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Placenta Percreta with Invasion of Pelvic Sidewall
Abstract Number: SUN-49
Abstract Type: Case Report/Case Series
Case: An obese 29 year old woman, G8P2143 at 35.5 weeks with a placenta previa was
scheduled for a cesarean hysterectomy due to ultrasound diagnosis highly suspicious for a
placenta accreta, with possibility of percreta. The patient’s history was significant for three
previous cesarean deliveries and multiple dilation and curettage procedures. A multi-disciplinary
conference was held with Maternal-Fetal Medicine, Gynecologic Oncology (Gyn Onc), Interventional
Radiology (IR), Neonatology, Blood Bank, and Anesthesia.(1) Surgery was scheduled in the
main OR. Two large bore IV’s and a radial arterial line were placed. The patient was
given a single-shot intrathecal preservative-free morphine injection prior to induction of
anesthesia. General anesthesia was induced using rapid sequence and video laryngoscopy.
Surgery progressed uneventfully and a healthy neonate was delivered. Soon after delivery
significant bleeding ensued. The surgeons, in consultation with Gyn Onc, decided
to proceed with the hysterectomy. The surgery was complicated by the invasion of the placenta
into the surrounding pelvic sidewall and vaginal vault. Hemostasis was not possible, so after
the hysterectomy, the pelvis was packed and retention sutures were placed by general surgery.
The estimated blood loss at that time was twenty liters of blood, which was being replaced using
massive transfusion protocol (2). The patient was taken to IR for embolization of pelvic
vasculature. Hemostasis gradually improved and patient remained intubated in the ICU. On
post-operative day 2, the patient returned to the operating room for attempted wound closure,
but it was not possible due to bowel engorgement. On post-operative day four, closure was
successfully reattempted by general surgery. The patient's trachea was extubated on postoperative
day six. Her post-operative recovery was complicated by bilateral pelvic abscesses,
which were drained percutaneously. The patient was discharged home on post-operative day
13 with IV antibiotics.
Discussion: This patient was presumed to have an invasive placenta due to the ultrasound in
combined with her history of multiple cesarean deliveries, uterine curettage, and placenta
previa. Based on this information, a multidisciplinary pre-operative conference and planning for
the surgery occurred. The growth of this patient’s placenta into sidewall structures meant that
complete resection of placenta tissue was not possible and contributed to this patient’s massive
blood loss. Ultimately, the multi-disciplinary team approach to these complicated invasive
placenta cases is the key to successful outcome.
1) Walker MG, Pollard L, et al. Obstetric and Anaethesia Checklists for the Management of
Morbidly Adherent Placenta. JOGC 2016;38 (11):1015-23.
2) Gutierrez MC, Goodnough LT, Druzin M, Butwick AJ. Postpartum hemorrhage treated with a
massive transfusion protocol at a tertiary obstetric center: a retrospective study. Int J Obstet Anesth 2012;21:230-5.