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Introduction

Placenta percreta is a potentially catastrophic complication of pregnancy and may be associated with uterine rupture, life-threatening hemorrhage, and major surgical morbidity. Due to a combination of the increasing incidence of cesarean delivery as well as improving diagnostic modalities, the incidence and recognition of placenta accreta has increased. Herein we describe a case of placenta percreta with occult uterine rupture during the first trimester in a patient with a history of two prior cesarean deliveries.

Case Report

A 21-year old gravida 3, para 2, with a history of two prior cesarean deliveries underwent an initial fetal ultrasound at 12 weeks demonstrating an enlarged placenta filled with lacunar lakes completely overlying the internal os. A pelvic MRI was obtained which was concerning for invasion of the placenta into the lower uterine segment.  She was counseled regarding management options and at that time, desired expectant management. At 13 weeks gestation the patient was admitted for severe abdominal pain with vaginal bleeding. Ultrasound identified possible small defect in the anterior uterine wall with a small volume of free fluid in the cul-de-sac.  An exploratory laparoscopy performed revealed a thin, but normal appearing lower uterine segment along with a small volume of blood-tinged peritoneal fluid with no obvious uterine scar dehiscence.  A cystoscopy was negative for overt placental invasion. Since the patient at that time still desired to continue the pregnancy and no obvious maternal or fetal contraindications to pregnancy were identified intra-operatively, conservative management was undertaken.  After one week, the patient developed heavy vaginal bleeding and elected for termination of pregnancy. 


    The patient underwent a total abdominal hysterectomy with intraoperative findings of placental tissue protruding through a 4 cm defect within the lower uterine segment below the level of the vesicouterine peritoneum. During her procedure, she had a sizeable hemorrhage requiring transfusion. Postoperatively, her hospital course was unremarkable; she was discharged home on postoperative day four. Pathologic examination of the uterus demonstrated a 3.6x2.9 cm defect in the anterior lower uterine segment with adherent placenta penetrating the full thickness of the uterine wall.

Discussion

Placenta accreta is characterized by a deficiency or complete absence of the normally intervening Nitabuch’s layer which separates placental villous tissue from myometrium. The uterine decidua is often replaced only by loose connective tissue, allowing for essentially unrestricted access of trophoblasts to myometrial fibers. Previously an exceedingly rare occurrence, the incidence of placenta accreta has seen a 10-fold increase, and currently approximates 3 per 1000 pregnancies [1,3]. A potentially catastrophic condition, the morbidity associated with abnormal placentation is profound and may include uterine rupture, life-threatening hemorrhage and shock, injury to surrounding structures, thromboembolism, consumptive coagulopathy, and death.  

    Early identification of abnormal placentation allows for close follow-up, arrangement for transfer to tertiary care center, and early multidisciplinary planning and has been shown to lead to improved outcomes [4,5]. With increasing utilization of first trimester screening ultrasonography, detection of abnormal placentation early in pregnancy has increased. Ultrasonic markers identified early in gestation include low implantation [6,7], hypoechoic defects, subjective interpretation of thinning, and invasion into adjacent structures [7,8]. Other first trimester sonographic observations seen with abnormal placentation include those which are more commonly seen at more advanced gestational ages such as an irregular myometrial-placental interface, vascular lacunae, and persistent previa [9,10]. Unfortunately, the sensitivity and specificity of these markers in the first trimester is low, 41% and 88%, respectively [10]. Adaptation of uniform criteria has yet to be established for early detection of abnormal placentation [5,11,12], and unfortunately, despite advances in ultrasound imaging, many cases of abnormal placentation are diagnosed with massive bleeding at the time of placental separation during delivery or with dilation and curettage.

    While the management of placenta percreta in a setting of acute hemorrhage or an unstable patient is relatively straightforward, the management in a stable patient in the first trimester represents a challenge. Management options abound in the literature, ranging from expectant to surgical. Few cases in the literature describe pregnancies that reach viability, fewer yet approaching term with favorable outcomes, and patients remain at risk throughout the duration of pregnancy for sudden, life-threatening complications [13,14].  Therefore patients must be very carefully selected, be highly motivated, and exceptionally compliant if expectant management is to be undertaken.

Conclusion

This case emphasizes the need for maintenance of high clinical suspicion for uterine scar dehiscence in patients at high risk even in the absence of direct visualization on exploratory laparoscopy and underscores the need for early ultrasonic evaluation of a previous cesarean scar.

References

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