Retrospective study of placenta accreta, placenta increta and placenta percreta in Peripartum hysterectomy specimens

Unexpected Dramatic Evolution of Placenta Increta: Case Report and Literature Review

Placental morbid adherence is a known risk factor for postpartum hemorrhage. The incidence of abnormal placental attachment has been increasing over the past few decades, mainly due to rising rates of cesarean deliveries, advanced maternal age, and the use of assisted reproductive technologies. Cesarean section is a significant risk factor for placenta increta, as it disrupts the normal architecture of the uterine wall, making it more difficult for the placenta to detach after delivery. We present the case of a woman who underwent a cesarean section at 28 weeks due to anterior placenta previa, accompanied by hemorrhage and rupture of membranes. Following the delivery, she experienced normal postoperative bleeding and was discharged home after five days. However, six weeks later, she presented with heavy bleeding, leading to the decision to perform a total hysterectomy. The levels of HCG were found to be low. The pathological examination of the specimens confirmed a diagnosis of placenta increta, as it revealed notable placental proliferation, necrotic villi, and placental invasion near the uterine serosa. Notably, we did not find any similar cases documented in the literature. Patients experiencing prolonged vaginal bleeding after childbirth and diagnosed with placenta accreta should be closely monitored through ultrasound examinations; abnormal proliferation of the placenta can occur, and prompt detection is crucial for appropriate management.

Retrospective evaluation of peripartum hysterectomy patients: 8 years' experience of tertiary health care

Background

Peripartum hysterectomy (PPH), which means surgical removal of the uterus during pregnancy or postpartum period, is a life-saving procedure performed as a last resort to stop obstetric serious bleeding.

Aim

Evaluation of the prevalence, risk factors, indications, associated complications, and neonatal outcomes of PPH performed in our clinic.

Patients and Methods

A total of 35 patients who underwent PPH in our clinic between 2013 and 2020 were analyzed retrospectively. Clinical and demographic characteristics of patients, age, gestational week, delivery type, type of hysterectomy performed, length of hospital stay, PPH indications, additional procedures and complications during PPH, maternal and fetal mortality, neonatal characteristics, intensive care unit (ICU) need after PPH, and blood transfusion amount and time were recorded. Patients with PPH were subdivided and studied in subgroups: Emergency - elective surgery, total - subtotal hysterectomy.

Results

PPH was performed in 35 (3.2/1000) patients who gave birth during the study period. The most common indication for hysterectomy was placental invasion anomaly (57.1%, n = 20), and the most performed operation was total hysterectomy (68.6%, n = 24). Bilateral hypogastric artery ligation (14.3%, n = 5) was the most common alternative procedure performed before hysterectomy, and the most common complication was bladder injury (22.9%, n = 8). Blood transfusion was performed in 94.3% (n = 33) of the patients due to acute blood loss. The mean newborn weight was 2788.79 ± 913.37 g, and the 1^st and 5^th-minute APGAR scores were 6.71 ± 2.25 and 7.56 ± 2.35, respectively.

Conclusion

Before PPH, uterine integrity should be preserved using medical and surgical methods, but if success is not achieved, hysterectomy is the last life-saving step. It should be kept in mind that in patients with anemia and increased gravidity, the risk of bleeding may be high in the first 24 h after birth and therefore PPH may be required. It would be more appropriate for patients with placentation anomalies to be operated in experienced centers due to possible complications, increased blood transfusion, and intensive care requirement.

A Retrospective Study of Placenta Accreta, Percreta, and Increta in Peripartum Hysterectomies in a Tertiary Care Institute in Northeast India

Background: Abnormal placentation such as placenta accreta, increta, and percreta are frequent causes of post-partum hemorrhage, which results in maternal morbidity and mortality. A previous history of cesarean section, placenta previa, and pre-eclampsia are the important risk factors for abnormal placentation. A reliable antenatal diagnosis and planned surgical approach can reduce the incidence of maternal morbidity and mortality from massive hemorrhage.

Aim: To study the incidence of abnormal placentation and the association of various risk factors with abnormal placentation.

Material and methods: A retrospective study over a period of eight years in patients with peripartum hysterectomies due to abnormal placentation presenting with massive hemorrhage.

Results: We received a total of 10 emergency hysterectomy specimens during an eight‑year period. Of the cases, placenta accreta accounted for 40% (4/10), increta up to 40% (4/10), and percreta 20% (2/10). Analysis of these findings with parity showed 20% of the women were uniparous (2/10), and 80% were multiparous (8/10). Risk factor analysis showed previous cesarean sections in 40% (4/10), placenta previa in 50% (5/10), and pre‑eclampsia in 10% (1/10).

Conclusion: The present study highlights the incidence of abnormal placentation in a tertiary care institute in Northeast India. Placenta accreta and increta constituted the major forms of abnormal placentation. Multiparous women with placenta previa followed by previous lower segment cesarean section were more at risk of having abnormal placentation. These findings will guide in antenatal care by risk prioritization and management planning of these patients.

The application of prophylactic balloon occlusion of the internal iliac artery for the treatment of placenta accreta spectrum with placenta previa: a retrospective case-control study

Background

Severe obstetric haemorrhage caused by placenta accreta spectrum (PAS) results in significant maternal morbidity and mortality. The effectiveness of prophylactic balloon occlusion of the internal iliac artery in PAS patients remains controversial. Therefore, we conducted a retrospective case-control study to investigate the clinical effectiveness of this treatment.

Methods

The clinical data of 104 patients with PAS complicated with placenta previa who delivered by caesarean section between January 2016 and January 2019 were collected, and the patients were divided into two groups. The study group (48 cases) underwent internal iliac artery preset balloon occlusion before caesarean section and uterine artery embolisation according to the bleeding status after surgery, while the control group (56 cases) did not undergo internal iliac artery preset balloon occlusion before caesarean section.

Results

The operation and hospitalisation times in the study group were longer than those in the control group. Additionally, the hysterectomy rate in the study group was significantly higher than that in the control group. No significant differences in blood loss, blood transfusion volume, urinary system injury, postoperative ICU transfer rate, or neonatal scores were identified between the groups. Among the patients without invasive placenta (placenta increta and percreta), blood loss was lower in the study group, and the caesarean hysterectomy rate did not significantly differ between the groups. Among the patients with invasive placenta, blood loss and the caesarean hysterectomy rate did not significantly differ between the groups. The risk of hysterectomy in the study group was related to invasive placenta penetration, a large area of placental invasion, or abnormal vascular filling. One patient in the study group had a thrombus in the left lower extremity artery.

Conclusions

Balloon occlusion of the internal iliac artery is effective for haemostasis of placenta previa in the absence of invasive placenta. For patients with invasive placenta, especially placenta percreta, a large area of placental invasion or abnormal vascular filling suggests the need for hysterectomy. The risks of the prophylactic use of internal iliac artery balloon occlusion include vascular injury and thrombus formation.