Placenta percreta invading the urinary bladder

The Sonographic Appearance of Placenta Accreta

Placenta accreta is an uncommon entity in which the placental villi invade the myometrium. The classic sonographic findings include the absence of a hypoechoic retroplacental zone, the presence of dilated vessels extending from the placenta through the myometrium, irregular cystic spaces in the placenta, and pulsatile maternal blood flow within these hypoechoic spaces. It is often accompanied by placenta previa. In this study, the authors report findings in six cases, four of which were accurately diagnosed sonographically as placenta accreta, one which resulted in a false-positive diagnosis, and one which resulted in a false-negative diagnosis. We review the roles of two-dimensional imaging, color-flow Doppler, and power Doppler in assessing this condition. Because of the associated high risk of maternal exsanguination, ultrasonography is an important and reliable tool in diagnosing accreta.

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.

Perioperative and transfusion outcomes in women undergoing cesarean hysterectomy for abnormal placentation

BACKGROUND

Women with placenta increta (PI) and placenta percreta (PP) are at high risk of obstetric hemorrhage; however, the severity of hemorrhage and perioperative morbidity may differ according to the degree of placental invasion. We sought to compare blood component usage and perioperative morbidity between women with PI versus PP undergoing cesarean hysterectomy (CH).

STUDY DESIGN AND METHODS

We identified 77 women who underwent CH for PI or PP from the NICHD MFMU Network Cesarean Registry, which sourced data from 19 centers from 1999 to 2002. We examined demographic, obstetric, and surgical data and rates of transfusion and perioperative morbidity. We performed statistical tests for between-group analyses; p values less than 0.05 were significant.

RESULTS

Rates of intraoperative or postoperative red blood cell (RBC) transfusion were similar between groups (PI 84% vs. PP 88%; p=0.7). We observed no between-group differences in rates of fresh-frozen plasma (FFP) transfusion (intraoperative FFP-PI 30% vs. PP 41%; p=0.3; postoperative FFP-PI 28% vs. PP 18%; p=0.4) or platelet (PLT) transfusion (intraoperative PLTs-PI 14% vs. PP 29%; p=0.2; postoperative PLTs-PI 9% vs. PP 9%; p=1.0). Among the morbidities, a higher proportion of PP women underwent cystotomy (PI 14% vs. PP 38%; p=0.02) and postoperative mechanical ventilation (PI 14% vs. PP 35%; p=0.03).

CONCLUSION

Rates of intraoperative RBC, FFP, and PLT transfusion are similar for PI and PP women, and perioperative outcomes are worse for PP women. We suggest the same mobilization transfusion medicine support for both groups, including blood ordering (type and cross-match for CH) and availability of emergency blood protocols including fibrinogen-containing preparations.

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.

Placenta percreta invading the urinary bladder

INTRODUCTION

Placenta percreta is a rare obstetric complication causing life-threatening hemorrhage.

CASE REPORT

The case of a woman with a placenta percreta invading the urinary bladder treated by cesarean hysterectomy and partial bladder resection is presented. Overall estimated blood loss was 11,130 ml, and 59 units of various blood products were transfused.

CONCLUSION

Obstetricians and urologists should be aware of this rare condition.

The urologist in the delivery room

Urologic injuries can and will occur during obstetric procedures. In my experience, a urologist should follow nine rules to ensure a successful outcome for the patient and a successful relationship with the obstetrician. These rules are outlined in Table 2.

Placenta percreta--two cases and review of the literature

Two cases of placenta pecreta confirmed histologically were treated conservatively with retention of the uterus. Both later went on to have successful pregnancies.

Placenta accreta in Kuwait: does a discrepancy exist between fundal and praevia accreta?

OBJECTIVE

The purpose of this retrospective study was to compare maternal and neonatal outcome in relation to site of placenta accreta by stratifying the site of placenta accreta into upper and lower uterine segment implantation.

SUBJECTS AND METHODS

Sixteen cases of placenta accreta which were reported in the Maternity Hospital of Kuwait over 11 years from January 1981 to July 1993 - (1990 and 1991 excluded) were retrospectively analyzed using the hospital medical records.

RESULTS

The incidence of placenta accreta was 9.8 per 100,000 deliveries. The rate of accreta in patients with placenta praevia was 880 per 100,000 placenta praevia, compared to a rate of 5 accreta per 100,000 placenta implanting in the upper uterine segment. There were no differences between accreta found in the upper segment and lower segment for maternal and neonatal mortality, maternal complication, past obstetric history and possibility of conserving the uterus. Significant differences were found in the birth weight, gestational age at birth, antenatal symptoms, time of diagnosis and mode of delivery when accreta was stratified by site of implantation.

CONCLUSION

Placenta praevia is a definite risk factor for placenta accreta. Combined abnormal penetration of placenta as in accreta and abnormality in site as in praevia does have a significant clinical implications.

