PLACENTA PREVIA PERCRETA WITH BLADDER INVASION PRESENTING AS INCARCERATED HERNIA CARL S. SMITH, M.D. L,EONARD P FERRARA,
M.D.
From the Division of Urology, Department Medical Center, Minneapolis, Minnesota
of Surgery,
Hennepin
Count!
ABSTRACT-Placenta percreta is a rare complication o.f pregnanuy in which the chorionic villi penetrate through the myometrium causing ztterilrc nlptrrr~~ and life-threatening hemorrhage. Bladder invasion h!y the oilli is ILIIILSII~Iccntl may be associated with hematuria and low abdominal pain during midtrrnr pregnancy.
tomy (Fig. 1). Severe hemorrhage from multiple pelvic sites necessitated h>.pogastric artery ligation. The estimated blood loss w~as 17,000 IllL.
Many urologic complications of pregnancy such as hydronephrosis, calculus disease, or infection reflect existing conditions made worse by mechanical ureteral obstruction by the gravid uterus. In contrast, involvement of the urinary tract by abnormal placental tissue in the form of aggressive misplaced chorionic villi reflects an aberrant form of the process that is the basis of establishing and maintaining a normal pregnancy.
Comment Adherence of placental chorlonic villi to denuded areas of myometrium as an abnormality of implantation is defined collectively as placental accreta and can be categorized in stages. Placenta accreta vera is the first stage, in m.hich adherence occurs in areas lacking a decidua basalis as a limiting membrane. Placenta increta is the subsequent abnormal ingrowth aof the villi
Case Report A twenty-eight-year-old woman with one previous cesarean section and known placenta previa presented at thirty weeks’ gestation complaining of severe periumbilical pain. An umbilical hernia had been manually reduced ten weeks earlier. The current examination showed a tender 4 x 4-cm umbilical hernia that could not be reduced. No hematuria was noted. An abdominal roentgenogram revealed probable air-flu:id interfaces consistent with incarcerated bowel. Because the severity of the pain increased, an exploratory laparotomy was performed at which significant hemoperitoneum was encountered, with the uterus identified as tissue had exthe blleeding source. Placental truded through the scar of the cesarean incision, alnd dense adhesions infiltrated the bladder wall. A viable female infant was delivered followed by a hysterectomy and partial cystec-
.1
371
into the myometrium; placenta percreta advances the penetration through the entire thickness of the uterine wall. Estimates differ widely regarding the incidence of placenta accreta, from one in 540 to one in 93,000 deliveries.’ There are 7 cases of bladder invasion by placenta percreta previously reported,2 8 all in multiparous patients with a history of cesarean sections and no previous urologic disease. One patient experienced life-threatening hemorrhage at the time of cesarean section as well as bleeding two months after delivery attibutable to residual placental tissue invading the bladder wall. Only 3 of the reported cases noted urologic symptoms such as hematuria.2,3,6 The common denominator was an acute abdomen with hemorrhage in the multiparous patient with a history of cesarean section or uterine trauma. The urologic involvement by this condition is often an intraoperative discovery made during immediate surgery with interruption of the pregnancy. In such cases, cystotomy to identify tissue planes in order to control hemorrhage is essential. Extensive blood transfusions with
372
their associated final outcome.
complications
play a role in the
Division of Urology Hennepin County Medical Center 701 Park Avenue South Minneapolis, Minnesota 55415 (DR. SMITH) References 1. Fox II: PatholoLT of the Placenta, I,ondon, W.B. Saunders, 1978, p 65. 2. Tacfi P, et al: Placenta percreta with bladder invasion and massive hemorrhage, Obstet Cynecol 368: 686 (1970). 3. Silber SJ, et al: Placenta percreta invading bladder. J Ural 109: 615 (1973). 4. Trenton WD: Placenta previa percreta with invasion of the bladder, J Am Osteopath Assoc 84: 373 (1984). 5. Collins ML, O’Brien P, and Tabrah N: Placenta previa percreta with bladder invasion, JAMA 249: 1749 (1978). 6. Grabert H, et al: Placenta percreta with penetration of the bladder, J Obstet Gynecol Br Commonw 77: 1142 (1970). 7. Weckstein I,N, hfasserman JS. and Garite TJ: Placenta accreta: a problem of increasing significance, Obstet Gynecol 69: 480 ( 1986). 8. Aho AJ, Pulkkinen MO. and Vaha-Eskeli K: Acute nrinar) bladder tamponade with hvpovolemic shock due to placenta percreta with bladder invasion, Stand J Ural h’ephrol 19: 157 (1985).
