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Mutiso SK, Oindi FM, Mundia DM. Uterine rupture in the first trimester: a case report and review of the literature. J Med Case Rep 2024; 18:5. [PMID: 38183151 PMCID: PMC10771000 DOI: 10.1186/s13256-023-04318-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/12/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Uterine rupture is a rare complication that can occur in the first trimester of pregnancy. It can lead to serious maternal morbidity or mortality, which is mostly due to catastrophic bleeding. First trimester uterine rupture is rare; hence, diagnosis can be challenging as it may be confused with other causes of early pregnancy bleeding such as an ectopic pregnancy. We present a case of first trimester scar dehiscence and conduct a literature review of this rare condition. CASE PRESENTATION A 39-year-old African patient with four previous hysterotomy scars presented with severe lower abdominal pain at 11 weeks of gestation. She had two previous histories of third trimester uterine rupture in previous pregnancies with subsequent hysterotomies and repair. She underwent a diagnostic laparoscopy that confirmed the diagnosis of a 10 cm anterior wall uterine rupture. A laparotomy and repair of the rupture was subsequently done. CONCLUSION In conclusion, the case presented adds to the body of evidence of uterine scar dehiscence in the first trimester. The risk factors, clinical presentation, diagnostic imaging, and management outlined may help in early identification and management of this rare but life threatening condition.
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Affiliation(s)
- Steve Kyende Mutiso
- Department of Obstetrics and Gynaecology, Aga-Khan University, P.O. Box 30270-00100, Nairobi, Kenya.
| | - Felix Mwembi Oindi
- Department of Obstetrics and Gynaecology, Aga-Khan University, P.O. Box 30270-00100, Nairobi, Kenya
| | - Debbie Muthoni Mundia
- Department of Obstetrics and Gynaecology, Aga-Khan University, P.O. Box 30270-00100, Nairobi, Kenya
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Fnon NF, Hassan AA, Hosney HH, Mohamed AK, Khalifa AM, Mostafa EMA, Ibrahim MA. Placenta percreta in primigravida with unscarred uterus complicated by uterine rupture and sudden maternal and fetal death: an autopsy case report. Forensic Sci Med Pathol 2023:10.1007/s12024-023-00690-7. [PMID: 37632681 DOI: 10.1007/s12024-023-00690-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 08/28/2023]
Abstract
Placenta percreta is a rare, aggressive, and severe form of the placenta accreta spectrum. One of its most devastating effects is the sudden rupture of uterus. Uterine scarring is the leading risk factor for uterine rupture, although it can also happen, but rarely, in an unscarred uterus showing more severe repercussions. The present study reported a case of an Egyptian primigravida female, aged 29 years old, at 32 weeks of gestation who died suddenly due to uterine rupture complicating placenta percreta, the diagnosis of which was first settled during autopsy. There was no history of abdominal trauma. No medical history of significance was present. Autopsy denoted an intrauterine fetal death of 32 weeks gestational age. The fundus of the uterus had a laceration (rupture) of the uterine wall including the serosa and myometrium. The placenta has extensively infiltrated the fundus uterine wall and penetrated the myometrium and serosa. Histopathological examination of the ruptured site on the uterus confirms total invasion of the uterine wall by chorionic villi with the presence of hemorrhage and fibrin indicating placenta percreta. Uterine rupture due to placenta percreta may go unnoticed, especially when no associated high-risk factors exist. The current case depicts that placenta percreta is a rare but critical complication of pregnancy that may exist at any stage of pregnancy without any associated high-risk factors with unusual symptoms and leads to uterine rupture and sudden death.
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Affiliation(s)
- Nora F Fnon
- Forensic Pathology Unit, Forensic Medicine Authority, Ministry of Justice, Cairo, Egypt
| | - Ayman A Hassan
- Forensic Medicine Department, Forensic Medicine Authority, Ministry of Justice, Cairo, Egypt
| | - Hanan H Hosney
- Forensic Pathology Unit, Forensic Medicine Authority, Ministry of Justice, Cairo, Egypt
| | - Ayman K Mohamed
- Forensic Medicine Department, Forensic Medicine Authority, Ministry of Justice, Cairo, Egypt
| | - Athar M Khalifa
- Pathology Department, College of Medicine, Jouf University, Sakakah, Aljouf, Saudi Arabia
| | - Enas M A Mostafa
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Suez Canal University (SCU), Ismailia, 41522, Egypt
| | - Mahrous A Ibrahim
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Suez Canal University (SCU), Ismailia, 41522, Egypt.
