Placenta percreta--two cases and review of the literature

Antepartum unscarred uterine rupture caused by placenta percreta: a case report and literature review

The main risk for uterine rupture is the presence of a uterine scar due to prior cesarean delivery or other uterine surgery. However, rupture in an unscarred uterus is extremely rare, and risk factors include multiple gestations, trauma, congenital anomalies, use of uterotonics and placenta accreta spectrum.

Placenta accreta spectrum, also known as morbidly adherent placenta, is becoming increasingly common and is associated with significant maternal and neonatal morbidity and mortality.

We report a case of unscarred uterine rupture due to placenta percreta in a multiparous woman that required emergency peripartum hysterectomy.

Postpartum unscarred uterine rupture caused by placenta accreta: A case report and literature review

Our case and the literature review suggest that placenta accreta spectrum, with use of uterotonics and manual removal of placenta, could be risk factors for postpartum unscarred uterine rupture.

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.

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.

Conservative Management of Invasive Placenta Using Combined Prophylactic Internal Iliac Artery Balloon Occlusion and Immediate Postoperative Uterine Artery Embolization

Purpose

The objective of the study was to evaluate the efficacy and safety of combined prophylactic intraoperative internal iliac artery balloon occlusion and postoperative uterine artery embolization in the conservative management (uterine preservation) of women with invasive placenta undergoing scheduled caesarean delivery.

Methods

Ten women (mean age 35 years) with invasive placenta choosing caesarean delivery without hysterectomy had preoperative insertion of internal iliac artery occlusion balloons, intraoperative inflation of the balloons, and immediate postoperative uterine artery embolization with absorbable gelatin sponge. A retrospective review was performed with institutional review board approval. Outcome measures were intraoperative blood loss, transfusion requirement, hysterectomy rate, endovascular complications, surgical complications, and postoperative morbidity.

Results

All women had placenta increta or percreta, and concomitant complete placenta previa. Mean gestational age at delivery was 36 weeks. In 6 women the placenta was left undisturbed in the uterus, 2 had partial removal of the placenta, and 2 had piecemeal removal of the whole placenta. Mean estimated blood loss during caesarean delivery was 1.2 L. Only 2 patients (20%) required blood transfusion. There were no intraoperative surgical complications, endovascular complications, maternal deaths, or perinatal deaths. Three women developed postpartum complications necessitating postpartum hysterectomy; the hysterectomy rate was therefore 30% and uterine preservation was successful in 70%.

Conclusion

Combined bilateral internal iliac artery balloon occlusion and uterine artery embolization may be an effective strategy to control intraoperative blood loss and preserve the uterus in patients with invasive placenta undergoing caesarean delivery.

How our practice of histopathology, especially tumour pathology has changed in the last two decades: reflections from a major referral center in Pakistan

Continued advances in the field of histo-pathology (and cyto-pathology) over the past two decades have resulted in dramatic changes in the manner in which these disciplines are now practiced. This is especially true in the setting of a large university hospital where the role of pathologists as clinicians (diagnosticians), undergraduate and postgraduate educators, and researchers has evolved considerably. The world around us has changed significantly during this period bringing about a considerable change in our lifestyles and the way we live. This is the world of the internet and the world-wide web, the world of Google and Wikipedia, of Youtube and Facebook where anyone can obtain any information one desires at the push of a button. The practice of histo (and cyto) pathology has also evolved in line with these changes. For those practicing this discipline in a poor, developing country these changes have been breathtaking. This is an attempt to document these changes as experienced by histo (and cyto) pathologists practicing in the biggest center for Histopathology in Pakistan, a developing country in South Asia with a large (180 million) and ever growing population. The Section of Histopathology, Department of Pathology and Microbiology at the Aga Khan University Hospital (AKUH) in Karachi, Pakistan's largest city has since its inception in the mid-1980s transformed the way histopathology is practiced in Pakistan by incorporating modern methods and rescuing histopathology in Pakistan from the primitive and outdated groove in which it was stuck for decades. It set histopathology in Pakistan firmly on the path of modernity and change which are essential for better patient management and care through accurate and complete diagnosis and more recently prognostic and predictive information as well.

