Author Information
More V*, Dalvi P**,
Panchbuddhe S*, Parulekar SV***.
(*Assistant Professor,
** First Year Resident, *** Professor and Head of Department., Department of
Obstetrics and Gynecology, Seth GS Medical
College & KEM Hospital , Mumbai ,
India
Abstract
Adherent placenta is a
not uncommon indication for emergency obstetric hysterectomy. We report a case
of partially adherent placenta diagnosed intraoperatively during an emergency
hysterotomy, which was performed for antenatal hemorrhage due to separation of
a placenta implanted in the other segment. In view of intractable post-partum
hemorrhage emergency obstetric hysterectomy was performed.
Introduction
Placenta accreta is a
rare and life threatening condition with high maternal mortality and morbidity.
Placenta normally is confined to the decidual lining of the uterus, but it may
sometime invade the myometrium due to defect in decidua basalis. This condition
is known as placenta accreta. It is a not uncommon indication for emergency
obstetric hysterectomy. The incidence of placenta accreta is on rise due to
increase in rate of cesarean section.
Case Report
A 26 year old women,
married for 7 months, second gravida with 19 weeks of pregnancy presented to
the emergency department with blood stained vaginal discharge for 10 hours. She
had no other complaints. She had a previous one spontaneous abortion at two
months of gestation for which dilatation and evacuation was done. She had no
significant medical or surgical illness. On examination her vital parameters
were stable. Abdominal examination revealed relaxed uterus of 18 weeks with
positive external ballottement and regular fetal heart sounds. On speculum
examination leak was seen. On vaginal examination cervical os was 2 3 cm
dilated, 40-50% effaced with absent membranes and fetal lower limbs palpable.
Ultrasonography was done which revealed intrauterine gestation of 18.3 weeks
with severe oligohyadraminous (amniotic fluid index - 1). In view of premature
prolonged rupture of menbrane with inevitable abortion, a decision for
termination of pregnancy with oxytocin augmentation was taken. Injectable antibiotics were started. Oxytocin
infusion was augmented as per uterine activity. She was reassessed after 24
hours. Clinical findings were similar to previous findings, hence decision for
administration of misoprostol 400 microgram vaginally was taken. After second
dose of misoprostol 400 micrograms per vaginum after four hours, she complained
of vaginal bleeding. On vaginal examination findings were again similar to the
previous findings with fresh bleeding of around 300 ml. Uterine rupture was suspected
and a decision for exploratory laprotomy with hysterotomy was taken.
Intraoperatively the uterus was of 18 weeks’ size, with ballooned out lower
segment. There was no rupture. Transverse incision was made on the lower
uterine segment and the fetus was delivered. The placenta was posterior
reaching lower segment. It was partially separated in the upper portion and was densely adherent on
the lower segment due to which it had to be removed piecemeal. Bleeding continued
to occur from the lower segment. Multiple hemostatic stitches were taken on the
lower segment and bilateral uterine artery ligation was done. Hemostasis could
not be achieved. Total obstetric hysterectomy was performed in view of
intractable hemorrhage. Intraoperatively three units of whole blood were
transfused. Histopathological
examination of the specimen showed invasion of the lower uterine segment
endometrium and myometrium by chorionic villi. Post operative course was
uneventful.
Figure 1. Figure1: Black arrow upper portion of the uterus and green arrow distended lower segment of the uterus. A small subserous leiomyoma is also seen.
Discussion
The incidence of
placenta accreta was approximately 1 in 2500 in the 1980s, 1 in 535 in 2002 and
1 in 210 in 2006.[1] Placenta accreta is described as an
implantation in which there is an abnormally firm adherence of the placenta to
the uterine wall. Placenta accreta occurs due to defects in the decidua basalis
causing the placenta to adhere to or invade the myometrium. It is further
classified: accreta, in which placenta is adherent to the myometrium; increta,
in which placenta invades the myometrium; and percreta, in which placenta
penetrates the myometrium and serosa and it may be attached to the adjacent
structure. Total placenta
accreta/increta/percreta is one in which all the lobules of the placenta are
abnormally adherent, while partial type involves only a few to several lobule -
as was seen in our case in which only lower half was morbidly adherent.
Defective decidual formation is commonly in the lower uterine segment over the
previous cesarean section scar or after uterine curettage. In our case, the
patient had an abortion in the past, for which curettage was performed. The
incidence of adherent placenta is increasing because of increasing rate of
cesarean section.[2] Other risk factors for placenta accreta include advanced maternal age, multiparity,
previous myomectomy, thermal ablation of the endometrium and uterine artery
embolization. Partially
separated adherent placenta causes intractable postpartum hemorrhage requiring
emergency obstetric hysterectomy.[3] In our case also emergency
obstetrics hysterectomy was performed for intractable postpartum hemorrhage.
Excessive bleeding in placenta accreta is either due to the involved lobule
being pulled off the myometrium, or the lobule getting torn from the placenta.
In most of the cases, placenta accreta is not identified till third stage of
labor. Ultrasonography is only 33% sensitive in detecting placenta accreta.[4]
Magnetic resonance imaging is more accurate in identifying placenta accreta.
References
- Stafford I, Belfort MA. Placenta accreta, increta, and percreta: A team-based approach starts with prevention. Contemp Ob/Gyn April: 2008; 53(4), 76-8.
- Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107(6):1226–1232.
- Zelop CM, Harlow BL, Frigoletto FD Jr, Safon LE, Saltzman DH: Emergency peripartum hysterectomy. Am J Obstet Gynecol May 1993;168(5):1443-1448.
- Lam H, Pun TC, Lam PW: Successful conservative management of placenta previa accreta during cesarean section. Int J Obstet Gynecol 2004;86(1):31-32.
Citation
More V, Dalvi P,
Panchbuddhe S, Parulekar SV. Morbidly Adherent Placenta. JPGO 2015. Volume 2
No. 2. Available from: http://www.jpgo.org/2015/02/morbidly-adherent-placenta.html