- Forensic Medicine and Clinical Toxicology, College of Medicine, Jouf University, Sakakah, Aljouf, Saudi Arabia.
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Uterine rupture with massive hemoperitoneum due to placenta percreta in a second trimester: A case report. Int J Surg Case Rep 2022; 99:107652. [PMID: 36152368 PMCID: PMC9568781 DOI: 10.1016/j.ijscr.2022.107652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/09/2022] [Accepted: 09/09/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Uterine rupture due to placenta percreta is very rare. It often occurs in patients with a history of Cesarean section. Quick diagnosis, management and intervention improves survival rate and decreases maternal and foetal morbidity. Observation Patient, 36 years old, mother of three children delivered by cesarean section, admitted for acute abdominal pain in the context of a poorly monitored pregnancy estimated at 25 weeks of amenorrhea. Pelvic ultrasound showed a large peritoneal effusion with the presence of an evolving intrauterine pregnancy with cardiac activity present, the placenta was with anterior coverage. An emergency laparotomy revealed uterine rupture with active hemorrhage localized on the anterior uterine scar with placental protrusion was noted. A cesarean section was quickly performed to save the fetus. The placenta was left in place and a difficult hysterectomy was then undertaken. Discussion Uterine rupture in second trimester caused by placental percreta is a rare event that can be life threatening for both mother and fetus. Placenta percreta should be considered when diagnosing internal bleeding in a patient during the first trimester of pregnancy. Conclusion Placenta percreta is a rare but severe obstetric complication that is potentially life threatening for both the mother and fetus. It is important to maintain a high level of clinical suspicion for this disease in pregnant women with acute abdomen, especially those with specific risk factors. Uterine rupture in second trimester caused by placental percreta is a rare event that can be life threatening for both mother and fetus. The clinical presentation of this complication ranges from mild abdominal pain to hemorrhagic shock. Quick diagnosis, management and intervention improves survival rate and decreases maternal and foetal morbidity.
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Jauniaux E, Hecht JL, Elbarmelgy RA, Elbarmelgy RM, Thabet MM, Hussein AM. Searching for placenta percreta: a prospective cohort and systematic review of case reports. Am J Obstet Gynecol 2022; 226:837.e1-837.e13. [PMID: 34973177 DOI: 10.1016/j.ajog.2021.12.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/04/2021] [Accepted: 12/12/2021] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Eric Jauniaux
- Faculty of Population Health Sciences, EGA Institute for Women's Health, University College London, London, United Kingdom.
| | - Jonathan L Hecht
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
| | - Rasha A Elbarmelgy
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Rana M Elbarmelgy
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Mohamed M Thabet
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
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Perdue M, Felder L, Berghella V. First-trimester uterine rupture: a case report and systematic review of the literature. Am J Obstet Gynecol 2022; 227:209-217. [PMID: 35487324 DOI: 10.1016/j.ajog.2022.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study aimed to present a case of first-trimester uterine rupture and perform a systematic review to identify common presentations, risk factors, and management strategies. DATA SOURCES Searches were performed in PubMed, Ovid, and Scopus using a combination of key words related to "uterine rupture," "first trimester," and "early pregnancy" from database inception to September 30, 2020. STUDY ELIGIBILITY CRITERIA English language descriptions of uterine rupture at ≤14 weeks of gestation were included, and cases involving pregnancy termination and ectopic pregnancy were excluded. METHODS Outcomes for the systematic review included maternal demographics, description of uterine rupture, and specifics of uterine rupture diagnosis and management. Data were extracted to custom-made reporting forms. Median values were calculated for continuous variables, and percentages were calculated for categorical variables. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklist for case reports and case series. RESULTS Overall, 61 cases of first-trimester uterine rupture were identified, including our novel case. First-trimester uterine ruptures occurred at a median gestation of 11 weeks. Most patients (59/61 [97%]) had abdominal pain as a presenting symptom, and previous uterine surgery was prevalent (44/61 [62%]), usually low transverse cesarean delivery (32/61 [52%]). The diagnosis of uterine rupture was generally made after surgical exploration (37/61 [61%]), with rupture noted in the fundus in 26 of 61 cases (43%) and in the lower segment in 27 of 61 cases (44%). Primary repair of the defect was possible in 40 of 61 cases (66%), whereas hysterectomy was performed in 18 of 61 cases (30%). Continuing pregnancy was possible in 4 of 61 cases (7%). CONCLUSION Uterine rupture is an uncommon occurrence but should be considered in patients with an acute abdomen in early pregnancy, especially in women with previous uterine surgery. Surgical exploration is typically needed to confirm the diagnosis and for management. Hysterectomy is not always necessary; primary uterine repair is sufficient in more than two-thirds of the cases to achieve hemostasis. Continuing pregnancy, although uncommon, is also possible.