UROLOGY
/ APRIL 1992
: VOLUME
XXIX.
NUMBER
3
M.D.
From the Division of Urology, Department Medical Center, Minneapolis, Minnesota
of Surgery,
Hennepin
Count!
ABSTRACT-Placenta percreta is a rare complication o.f pregnanuy in which the chorionic villi penetrate through the myometrium causing ztterilrc nlptrrr~~ and life-threatening hemorrhage. Bladder invasion h!y the oilli is ILIIILSII~Iccntl may be associated with hematuria and low abdominal pain during midtrrnr pregnancy.
tomy (Fig. 1). Severe hemorrhage from multiple pelvic sites necessitated h>.pogastric artery ligation. The estimated blood loss w~as 17,000 IllL.
Many urologic complications of pregnancy such as hydronephrosis, calculus disease, or infection reflect existing conditions made worse by mechanical ureteral obstruction by the gravid uterus. In contrast, involvement of the urinary tract by abnormal placental tissue in the form of aggressive misplaced chorionic villi reflects an aberrant form of the process that is the basis of establishing and maintaining a normal pregnancy.
Comment Adherence of placental chorlonic villi to denuded areas of myometrium as an abnormality of implantation is defined collectively as placental accreta and can be categorized in stages. Placenta accreta vera is the first stage, in m.hich adherence occurs in areas lacking a decidua basalis as a limiting membrane. Placenta increta is the subsequent abnormal ingrowth aof the villi
Case Report A twenty-eight-year-old woman with one previous cesarean section and known placenta previa presented at thirty weeks’ gestation complaining of severe periumbilical pain. An umbilical hernia had been manually reduced ten weeks earlier. The current examination showed a tender 4 x 4-cm umbilical hernia that could not be reduced. No hematuria was noted. An abdominal roentgenogram revealed probable air-flu:id interfaces consistent with incarcerated bowel. Because the severity of the pain increased, an exploratory laparotomy was performed at which significant hemoperitoneum was encountered, with the uterus identified as tissue had exthe blleeding source. Placental truded through the scar of the cesarean incision, alnd dense adhesions infiltrated the bladder wall. A viable female infant was delivered followed by a hysterectomy and partial cystec-
.1
371
into the myometrium; placenta percreta advances the penetration through the entire thickness of the uterine wall. Estimates differ widely regarding the incidence of placenta accreta, from one in 540 to one in 93,000 deliveries.’ There are 7 cases of bladder invasion by placenta percreta previously reported,2 8 all in multiparous patients with a history of cesarean sections and no previous urologic disease. One patient experienced life-threatening hemorrhage at the time of cesarean section as well as bleeding two months after delivery attibutable to residual placental tissue invading the bladder wall. Only 3 of the reported cases noted urologic symptoms such as hematuria.2,3,6 The common denominator was an acute abdomen with hemorrhage in the multiparous patient with a history of cesarean section or uterine trauma. The urologic involvement by this condition is often an intraoperative discovery made during immediate surgery with interruption of the pregnancy. In such cases, cystotomy to identify tissue planes in order to control hemorrhage is essential. Extensive blood transfusions with
372
their associated final outcome.
complications
play a role in the
Division of Urology Hennepin County Medical Center 701 Park Avenue South Minneapolis, Minnesota 55415 (DR. SMITH) References 1. Fox II: PatholoLT of the Placenta, I,ondon, W.B. Saunders, 1978, p 65. 2. Tacfi P, et al: Placenta percreta with bladder invasion and massive hemorrhage, Obstet Cynecol 368: 686 (1970). 3. Silber SJ, et al: Placenta percreta invading bladder. J Ural 109: 615 (1973). 4. Trenton WD: Placenta previa percreta with invasion of the bladder, J Am Osteopath Assoc 84: 373 (1984). 5. Collins ML, O’Brien P, and Tabrah N: Placenta previa percreta with bladder invasion, JAMA 249: 1749 (1978). 6. Grabert H, et al: Placenta percreta with penetration of the bladder, J Obstet Gynecol Br Commonw 77: 1142 (1970). 7. Weckstein I,N, hfasserman JS. and Garite TJ: Placenta accreta: a problem of increasing significance, Obstet Gynecol 69: 480 ( 1986). 8. Aho AJ, Pulkkinen MO. and Vaha-Eskeli K: Acute nrinar) bladder tamponade with hvpovolemic shock due to placenta percreta with bladder invasion, Stand J Ural h’ephrol 19: 157 (1985).
UROLOGY
/ APRIL 1992
: VOLUME
XXIX.
NUMBER
3
