///2017 Abstract Details
2017 Abstract Details2019-08-02T15:54:53-06:00

Placenta Percreta with Invasion of Pelvic Sidewall

Abstract Number: SUN-49
Abstract Type: Case Report/Case Series

Jason J White MD1 ; Bryan Mahoney MD2; Julio Marenco MD3; Deborah J. Stein MD4; Jacqueline Geier MD5; Migdalia Saloum MD6

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.

SOAP 2017