Placenta praevia percreta with bladder penetration

Searching for placenta percreta: a prospective cohort and systematic review of case reports

BACKGROUND

Placenta percreta is described as the most severe grade of placenta accreta spectrum and accounts for a quarter of all cases of placenta accreta spectrum reported in the literature.

OBJECTIVE

We investigated the hypothesis that placenta percreta, which has been described clinically as placental tissue invading through the full thickness of the uterus, is a heterogeneous category with most cases owing to primary or secondary uterine abnormality rather than an abnormally invasive form of placentation.

STUDY DESIGN

We have evaluated the agreement between the intraoperative findings using the International Federation of Gynecology and Obstetrics classification with the postoperative histopathology diagnosis in a prospective cohort of 101 consecutive singleton pregnancies presenting with a low-lying placenta or placenta previa, a history of at least 1 prior cesarean delivery and ultrasound signs suggestive of placenta accreta spectrum. Furthermore, a systematic literature review of case reports of placenta percreta, which included histopathologic findings and gross images, was performed.

RESULTS

Samples for histologic examination were available in 80 of 101 cases of the cohort, which were managed by hysterectomy or partial myometrial resection. Microscopic examination showed evidence of placenta accreta spectrum in 65 cases (creta, 9; increta, 56). Of 101 cases included in the cohort, 44 (43.5%) and 54 (53.5%) were graded as percreta by observer A and observer B, respectively. There was a moderate agreement between observers. Of note, 11 of 36 cases that showed no evidence of abnormal placental attachment at delivery and/or microscopic examination were classified as percreta by both observers. The systematic literature review identified 41 case reports of placenta percreta with microscopic images and presenting symptomatology, suggesting that most cases were the consequence of a uterine rupture. The microscopic descriptions were heterogeneous, and all descriptions demonstrated histology of placenta creta rather than percreta.

CONCLUSION

Our study supported the concept that placenta accreta is not an invasive disorder of placentation but the consequence of postoperative surgical remodeling or a preexisting uterine pathology and found no histologic evidence supporting the existence of a condition where the villous tissue penetrates the entire uterine wall, including the serosa and beyond.

Approaches to reduce urinary tract injury during management of placenta accreta, increta, and percreta: a systematic review

OBJECTIVE

A systematic review of the literature was conducted to answer the following question: are there enhancements to standard peripartum hysterectomy technique that minimize unintentional urinary tract (UT) injury in pregnancies complicated by invasive placental attachment (INPLAT)?

METHODS

A PubMed search of English language articles on INPLAT published by June 2010 was conducted. Data regarding the following parameters was required for inclusion in the quantitative analysis of the review's objective: (1) type of INPLAT, (2) details pertaining to medical and surgical management of INPLAT, and (3) complications, if any, associated with management. An attempt was made to identify approaches that may lower the risk of unintentional UT injury.

RESULTS

Most cases (285 of 292) were managed by hysterectomy. There were 83 (29%) cases of unintentional UT injury. Antenatal diagnosis of INPLAT lowered the rate of UT injury (39% vs. 63%; P = 0.04). Information regarding surgical technique or medical management was available for 90 cases; 14 of these underwent a standard hysterectomy technique. Methotrexate treatment and 11 modifications of the surgical technique were associated with 16% unintentional UT injury rate as opposed to 57% for standard hysterectomy (P = 0.002). The use of ureteral stents reduced risk of urologic injury (P = 0.01). Multiple logistic regression analysis identified antenatal diagnosis as the significant predictor of an intact UT.

CONCLUSIONS

Antenatal diagnosis of INPLAT is paramount to minimize UT injury. Utilization of management modifications identified in this review may reduce urologic injury due to INPLAT.

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.

Placenta percreta invading the urinary bladder

The placenta, normally confined to the decidual lining of the uterine cavity, can in some circumstances invade the muscular wall of the uterus, a condition known as placenta accreta. Less common is placenta increta, in which placental cotyledons become intertwined with the muscular stroma of the uterus. Placenta percreta, in which the trophoblastic tissues penetrate the serosa of the uterus and may extend directly to adjacent structures, is even more rare and is potentially life-threatening. There have been only 10 reports of direct invasion of placenta percreta into the urinary bladder. We review these cases and report 3 recent patients, one of whom was diagnosed pre-operatively by ultrasonography.

An unusual cause of abdominal pain and shock in pregnancy: case report and review of the literature

A near fatal case of spontaneous uterine rupture resulting from placenta percreta is presented. Placenta accreta refers to all conditions in which placental villi attach to, invade, or penetrate the myometrium. Placenta percreta is the most extreme form of morbid placental attachment and is said to exist when the uterine wall is completely breached by invading placental villi. Although uncommon, placenta percreta is an important entity of which the emergency physician should be aware because of its propensity to cause uterine rupture and catastrophic bleeding. This article reviews the pathophysiology, presentation, diagnosis, and emergency department management of placenta accreta, increta, and percreta.