Placenta percreta causing spontaneous uterine rupture in late pregnancy: Conservative surgical management

Placenta percreta as a cause of uterine rupture in the second trimester: Case report

Introduction

Placenta accreta spectrum is a very life-threatening obstetrical condition whose rate increased significantly the past years due to the increase of caesarean deliveries. In some rare cases, it can cause uterine rupture which needs to be diagnosed and managed quickly to avoid catastrophic outcomes.

Case report

We present a case of a 33-year-old patient who was admitted to the emergency room for signs of shock at 29 weeks of a poorly supervised pregnancy, secondary to a spontaneous uterine rupture on a previously scarred uterus by a caesarean delivery two years prior to the events. She presented with massive haemoperitoneum with no vaginal bleeding. Foetus was in bradycardia. Quick total hysterectomy allowed favorable maternal and foetal outcome.

Discussion

Placenta accreta spectrum (PAS) occurs when the placenta becomes abnormally adherent to the myometrium and serosa rather than the uterine decidua. Its most important complication is hemorrhage after delivery of the placenta. In rare cases it can lead to spontaneous uterine rupture at any trimester, as it was the case of our patient. Antepartum diagnosis by ultrasound examination is recommended to avoid complications and improve management. It should be carefully done in high-risk patients of PAS. PAS is associated with high maternal and foetal morbidity and mortality. Definitive diagnosis is obtained after pathology examination of the specimen.

Conclusion

Uterine rupture should be considered a differential diagnosis for abdominal pain in any trimester, in case of shock even in the absence of vaginal bleeding, especially when associated to abnormal placentation. Quick diagnosis, management and intervention improves survival rate and decreases maternal and foetal morbidity.

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Placenta percreta is a rare but must be known cause of midgestational spontaneous uterine rupture

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Antepartum diagnosis helps prevent hemorrhage complications

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Early identifiation of clinical signs, and utilization of ultrasound helps establish a diagnosis and increase survival rate

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Quick management and surgery improve maternal and foetal outcome

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.

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.

Invasive placentation and uterus preserving treatment modalities: a systematic review

Purpose

We present a systematic review to evaluate failure rates (secondary hysterectomy or maternal mortality) and success rates (subsequent menstruation or pregnancy) after different uterus preserving treatment modalities in women with invasive placentation.

Methods

A review of English, German or Dutch language-published research, using Medline and Embase databases, was performed. Studies of any design were included.

Results

Ten cohort studies and 50 case series or case reports were included. Expectant management reported a secondary hysterectomy in 55/287 (19%), maternal mortality in 1/295 (0.3%), a subsequent menstruation in 44/49 (90%) and a subsequent pregnancy in 24/36 (67%). Embolization of the uterine arteries described a secondary hysterectomy in 8/45 (18%), a subsequent menstruation in 8/13 (62%) and a subsequent pregnancy in 5/33 (15%). Methotrexate therapy presented a secondary hysterectomy in 1/16 (6%), a subsequent menstruation in 4/5 (80%) and a subsequent pregnancy in 1/2 (50%). Uterus preserving surgery showed a secondary hysterectomy in 24/77 (31%), maternal mortality in 2/55 (4%), a subsequent menstruation in 28/34 (82%) and a subsequent pregnancy in 19/26 (73%).

Conclusions

This review indicates that different uterus preserving treatment modalities may be effective in managing invasive placentation. Despite the extensive review of the literature, no conclusions about the superiority of any modality can be drawn.

Antifibrinolytic therapy with tranexamic acid in pregnancy and postpartum

OBJECTIVE

The aim of this study is critically to review the available evidence regarding the use, efficacy and safety of tranexamic acid in the management of hemorrhage during pregnancy and for prevention and treatment of postpartum hemorrhage.

RESEARCH DESIGN AND METHODS

We performed a systematic search of electronic literature (PubMed, Embase, CINAHL, Scopus, Cochrane, DARE) to review all studies looking at the use of tranexamic acid during pregnancy and puerperium. We did a meta-analysis on three randomized controlled trials that evaluated reduction in blood loss in women undergoing cesarean sections with the use of tranexamic acid.

RESULTS

An electronic search yielded 34 articles, the studies dating from 1976 to 2010, five randomized controlled trials, seven observational studies, and twenty-two case reports. Meta-analysis showed that the estimate of the combined effect of tranexamic acid compared with placebo was a difference of 32.5 ml reduction in blood loss (95% CI -4.1-69.13; p = 0.08). Tranexamic acid was also used successfully to prevent and treat bleeding in observation studies and case reports. Pulmonary embolism was reported in two cases; however, the possible involvement of tranexamic acid in these thrombotic episodes could neither be confirmed nor excluded.

CONCLUSIONS

The clinical studies suggest that tranexamic acid reduces the amount of blood loss after delivery during cesarean sections and vaginal deliveries, and reduces the requirement for blood transfusion. Tranexamic acid seems to be safe and effective in the prevention and management of bleeding during pregnancy. Further investigation and larger clinical trials with better design and methodological quality are required to confirm these findings.