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Affiliation(s)
- Makenzie Perdue
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Laura Felder
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA.
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Dos Anjos Siqueira I, Murugappan S, Howat P, Khalid A. Posterior uterine rupture in early first trimester. BMJ Case Rep 2021; 14:e244801. [PMID: 34853042 PMCID: PMC8638126 DOI: 10.1136/bcr-2021-244801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2021] [Indexed: 11/03/2022] Open
Abstract
Uterine rupture can be associated with severe maternal and neonatal morbidity and mortality. It should be considered as a differential diagnosis in all pregnant women who present with acute abdomen, haemoperitoneum and have specific risk factors, even during the first trimester. This is a case report of a 25-year-old woman who presented to emergency department with abdominal pain and vaginal bleeding at approximately 6-8 weeks gestation. She developed an acute surgical abdomen and required urgent surgical management. Despite intervention, she had massive haemorrhage, disseminate intravascular coagulation, admission to intensive care unit and prolonged hospital stay as complications. Posterior uterine wall rupture while rare, must be considered as a differential diagnosis as early intervention is crucial to prevent bad outcomes.
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Affiliation(s)
| | - Sita Murugappan
- Department of Obstetrics, The Northern Hospital, Melbourne, Victoria, Australia
| | - Paul Howat
- Department of Obstetrics, The Northern Hospital, Melbourne, Victoria, Australia
| | - Arzoo Khalid
- Department of Obstetrics, The Northern Hospital, Melbourne, Victoria, Australia
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Fonseca A, Ayres de Campos D. Maternal morbidity and mortality due to placenta accreta spectrum disorders. Best Pract Res Clin Obstet Gynaecol 2020; 72:84-91. [PMID: 32778495 DOI: 10.1016/j.bpobgyn.2020.07.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 11/29/2022]
Abstract
Placenta accreta spectrum (PAS) disorders are an increasing health problem in many parts of the world. They are an important risk factor for adverse maternal outcomes related to delivery, with a reported 18-fold increase in maternal morbidity. Profuse haemorrhage after attempting to remove the placenta is the most frequent complication and can lead to major maternal morbidity and ultimately to maternal death. Morbidity can also arise from the multiple procedures required to treat PAS disorders. Intensive care unit admission, mechanical ventilation, infection, and prolonged hospitalization are common in these patients. Long-term complications related to infertility and psychological disturbances can also occur and may have a strong and long-lasting impact on women's health. Antenatal diagnosis allows for appropriate scheduling of delivery and referral to a specialized centre and has been shown to reduce maternal morbidity and mortality.
