Second trimester placenta percreta presenting as acute abdomen Lauren Dew, MD, Steven Harris, MD, MPH, Nicole Yost, MD, Kevin Magee, MD, and Gregory dePrisco, MD

Diagnosing placenta percreta can be difficult. We describe a 41-year-old woman presenting at 21 weeks’ gestation with intraabdominal bleeding and no signs of placental abnormality on ultrasound. The disagreement between results of the ultrasound and magnetic resonance imaging made definitive diagnosis difficult. The bleeding resolved spontaneously after a blood transfusion, and the patient was hospitalized for the remainder of the pregnancy. Delivery was by scheduled repeat cesarean at 34 weeks’ gestation. Spontaneous rupture of the entire fundus occurred at the time of delivery. Placenta percreta was confirmed by histologic examination of the operatively excised uterus.

P

lacenta percreta is becoming more common as cesarean section and other uterine surgeries increase. Clinical diagnosis can be difficult. Both ultrasound and magnetic resonance imaging (MRI) may have misleading results. This case demonstrates how an unusual presentation can be well managed with multidisciplinary cooperation between obstetricians, perinatologists, and radiologists. CASE DESCRIPTION A 41-year-old G3P1011 African American woman at 20 weeks 6/7 days’ gestation presented to labor and delivery triage with the acute onset of abdominal pain beginning approximately 17 hours prior to presentation. The pain had progressively increased in intensity. Her past medical history included hypothyroidism and Asherman’s syndrome. Previous surgical history included one low transverse cesarean section and operative hysteroscopic lysis of adhesions complicated by uterine perforation. On admission, the patient’s blood pressure was 101/55 mm Hg and her heart rate was 88 beats per minute. Abdominal exam revealed diffuse tenderness with rebound. During the first 24 hours after admission, her heart rate increased to 112 beats per minute, blood pressure fell to 95/50 mm Hg, and blood hematocrit fell from 33.4% to 22.5%. After receiving 2 units of packed red blood cells, her hematocrit rose to 29%. A dedicated obstetric sonogram showed a posterior fundal placenta and a normal uteroplacental interface with normal color Doppler images, without any evidence of abnormal placentation. MRI revealed deep invasion of placental tissue at the fundal area of the uterus (Figure 1). Complex free fluid compatible with 38

hemoperitoneum also was visualized in the pelvis and right upper quadrant. The patient was transferred to the antepartum unit where she and her fetus remained on inpatient bedrest. Antenatal corticosteroids were administered at 29 weeks’ gestation for fetal lung maturation after increased abdominal pain and uterine contractions. She had no further intraabdominal bleeding episodes, and blood counts remained stable. A scheduled cesarean section was performed at 34 weeks 2 days’ gestation with delivery of a liveborn female infant weighing 4 pounds 13 ounces with an APGAR score of 9 and 9 at 1 and 5 minutes, respectively. Examination of the uterus in situ disclosed a 2 cm defect in the uterine serosa in the posterior fundal location with palpable placenta. There was minimal bleeding from the area and no invasion of surrounding organs. After exteriorization of the uterus, the thin serosal layer covering the remainder of the placenta splayed open (Figure 2). Excessive bleeding from the placental bed was then encountered, and a supracervical hysterectomy was performed. The patient’s total estimated blood loss from the procedure was 2 L; she was appropriately volume resuscitated with intravenous fluids and blood products intraoperatively. She had an uncomplicated postoperative course and was discharged home in stable condition on postoperative day 4. Her infant was discharged on day 7 of life in good condition. Histologic examination confirmed the clinical diagnosis of placenta percreta with placental tissue deeply invading the myometrium to the uterine serosal surface associated with hemorrhage and fibrin deposition. DISCUSSION Placenta percreta is characterized by the invasion of the chorionic villi through the myometrial and serosal layer of the uterus, typically in the absence of normal decidualized endometrial stroma. This absence of the decidua basalis leads to a clinically adherent placenta. Uterine instrumentation, previous cesarean section, and other procedures causing myometrial From the Department of Obstetrics and Gynecology (Dew, Harris), Division of Maternal and Fetal Medicine (Yost, Magee), and Department of Radiology (dePrisco), Baylor University Medical Center at Dallas. Corresponding author: Steven A. Harris, MD, MPH, 3801 Gaston Avenue, Suite 200, Dallas, TX 75246 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2015;28(1):38–40

b

a

Figure 1. (a) Sagittal MR image of deep placental invasion suggestive of increta or percreta (arrow). (b) Coronal MR image of placenta (arrowhead) extending deep through the surrounding myometrium (arrows).