First trimester spontaneous uterine rupture in a young woman with uterine anomaly

Spontaneous uterine rupture is a life-threatening obstetrical emergency carrying a high risk for the mother and the fetus. Spontaneous uterine rupture in early pregnancy is very rare complication and it occurs usually in scarred uterus. Uterine anomalies are one of the reasons for spontaneous unscarred uterine rupture in early pregnancy. Obstetricians must consider this diagnosis when a pregnant patient presented with acute abdomen in early pregnancy. We present a case of spontaneous uterine rupture at 12 weeks of gestation in 24-year-old multigravida who had uterine anomaly presenting as an acute abdomen. Our preoperative diagnosis was ectopic pregnancy. Emergency laparotomy confirmed a spontaneous uterine rupture. Uterine anomaly is a risk factor for spontaneous uterine rupture in the early pregnancy. Clinical signs of uterine rupture in early pregnancy are nonspecific and must be distinguished from acute abdominal emergencies.

Placenta Accreta and Percreta

The incidence of abnormally adherent placenta (accreta/percreta) has increased 10-fold in the past 50 years, predominantly due to the increased use of cesarean section delivery. The causes, clinical correlates, and pathology of these conditions are discussed in this article.

Placenta Accreta Causing Uterine Rupture in Second Trimester of Pregnancy after in vitro Fertilization: A Case Report

BACKGROUND

Placenta accreta is a rare obstetrical condition that mainly occurs in the third trimester leading to life-threatening complications. Hereby, a case of uterine rupture due to placenta accreta occuring in the second trimester is presented.

CASE PRESENTATION

A forty-year old patient who conceived after in vitro fertilization treatment (oocyte donation and embryo transfer) presented in emergency department in the nineteen weeks of gestation with acute abdominal pain, heamoperitoneum and fetal death. Emergency laprotomy showed uterine rupture along with placenta accreta for which the patient underwent subtotal hysterectomy.

CONCLUSION

Although, an uncommon occurrence, physicians in assisted reproductive techniques (ART) clinics should consider placenta accreta in gravid patients who present with acute abdominal pain and shock, considering the fact that they usually have associated high risk factors for abnormal placentation.

Urologic emergencies in pregnancy

The management of urological emergencies during pregnancy presents unique clinical challenges for the treating physician. Clinical signs and symptoms are often subtle while diagnostic and therapeutic options are limited in treating patients to avoid fetal morbidity. A high index of suspicion with early diagnosis and treatment are essential for the management of genitourologic emergencies in pregnant women. It is essential for patients to be managed on an individual basis using a multidisciplinary approach.

Placenta percreta: urologic complication after successful conservative management by uterine arterial embolization: a case report

We report a case of placenta accreta that was managed conservatively by uterine arterial embolization and subsequently was complicated by hematuria. Ultrasound revealed a calcified mass at the posterior bladder wall. A careful resection under cystoscopy was carried out without hemorrhagic complication. Pathologic examination showed placental tissue that confirmed placenta percreta.

Difficulty of the surgical management of a case with placenta percreta invading towards parametrium

A 37-year-old woman was admitted due to vaginal bleeding at 25 weeks of gestation to our gynecology unit. Placenta percreta, which stems from posterior wall of the uterus, forming a mass in Douglas cavity and invading towards right parametrium was clinically diagnosed by exploration. Bilateral internal iliac artery ligation and supracervical hysterectomy could not prevent bleeding. A right radical parametrectomy was necessary to remove invaded parametrium and to control bleeding. The placenta percreta invading parametrium may need an extended hysterectomy procedure. Excess bleeding may be prevented by leaving the placenta in situ during surgery if the placenta percreta is diagnosed before termination of pregnancy, A classical incision may help leaving placenta is situ during operation.