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Affiliation(s)
- Andreia Fonseca
- Department of Obstetrics, Santa Maria University Hospital, Av. Prof. Egas Moniz, 1649-028 Lisbon, Portugal.
| | - Diogo Ayres de Campos
- Department of Obstetrics, Santa Maria University Hospital, Av. Prof. Egas Moniz, 1649-028 Lisbon, Portugal; Medical School, University of Lisbon, Av. Prof. Egas Moniz, 1649-028 Lisbon, Portugal
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8
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Badr DA, Al Hassan J, Salem Wehbe G, Ramadan MK. Uterine body placenta accreta spectrum: A detailed literature review. Placenta 2020; 95:44-52. [PMID: 32452401 DOI: 10.1016/j.placenta.2020.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/14/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Dominique A Badr
- Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Jihad Al Hassan
- Al-Zahraa Hospital University Medical Center, Lebanese University, Beirut, Lebanon
| | - Georges Salem Wehbe
- Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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9
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First Trimester Uterine Rupture: A Case Report and Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17082976. [PMID: 32344763 PMCID: PMC7215710 DOI: 10.3390/ijerph17082976] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/17/2020] [Accepted: 04/21/2020] [Indexed: 11/17/2022]
Abstract
The aim is to report a case of spontaneous uterine rupture in the first trimester of pregnancy and to review the literature on the topic. METHODS A literature search was performed using PubMed and Scopus. Relevant English articles were identified without any time or study limitations. The data were aggregated, and a summary statistic was calculated. RESULTS A 35-year-old gravida 5, para 2 was admitted at our department because of fainting and abdominal pain. The woman had a first-trimester twin pregnancy and a history of two previous cesarean sections (CSs). Suspecting a uterine rupture, an emergency laparotomy was performed. The two sacs were completely removed, and the uterine rupture site was closed with a double-layer suture. The patient was discharged from hospital four days later in good condition. On the basis of this experience, a total of 76 case reports were extracted from PubMed and included in the review. Fifty-three patients out of 76 (69.74%) underwent previous surgery on the uterus. Most women (67.92%) had a CS, and in this group a cesarean scar pregnancy (CSP) or a placenta accreta spectrum (PAS) disorder was found to be the etiology in 77.78% of cases. Furthermore, 35.85% of the women had hysterectomy after uterine rupture. Twenty-three patients out of 76 (30.26%) had an unscarred uterus. Of this group, most women presented a uterine anomaly (43.48%). Moreover, 17.39% of these women had a hysterectomy. CONCLUSION According to the literature, the current pandemic use of CS explains most cases of first-trimester uterine rupture.
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10
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Lee F, Zahn K, Knittel AK, Morse J, Louie M. Laparoscopic hysterectomy to manage uterine rupture due to placenta percreta in the first trimester: A case report. Case Rep Womens Health 2019; 25:e00165. [PMID: 31886137 PMCID: PMC6920503 DOI: 10.1016/j.crwh.2019.e00165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/23/2019] [Accepted: 11/26/2019] [Indexed: 11/26/2022] Open
Abstract
Placenta percreta causing uterine rupture is a rare complication of pregnancy. It is most commonly diagnosed after the second trimester and can lead to significant morbidity necessitating abdominal hysterectomy of a gravid or immediately postpartum uterus. We describe a patient who presented with abdominal pain at 13 weeks of gestation and was diagnosed with placenta percreta during laparoscopy for presumed appendicitis. Intraoperatively, placenta was seen perforating the uterine fundus and 1 l of hemoperitoneum was evacuated. However, the uterus was hemostatic and the patient was stable, so the procedure was terminated. The patient was then transferred to a tertiary care center, where she ultimately underwent an uncomplicated laparoscopic gravid hysterectomy. We conclude that placenta percreta can occur in the first trimester even in patients without traditional risk factors. In stable patients, it is appropriate to consider minimally invasive hysterectomy with utilization of specific techniques to minimize intraoperative blood loss. Uterine rupture due to placenta percreta can present in the first trimester. Minimally invasive laparoscopic hysterectomy can provide definitive treatment with decreased surgical morbidity and shorter convalescence. Blood loss and allogenic transfusion can be minimized with appropriate hemostatic techniques and surgical planning.
