///2010 Abstract Details
2010 Abstract Details2018-05-01T17:52:49+00:00

Placenta accreta percreta and uterine rupture in a patient with no previous cesarean section

Abstract Number: 174
Abstract Type: Case Report/Case Series

NIKESH SETH MD1 ; MADHUMANI N RUPASINGHE FRCA2

Introduction:

Placenta accreta is an abnormally firm attachment of the placenta directly to the muscle of the uterine wall. The average incidence of placenta accreta is 1 in 7000 deliveries. The most significant complication of placenta accreta is postpartum hemorrhage. We present a rare case of a patient with no prior cesarean section or uterine trauma who presented with a placenta previa accreta and a lower segment perforation.

Case Report:

A 36 year old G3P2 presented at 39 weeks in active labor. The patient had 2 previous term spontaneous vaginal deliveries with no known peripartum complications. An epidural was placed in labor and she had a spontaneous vaginal delivery. 40 units of oxytocin was started after the placenta was delivered. Over the course of the next hour the patient continued to bleed and was given 200 mcg of methylergonovine, 800 mcg mesoprostol and 250 mcg carboprost.

Within another hour it was noted that the patient may have lost up to 1500 cc of blood. On examination under epidural anesthesia, the patient had a 6 cm cervical laceration in the 9 oclock position. After ligation of this laceration the patient continued to bleed hence D and C via ultrasound guidance was performed with no products returned. A Bakri balloon was placed in the lower uterine segment to create tamponade. This method seemed to resolve the bleeding and the patient was then taken to the recovery room. During this procedure the patients blood loss was estimated to be around 1800cc and the patient received 4 units of packed RBCs, 2 units of FFP, 1 pack of jumbo platelets, and 10 units of cryoprecipitate.

The Bakri balloon was accidentally displaced in the recovery room and vaginal bleeding became significant again. While more blood products were being given the patient returned to the operating room for an exploratory laparotomy and possible hysterectomy.

During surgery under general anesthesia a 3 cm right lower uterine segment perforation was discovered along with a 10 cm right broad ligament hematoma. A hysterectomy was performed and an additional 1100 cc of blood was lost. Adequate hemostasis was obtained and the patient was transported to the surgical intensive care unit having received a total of 10 units of pRBC, 6 units of FFP, 10 units of cryoprecipitate and 2 bags of jumbo platelets.

She was extubated postop day 1 and the epidural was removed on postop day 2 with no known complications. The pathology report of the resected uterus was found to have a placenta previa accreta with a lower segment perforation.

Discussion:

In patients with placenta previa, the incidence of placenta accreta correlates with the number of previous cesarean sections. Other reported risk factors include maternal age greater than 35, multiple previous pregnancies, previous uterine surgery, and D&C. It is interesting to note that the only demonstrable risk factor in our patient was the advanced maternal age.

SOAP 2010