Conservative Management of Abnormally Invasive Placentation

Due to the growing number of cesarean deliveries, the frequency of abnormally invasive placentation is increasing. The optimal management of this condition remains unclear. This article reviews the efficacy and safety of conservative management of abnormally invasive placentation. We performed a MEDLINE and Embase search and reviewed all articles on conservative management of abnormally invasive placentation published from 1985 through 2006. Over the past 20 years, 48 reports have described outcomes of 60 women who were treated conservatively for abnormally invasive placentation. Twenty-six women were managed without any additional interventions. In most of these patients (19/26), the placenta had been partially removed. In 4 of these 26, conservative therapy failed. Twenty-two women received adjuvant methotrexate. In most of these women (19/22), the entire placenta was left in situ. In 5, therapy failed. Twelve women were managed with arterial embolization. In most of these (9/12), the diagnosis was made antepartum and the placenta was completely left in situ. In 3, therapy failed. Overall, 11 women experienced infection (11/60), 21 women experienced vaginal bleeding (21/60), and 4 suffered disseminated intravascular coagulopathy (4/60). Spontaneous loss of placental tissue was noted in 16 women. Subsequent pregnancies were reported in 8 women. Conservative management of abnormally invasive placentation can be effective and fertility can be preserved. It should only be considered in highly selected cases when blood loss is minimal and there is desire for fertility preservation. Whether adjuvant methotrexate or selective arterial embolization is beneficial is uncertain. Undetectable hCG values do not seem to guarantee complete resorption of retained placental tissue.

Lessons Learnt from Two Women with Morbidly Adherent Placentas and a Review of Literature

Introduction: Pathologically adherent placentas occur when there is a defect of the decidua basalis, typically arising from previous caesarean section, resulting in abnormally invasive implantation of the placenta. The depth of placental invasion varies from the superficial (accreta), to transmural and possibly beyond (percreta). Clinical Picture: We report on 2 cases, one treated “conservatively”, the other with a caesarean hysterectomy, both of which led to a safe outcome for both mother and baby. Conclusions: Management relies on accurate early diagnosis with appropriate perioperative multidisciplinary planning to anticipate and avoid massive obstetric haemorrhage at delivery. Key words: Management, Obstetric haemorrhage, Placenta accreta, Placenta percreta, Placenta increta

Placental retention in a golden lion tamarin (Leontopithecus rosalia)

A 4-yr-old female golden lion tamarin (Leontopithecus rosalia) had placental retention after delivery of a stillborn fetus. Conservative therapy with oxytocin and dinoprost tromethamine did not result in placental expulsion and ovariohysterectomy was performed. Placental retention is a rare condition in humans and has not been well documented in non-human primates.

Conservative management of second-trimester cervical ectopic pregnancy with placenta percreta

OBJECTIVE

To report successful conservative management of advanced cervical ectopic pregnancy with placenta percreta.

DESIGN

Case report.

SETTING

University tertiary care hospital.

PATIENT(S)

A 37-year-old woman with second-trimester cervical ectopic pregnancy and placenta percreta.

INTERVENTION(S)

Ultrasound-guided injection of potassium chloride into the fetal heart followed by multiple systemic methotrexate injections, removal of fetal bones, cervical cerclage suture, and Foley catheter placement for control of hemorrhage.

MAIN OUTCOME MEASURE(S)

Low maternal morbidity and successful conservative management with preservation of fertility.

RESULT(S)

The cervical ectopic pregnancy was treated successfully without significant morbidity; the uterus was preserved, and the woman was delivered of a full-term live fetus in the next pregnancy.

CONCLUSION(S)

Advanced cervical ectopic pregnancy with placenta percreta is associated with high morbidity with surgical intervention. Conservative management with attendant low morbidity and uterus preservation is possible in advanced cervical ectopic pregnancy.

Placenta percreta causing rupture of an unscarred uterus at the end of the first trimester of pregnancy: Case report

Reports on placenta percreta in early pregnancy leading to a spontaneous rupture of the uterus are rare. We report a case of this potentially life-threatening complication in the 14th week of pregnancy in an otherwise healthy woman who underwent a manual extraction of the placenta during a previous delivery but who had no history of severe pathology that could have potentially resulted in uterine damage. The occurrence of severe abdominal pain and the presence of a large quantity of free fluid in the abdomen necessitated an emergency laparotomy, revealing a haemoperitoneum due to rupture of the uterus, which was followed by a hysterectomy. This case demonstrates that in patients with a history of placenta accreta and subsequent manual extraction of the placenta, a close investigation of the uterine wall and placentation should be performed in the first trimester in order to anticipate a placenta percreta.

Spontaneous uterine rupture as an unusual cause of abdominal pain in the early second trimester of pregnancy

A case of placenta percreta causing spontaneous uterine rupture is presented. This is a rare condition, which may present in the antepartum period as abdominal pain, with or without signs of hemorrhagic shock. This entity can lead to significant morbidity and mortality if not aggressively managed. A discussion follows on the pathophysiology, incidence, risk factors, presentation and management of this condition.