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Affiliation(s)
- Fan Lee
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States of America
| | - Katelin Zahn
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States of America
| | - Andrea K Knittel
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States of America.,Division of Generalist Obstetrics and Gynecology, United States of America
| | - Jessica Morse
- Division of Family Planning, United States of America
| | - Michelle Louie
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States of America.,Division of Minimally Invasive Gynecological Surgery, United States of America
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Atypical presentation of hemorrhagic shock in pregnancy: a case highlighting the developing field of emergency medicine in Israel. BMC Emerg Med 2019; 19:70. [PMID: 31752688 PMCID: PMC6868723 DOI: 10.1186/s12873-019-0272-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 09/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Occult hemorrhagic shock secondary to uterine rupture represents a true obstetric emergency and can result in significant morbidity and mortality for both the patient and the fetus. Multiparity and prior cesarean sections are known risk factors. Typically, these patients present late in gestation, often secondary to the physiologic stresses on the uterus related to contractions. This pathology is less common earlier in pregnancy and can often be overlooked in the acute setting. CASE PRESENTATION We present the case of a 31-year-old female with three prior gestations, two parities and two prior cesarean sections, resulting in three live births, who presented to the Emergency Department (ED) 22-weeks pregnant with acute onset dyspnea and an episode of syncope. Due to her altered mental status there was concern for occult shock, despite normal vital signs. Large amounts of free fluid in the abdomen were noted on bedside ultrasonography with a high suspicion for uterine pathology. She was resuscitated with blood and taken immediately to the operating room for surgical management where she was found to have had a uterine rupture. CONCLUSION This case highlights a rare presentation of a well-known obstetric emergency, due to the patient's development of uterine rupture early in gestation. Consequently, emergency physicians should consider atraumatic hypovolemic shock, secondary to this obstetric catastrophe, even at a stage that far precedes its expected presentation. In addition, we make note of how this case validated our department's integrated emergency medicine model, the first in the State of Israel.
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12
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Abbas AM, Michael A, Ali SS, Abdalmageed OS. Placenta percreta presenting with marked hemoperitoneum in the first trimester of pregnancy: A case report. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2018. [DOI: 10.1016/j.mefs.2017.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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13
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Placenta Percreta and Uterine Rupture in the First Trimester of Pregnancy. Case Rep Obstet Gynecol 2018; 2018:6842892. [PMID: 29850318 PMCID: PMC5925146 DOI: 10.1155/2018/6842892] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/02/2018] [Accepted: 03/11/2018] [Indexed: 12/04/2022] Open
Abstract
Spontaneous uterine rupture in the first trimester of pregnancy is uncommon and difficult to diagnose. Although extremely rare, it is important to consider the occurrence of placenta percreta as differential diagnosis of acute hemorrhagic abdomen at the beginning of pregnancy. We describe below a case of uterine rupture in the first trimester of pregnancy related to placenta percreta.
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14
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Cho MK, Ryu HK, Kim CH. Placenta Percreta–Induced Uterine Rupture at 7th Week of Pregnancy After In Vitro Fertilization in a Primigravida Woman: Case Report. J Emerg Med 2017; 53:126-129. [DOI: 10.1016/j.jemermed.2017.01.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 01/27/2017] [Indexed: 11/25/2022]
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16
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Rebarber A, Varrey A, Scherr D, Fox N, Sassoon R, Ciorica D, Saltzman D. Sonographic appearance of a cesarean scar pregnancy with placenta percreta invading the bladder in the first trimester and management with fertility preservation. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:163-167. [PMID: 27219670 DOI: 10.1002/jcu.22368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 04/11/2016] [Accepted: 04/24/2016] [Indexed: 06/05/2023]
Abstract
A 36-year-old, gravida 8, para 6, woman with six prior cesarean sections presented at 6 weeks with a cesarean scar pregnancy. Medical management was performed initially; however, subsequent three-dimensional sonographic examinations revealed trophoblastic invasion into the bladder. This led to robotic-assisted partial cystectomy, fulguration of invaded pregnancy, and repair of the uterine defect. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:163-167, 2017.
