified. A dead fetus was located within the amniotic sac in a blood-filled abdominal cavity. She received a total of 10 units of packed red blood cells and 6 units of fresh frozen plasma for the resuscitation. She was discharged on the eighth postoperative day without any complications.

Placenta accreta: pathogenesis of a 20th century iatrogenic uterine disease

Placenta accreta refers to different grades of abnormal placental attachment to the uterine wall, which are characterised by invasion of trophoblast into the myometrium. Placenta accreta has only been described and studied by pathologists for less than a century. The fact that the first detailed description of a placenta accreta happened within a couple of decades of major changes in the caesarean surgical techniques is highly suggestive of a direct relationship between prior uterine surgery and abnormal placenta adherence. Several concepts have been proposed to explain the abnormal placentation in placenta accreta including a primary defect of the trophoblast function, a secondary basalis defect due to a failure of normal decidualization and more recently an abnormal vascularisation and tissue oxygenation of the scar area. The vast majority of placenta accreta are found in women presenting with a previous history of caesarean section and a placenta praevia. Recent epidemiological studies have also found that the strongest risk factor for placenta praevia is a prior caesarean section suggesting that a failure of decidualization in the area of a previous uterine scar can have an impact on both implantation and placentation. Ultrasound studies of uterine caesarean section scar have shown that large and deep myometrial defects are often associated with absence of re-epithelialisation of the scar area. These findings support the concept of a primary deciduo-myometrium defect in placenta accreta, exposing the myometrium and its vasculature below the junctional zone to the migrating trophoblast. The loss of this normal plane of cleavage and the excessive vascular remodelling of the radial and arcuate arteries can explain the in-vivo findings and the clinical consequence of placenta accreta. Overall these data support the concept that abnormal decidualization and trophoblastic changes of the placental bed in placenta accreta are secondary to the uterine scar and thus entirely iatrogenic.