Abdominal pain and hemoperitoneum in the gravid patient: a case report of placenta percreta

A 24-year-old woman, G4P3 at 14 weeks gestation, presented to the ED with acute abdominal pain, hemoperitoneum, and fetal demise. Emergent laparotomy showed placenta percreta, requiring hysterotomy for delivery of the fetus and gestational sac followed by oversewing of the uterine defect. Although an uncommon occurrence, clinicians should consider placenta percreta in the gravid patient who presents with acute abdominal pain and shock.

The outcome of placenta accreta in Kuwait (1981-1993)

OBJECTIVES

To study the demographic characteristics of patients with placenta accreta and to identify the clinical features, maternal and neonatal complications of this condition.

METHODS

Sixteen cases of placenta accreta were identified in the Maternity Hospital of Kuwait during the period January 1981 to July 1993. Medical records were reviewed regarding past obstetric history, type of placenta, clinical presentation, maternal and fetal outcome.

RESULTS

The rate of placenta accreta was found to be 98 per 1,000,000 deliveries. Emergency hysterectomy was needed in 87.5% of cases. There was one maternal death (6.25%) and three perinatal deaths (18.75%). Hemorrhage was the major presenting symptom either externally and antenatally in previa accreta or postpartum in accreta of the upper segment or internally in the same cases. The major postoperative complications were coagulopathy, urinary injury, pelvic hematoma and abscess, in addition to cardiac arrest. These complications, when considered separately, were not affected by a previous history of uterine scarring.

CONCLUSIONS

Placenta accreta is a major cause of obstetric hemorrhage and has an adverse effect on maternal and neonatal outcome. It ought to be considered a possibility in patients with previous uterine scarring, placenta previa or retained placenta. It will remain a growing problem in the developing countries due to the rising incidence of previous multiple cesarean sections. Unfortunately the latter do not deter women in this part of the world from insisting upon having big families and refusing tubal ligation.

Placenta percreta with bladder invasion: surgical strategy to avoid massive blood loss

Placenta percreta with bladder invasion is a rare complication of pregnancy, causing life-threatening hemorrhage. We report two further cases. In the second case we opted for a specific surgical guideline based on immediate ligature of both the hypogastric arteries before hysterectomy. This approach resulted in considerably less blood loss than is usually reported.

Emergency peripartum hysterectomy

OBJECTIVES

By means of hospital-based data over 9 years we sought to evaluate the clinical indications and incidence of emergency peripartum hysterectomy by demographic characteristics and reproductive history.

STUDY DESIGN

From the obstetric records of all deliveries at Brigham and Women's Hospital between Oct. 1, 1983, and July 31, 1991, we identified all women undergoing emergency peripartum hysterectomy, calculated crude and adjusted incidence rates, conducted statistical tests of linear trends and heterogeneity, and observed the clinical indications preceding the onset of this procedure.

RESULTS

There were 117 cases of peripartum gravid hysterectomy identified during this period, for an overall annual incidence of 1.55 per 1000 deliveries. The rate increased with increasing parity and was significantly influenced by placenta previa and a history of cesarean section. The incidence by parity increased from one in 143 deliveries in nulliparous women with placenta previa to one in four deliveries in multiparous women with four or more deliveries with placenta previa. Likewise, the incidence increased from one in 143 deliveries in women with one prior live birth and a prior cesarean section to one in 14 deliveries in multiparous women with four or more deliveries with a history of a prior cesarean section. Both these trends were highly significant (p < 0.001). Abnormal adherent placentation was the most common cause preceding gravid hysterectomy (64%, p < 0.001), with uterine atony accounting for 21%. Although no maternal deaths occurred, maternal morbidity remained high, including postoperative infection in 58 (50%), intraoperative urologic injury in 10 patients (9%), and need for transfusion in 102 patients (87%).

CONCLUSIONS

The data identify abnormal adherent placentation as the primary cause for gravid hysterectomy. The data also illustrate how the incidence of emergency peripartum hysterectomy increases significantly with increasing parity, especially when influenced by a current placenta previa or a prior cesarean section. Maternal morbidity remained high although no maternal deaths occurred.

A case report: cervical pregnancy with placenta percreta an ultrasonic assisted diagnosis

A rare cervical pregnancy is reported, discussing the difficulty differentiating this condition from the cervical phase of an incomplete abortion. Placenta percreta further complicates this case. Ultrasound will give a firm diagnosis of cervical pregnancy and associated placenta percreta. Conservative and radical surgical care determined by vital signs are discussed.

Placenta praevia percreta invading the urinary bladder

A case of placenta praevia percreta involving the urinary bladder is presented. A classical Caesarean section was performed at 35 weeks' gestation but the placenta was left in situ and an elective hysterectomy was successfully performed 2 weeks postpartum.

Placenta percreta invading the urinary bladder

The case of a woman with a placenta percreta invading the urinary bladder treated by hysterectomy and partial bladder resection is presented. It is emphasized that if physicians in an emergency clinic are aware of this rare condition, preoperative diagnosis can be made and surgical intervention may be accomplished under ideal conditions.