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Affiliation(s)
- Andrei Rebarber
- Carnegie Imaging for Women, PLLC, Mount Sinai School of Medicine, New York, New York
- Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai School of Medicine, New York, New York
| | - Aneesha Varrey
- Department of Obstetrics & Gynecology, NY Presbyterian--Weill Cornell Medical College, New York, New York
| | - Doug Scherr
- Department of Urology, New York Presbyterian--Weill Cornell Medical College, New York, New York
| | - Nathan Fox
- Carnegie Imaging for Women, PLLC, Mount Sinai School of Medicine, New York, New York
- Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai School of Medicine, New York, New York
| | - Robert Sassoon
- Department of Obstetrics & Gynecology, NY Presbyterian--Weill Cornell Medical College, New York, New York
| | - Doina Ciorica
- Carnegie Imaging for Women, PLLC, Mount Sinai School of Medicine, New York, New York
| | - Daniel Saltzman
- Carnegie Imaging for Women, PLLC, Mount Sinai School of Medicine, New York, New York
- Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai School of Medicine, New York, New York
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17
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Greenbaum S, Khashper A, Leron E, Ohana E, Meirovitz M, Hershkovitz R, Erez O. Escalating placenta invasiveness: repeated placenta accreta at the limit of viability. Int J Womens Health 2016; 8:119-23. [PMID: 27143953 PMCID: PMC4846064 DOI: 10.2147/ijwh.s100321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Placenta percreta is an obstetric condition in which the placenta invades through the myometrium. This is the most severe form of placenta accreta and may result in spontaneous uterine rupture, a rare complication that threatens the life of both mother and fetus. In this case report, we describe a 32-year-old woman in her fourth pregnancy, diagnosed with repeated placenta accreta, which was eventually complicated by spontaneous uterine rupture at 24 weeks’ gestation. This patient had a history of abnormal placentation in prior pregnancies and previous uterine injuries. This case demonstrates a pattern of escalating placental invasiveness, and raises questions regarding the process of abnormal placentation and the manifestation of uterine rupture in scarred uteri.
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Affiliation(s)
- Shirley Greenbaum
- Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Alla Khashper
- Department of Radiology, Soroka University Medical Center, School of Medicine, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Elad Leron
- Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Eric Ohana
- Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Mihai Meirovitz
- Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Reli Hershkovitz
- Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Offer Erez
- Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Ben-Gurion University of the Negev, Be'er Sheva, Israel
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Tuştaş Haberal E, Çekmez Y, Ulu İ, Divlek R, Göçmen A. Placenta percreta with concomitant uterine didelphys at 18 weeks of pregnancy: a case report and review of the literature. J Matern Fetal Neonatal Med 2015; 29:3445-8. [PMID: 26653847 DOI: 10.3109/14767058.2015.1130819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Esra Tuştaş Haberal
- a Department of Obstetrics and Gyneacology , Ümraniye Medical and Research Hospital , İstanbul , Turkey
| | - Yasemin Çekmez
- a Department of Obstetrics and Gyneacology , Ümraniye Medical and Research Hospital , İstanbul , Turkey
| | - İpek Ulu
- a Department of Obstetrics and Gyneacology , Ümraniye Medical and Research Hospital , İstanbul , Turkey
| | - Radia Divlek
- a Department of Obstetrics and Gyneacology , Ümraniye Medical and Research Hospital , İstanbul , Turkey
| | - Ahmet Göçmen
- a Department of Obstetrics and Gyneacology , Ümraniye Medical and Research Hospital , İstanbul , Turkey
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19
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Shaamash AH, Houshimi WM, El-kanzi EMM, Zakaria AE. Abortion hysterectomy at 11weeks’ gestation due to undiagnosed placenta accreta (PA): A case report and a mini review of literatures. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2014. [DOI: 10.1016/j.mefs.2014.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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20
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Bandarian M, Bandarian F. Spontaneous rupture of the uterus during the 1st trimester of pregnancy. J OBSTET GYNAECOL 2014; 35:199-200. [PMID: 25058117 DOI: 10.3109/01443615.2014.937334] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- M Bandarian
- Hazrat Zahra Hospital, Qom University of Medical Sciences , Qom
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21
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F. ABDULWAHAB D, ISMAIL H, NUSEE Z. Second-trimester uterine rupture: lessons learnt. Malays J Med Sci 2014; 21:61-65. [PMID: 25977625 PMCID: PMC4418117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 02/17/2014] [Indexed: 06/04/2023] Open
Abstract
UNLABELLED Uterine rupture is a rare life-threatening complication. It mainly occurs in the third trimester of pregnancy and is rarely seen during the first or second trimesters. Our centre experienced three important cases of uterine rupture. FIRST CASE spontaneous uterine rupture at 14 weeks of pregnancy, which was diagnosed at autopsy. It was misled by the ultrasound finding of an intrauterine pregnancy, and searching for other non-gynaecological causes delayed the urgent obstetric surgical management. SECOND CASE ruptured uterus at 24 weeks following medical termination due to foetal anomaly. It was diagnosed only at laparotomy indicated for failed medical termination and chorioamnionitis. Third case: uterine rupture at 21 weeks of pregnancy in a patient with gastroenterology symptoms. In these reports, we have discussed the various risk factors, presentations, course of events and difficulties in diagnosing uterine rupture. The study concludes that the clinical presentation of uterine ruptures varies. It occurs regardless of gestational age. Ultrasound findings of intrauterine pregnancy with free fluid do not exclude uterine rupture or ectopic pregnancy. Searching for non-gynaecological causes in such clinical presentations might delay crucial surgical intervention, which leads to unnecessary morbidity, mortality or loss of obstetrics function.