scarring all increase the risk of abnormal placentation (1, 2). Antenatal diagnosis of placenta percreta can be difficult, especially in the setting of intraabdominal hemorrhage. The early diagnosis of this condition in the antepartum period using ultrasound, color Doppler, and MRI can reduce maternal morbidity and allow for elective delivery with the availability of proper personnel (3).

Placenta percreta is one of the most devastating obstetric diseases associated with abnormal placentation. Complications associated with the condition include uterine rupture, massive blood transfusion, ureteral ligation or fistula formation, infection, perinatal death, and maternal death (4). There is no recommended management strategy for intraabdominal bleeding due to placenta percreta diagnosed in the previable period in a stable patient. Possible options include hysterectomy with or without embolization of uterine or internal iliac arteries to prevent a potential life-threatening hemorrhage without consideration of fetus or uterus; embolization and hysterotomy with removal of fetus and placenta in hopes of preserving the uterus; feticide combined with methotrexate possibly resulting in a spontaneous vaginal abortion or, if needed, vaginal or abdominal removal; and an expectant management approach within a clinical setting with all precautions of adequate intervention available in case of recurrent bleeding (5). With expectant management, the timing of delivery for placenta percreta needs to be individualized to optimize both maternal and fetal outcomes. A recent decision analysis states that in a stable patient, planned delivery at 34 weeks’ gestation without amniocentesis for fetal lung maturity is acceptable (6). The incidence of placenta percreta has gradually increased coinciding with the increasing rate of cesarean delivery: the incidence was 1/70,000 (7) in the 1970s and 1/533 (1) in 2005. Not surprisingly, previous cesarean section is one of the strongest risk factors for development of abnormal placentation. Additional risk factors for the development of placenta percreta include advanced maternal age, placenta previa, and other previous uterine procedures (1, 2).

Figure 2. Intraoperative appearance of the uterus with invasion of placental tissue through the uterine serosa.

1.

January 2015

Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 2005;192(5):1458–1461.

Second trimester placenta percreta presenting as acute abdomen

39

2. 3.

4.

40

Tantbirojn P, Crum CP, Parast MM. Pathophysiology of placenta creta: the role of decidua and extravillous trophoblast. Placenta 2008;29(7):639–645. Merz W, Van de Vondel P, Strunk H, Geipel A, Gembruch U. Diagnosis, treatment and application of color Doppler in conservative management of abnormally adherent placenta. Ultraschall Med 2009;30(6):571–576. O’Brien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative strategies. Am J Obstet Gynecol 1996;175(6):1632–1638.

5.

6.

7.

Roeters AE, Oudijk MA, Heydanus R, Bruinse HW. Pregnancy outcome after intra-abdominal bleeding due to placenta percreta at 14 weeks of gestation. Obstet Gynecol 2007;109(2 Pt 2):574–576. Robinson BK, Grobman WA. Effectiveness of timing strategies for delivery of individuals with placenta previa and accreta. Obstet Gynecol 2010;116(4):835–842. Hudon L, Belfort MA, Broome DR. Diagnosis and management of placenta percreta: a review. Obstet Gynecol Surv 1998;53(8):509–517.

Baylor University Medical Center Proceedings

Volume 28, Number 1

Second trimester placenta percreta presenting as acute abdomen.

Diagnosing placenta percreta can be difficult. We describe a 41-year-old woman presenting at 21 weeks' gestation with intraabdominal bleeding and no s...
522KB Sizes 0 Downloads 11 Views