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Affiliation(s)
- Dalia F. ABDULWAHAB
- Department of Obstetrics & Gynaecology, Kulliyyah of Medicine, International Islamic University Malaysia, Jalan Hospital Campus, 25150 Kuantan, Pahang, Malaysia
| | - Hamizah ISMAIL
- Department of Obstetrics & Gynaecology, Kulliyyah of Medicine, International Islamic University Malaysia, Jalan Hospital Campus, 25150 Kuantan, Pahang, Malaysia
| | - Zalina NUSEE
- Department of Obstetrics & Gynaecology, Kulliyyah of Medicine, International Islamic University Malaysia, Jalan Hospital Campus, 25150 Kuantan, Pahang, Malaysia
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22
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Genc M, Genc B, Solak A, Sivrikoz ON. Placenta percreta resulting in incomplete spontaneous abortion in first trimester. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2014; 8:347-50. [PMID: 25379165 PMCID: PMC4221523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 09/22/2013] [Indexed: 10/26/2022]
Abstract
Placenta percreta is a rare complication potentially fatal to fetus and the mother. We present here a 41-year-old female patient who underwent curettage for incomplete abortion at 6(th) week of pregnancy. She had persistent vaginal bleeding for 2 months after the curettage, for which she was treated with hysterectomy. Preoperative ultrasonography and magnetic resonance imaging (MRI) made the diagnosis of placenta percreta. Postoperative pathological examination confirmed this diagnosis.
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Affiliation(s)
- Mine Genc
- Department of Obstetrics and Gynecology, Sifa University School of Medicine, Izmir, Turkey,Department of Obstetrics and GynecologySifa University School of MedicineİzmirTurkey
| | - Berhan Genc
- Department of Radiology, Sifa University School of Medicine, Izmir, Turkey
| | - Aynur Solak
- Department of Radiology, Sifa University School of Medicine, Izmir, Turkey
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23
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Ulkumen BA, Pala HG, Baytur Y. Acute abdomen and massive hemorrhage due to placenta percreta leading to spontaneous uterine rupture in the second trimester. Saudi Med J 2014; 35:1131-2. [PMID: 25228189 PMCID: PMC4362154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Placental invasion anomalies are rare obstetrical complications. They cause severe third trimester hemorrhage, severe postpartum bleeding, and maternal morbidity and mortality unless they are diagnosed antenatally. We present a rare case with placenta percreta leading to spontaneous uterine rupture during the second trimester with an acute abdomen and hypovolemia.
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Affiliation(s)
- Burcu A. Ulkumen
- From the Obstetrics and Gynecology Department, School of Medicine, Celal Bayar University, Manisa, Turkey.,Address correspondence and reprint request to: Assistant Professor Burcu A. Ulkumen, Obstetrics and Gynecology Department, School of Medicine, Celal Bayar University, Manisa 45210, Turkey. Tel. +90 (236) 4144162. Fax. +90 (236) 4652434. E-mail:
| | - Halil G. Pala
- From the Obstetrics and Gynecology Department, School of Medicine, Celal Bayar University, Manisa, Turkey.
| | - Yesim Baytur
- From the Obstetrics and Gynecology Department, School of Medicine, Celal Bayar University, Manisa, Turkey.
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24
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Bharatnur S, Hebbar S, Shyamala G. Early second trimester uterine scar rupture. BMJ Case Rep 2013; 2013:bcr-2013-200960. [PMID: 24326433 DOI: 10.1136/bcr-2013-200960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Spontaneous uterine scar rupture can be lethal in pregnant women. A spontaneous uterine scar rupture in the early mid-trimester is rare and difficult to diagnose. This is a case of a 30-year-old woman (G2P1L1) at 19 weeks of gestation and having undergone a previous caesarean section presented with acute abdomen in shock. Laparotomy revealed a uterine scar rupture, which was resutured after evacuation of products of conception. This case merits that the uterine rupture should be considered as a differential diagnosis in pregnant women presenting with acute abdomen. In this case, although there was uterine rupture in the second trimester and a complete placental separation, fetus was alive which is quite unusual in patients presenting with rupture uterus.
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25
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Berkley EM, Abuhamad AZ. Prenatal diagnosis of placenta accreta: is sonography all we need? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:1345-1350. [PMID: 23887942 DOI: 10.7863/ultra.32.8.1345] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Eliza M Berkley
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, VA 23507 USA.
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26
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Siwatch S, Chopra S, Suri V, Gupta N. Placenta percreta: rare presentation of haemorrhage in the second trimester. BMJ Case Rep 2013; 2013:bcr-2012-007782. [PMID: 23391949 DOI: 10.1136/bcr-2012-007782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 25-year-old woman, third gravid, with previous two miscarriages presented to the emergency at 17 weeks 2 days of gestation with complaints of pain in the abdomen for 1 day and decreased urine output for 2 days. She was in shock. There was no history of bleeding per vaginum, trauma, surgical procedure or medical illness. Her obstetrical history was marked by a spontaneous second trimester miscarriage at 24 weeks that was followed by fever for 1 week. Ultrasound revealed an extra uterine fetus with sac en caul secondary to uterine rupture. She was resuscitated and taken up for emergency salvage laparotomy. The ragged fundal rent was excised and uterine reconstruction was performed. Histology revealed placenta percreta. The patient had a rapid recovery.
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27
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Jauniaux E, Jurkovic D. Placenta accreta: pathogenesis of a 20th century iatrogenic uterine disease. Placenta 2012; 33:244-51. [PMID: 22284667 DOI: 10.1016/j.placenta.2011.11.010] [Citation(s) in RCA: 233] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Revised: 11/16/2011] [Accepted: 11/18/2011] [Indexed: 01/11/2023]
Abstract
Placenta accreta refers to different grades of abnormal placental attachment to the uterine wall, which are characterised by invasion of trophoblast into the myometrium. Placenta accreta has only been described and studied by pathologists for less than a century. The fact that the first detailed description of a placenta accreta happened within a couple of decades of major changes in the caesarean surgical techniques is highly suggestive of a direct relationship between prior uterine surgery and abnormal placenta adherence. Several concepts have been proposed to explain the abnormal placentation in placenta accreta including a primary defect of the trophoblast function, a secondary basalis defect due to a failure of normal decidualization and more recently an abnormal vascularisation and tissue oxygenation of the scar area. The vast majority of placenta accreta are found in women presenting with a previous history of caesarean section and a placenta praevia. Recent epidemiological studies have also found that the strongest risk factor for placenta praevia is a prior caesarean section suggesting that a failure of decidualization in the area of a previous uterine scar can have an impact on both implantation and placentation. Ultrasound studies of uterine caesarean section scar have shown that large and deep myometrial defects are often associated with absence of re-epithelialisation of the scar area. These findings support the concept of a primary deciduo-myometrium defect in placenta accreta, exposing the myometrium and its vasculature below the junctional zone to the migrating trophoblast. The loss of this normal plane of cleavage and the excessive vascular remodelling of the radial and arcuate arteries can explain the in-vivo findings and the clinical consequence of placenta accreta. Overall these data support the concept that abnormal decidualization and trophoblastic changes of the placental bed in placenta accreta are secondary to the uterine scar and thus entirely iatrogenic.
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Affiliation(s)
- E Jauniaux
- UCL Institute for Women's Health, University College London (UCL), London, UK.
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