Pregnant noncommunicating rudimentary uterine horn with placenta percreta.

BACKGROUND: To report a placenta percreta in a 7-week gestational rudimentary noncommunicating uterine horn pregnancy. METHODS: A 28-year-old woman with no complaints presented with a rudimentary uterine horn pregnancy at 7-weeks gestation. The diagnosis was suspected by ultrasonography and diagnosed by laparoscopy. Laparoscopic excision of the rudimentary uterine horn and ipsilateral salpingectomy were performed, as well as biopsy of several peritoneal endometriosis lesions. RESULTS: A 7-week gestation pregnancy with placenta percreta was identified in the rudimentary uterine horn. No communication was found with the right unicornuate uterus. Endometriosis was confirmed. Clinical outcome was favorable. CONCLUSION: Placenta percreta may occur in rudimentary uterine horn pregnancies, but accidents may be avoided by an early diagnosis and surgical management. However, in young women who desire pregnancy, planned laparoscopic resection of a rudimentary uterine horn revealed accidentally should be discussed.     

Fundal partial placenta percreta complicated with postpartum hemoperitoneum: A case report

IntroductionThe fundus of the uterus is a rare location for abnormally invasive placenta compared with the common site of abnormally invasive placenta in the lower segment of the uterus.Presentation of caseWe report a case of a 38-year-old multipara woman who had a fundal partial placenta percreta with no prior cesarean sections, which presented as a retained placenta after preterm labor, and complicated with hemorrhagic shock due to postpartum hemoperitoneum, thus it was diagnosed after surgery and managed by subtotal hysterectomy.DiscussionWe discuss the most common risk factors for abnormally invasive placenta and its diagnosis and management. We compare the possibility of leading to invasive placenta resulting from curettage trauma and cesarean delivery scars.ConclusionHistory of uterine surgical procedures without prior cesarean delivery must raise suspicion of abnormally invasive placenta regardless of its localization, especially when associates with preterm labor or retained placenta.     

Multidisciplinary management of placenta percreta complicated by embolic phenomena

Hemorrhage and thrombosis are major causes of maternal mortality. This case discusses the management of a woman with placenta percreta complicated by intraoperative pulmonary embolism. A 39-year-old gravida 3 with two previous cesarean deliveries presented at 34 weeks of gestation with an antepartum hemorrhage. Magnetic resonance imaging confirmed placenta percreta. The multidisciplinary group including obstetricians, gynecological oncologists, interventional radiologists and anesthesiologists developed a delivery plan. Cesarean delivery was performed with internal iliac artery occlusion and embolization catheters in place. After the uterine incision our patient experienced acute hypotension and hypoxia associated with a drop in the end-tidal carbon dioxide and sinus tachycardia. She was resuscitated and the uterus closed with the placenta in situ. Postoperatively, uterine bleeding was arrested by immediate uterine artery embolization. With initiation of embolization, hypotension and hypoxia recurred. Oxygenation and hemodynamics slowly improved, the case continued and the patient was extubated uneventfully at the end of the procedure. Computed tomography revealed multiple pulmonary emboli. The patient was anticoagulated with low-molecular-weight heparin and returned six weeks later for hysterectomy. Placenta percreta with invasion into the bladder can be catastrophic if not recognized before delivery. The chronology of events suggests that this may have been amniotic fluid emboli. An intact placenta with abnormal architecture, such as placenta percreta, may increase the risk of amniotic fluid embolus. The clinical findings and co-existing filling defects on computed tomography may represent a spectrum of amniotic fluid embolism syndrome.     

Cesarean hysterectomy for placenta percreta invading the anterior abdominal wall: anesthetic considerations--a case report

Placenta accreta is defined as an abnormal adherence of the placenta to the uterine wall owing to a faulty or an absent decidua basalis. Placenta accreta is further subdivided into placenta accreta vera, increta and percreta, depending on the level of invasion of the uterine wall and surrounding structures. Placenta percreta represents invasion to the serosa and/or other pelvic structures. We herein present the case of a pregnant patient with placenta percreta invading anterior abdominal wall and review the perioperative (Cesarean hysterectomy) anesthetic management of this complication.     

Anesthetic management of two cases with placenta percreta that caused massive hemorrhage during cesarean section

We report the anesthetic management of two cases with placenta percreta that caused massive hemorrhage during cesarean section. These pregnant women, with a past history of cesarean section underwent elective operation after being diagnosed with total placenta previa and suspected adhesion of the placenta. The placenta percreta became evident after laparotomy and the patients underwent total hysterectomy after infant expulsion. They went into serious hemorrhagic shock, and recovered after the application of intensive cardiovascular support and blood transfusion. In recent years, the incidence of adhesion of the placenta has increased, but definitive, preoperative diagnosis is difficult; especially for the severe type: placenta percreta. Therefore, intensive management is necessary for the anesthesia of pregnant women with suspected adhesion of the placenta, including adequate preparation of transfused blood, since it might be difficult to save the mother's life after the onset of massive hemorrhage.     

胎盘植入62例临床分析

目的对北京协和医院胎盘植入病例的临床处理和结局进行分析。方法对2011年1月至2013年12月北京协和医院收治的胎盘植入病例62例进行回顾性病例分析。并对其中我院分娩的45例孕妇,根据超声或核磁共振结果,分为产前疑诊组和产前未疑诊组,比较两组患者一般情况及产科并发症发生情况。结果 62例胎盘植入病例中,24.2%合并剖宫产史,66.1%合并人工流产史。胎盘部分或全部残留占35.5%,合并产后出血51.6%,严重产后出血共7例。子宫切除共6例。产前疑诊胎盘植入病例合并剖宫产史者显著高于产前未疑诊病例(P=0.043);产前疑诊组合并前置胎盘、产后出血、胎盘穿透发生率均高于未疑诊组,但无统计学差异(P0.05)。6例子宫切除病例中有3例合并中央性前置胎盘,1例胎盘穿透,4例严重产后出血。结论剖宫产史和人工流产史是胎盘植入和胎盘穿透的高危因素,产前疑诊胎盘植入病例有助于制定分娩和抢救计划,以避免严重产科并发症的发生。     

Laparoscopic-assisted vaginal hysterectomy in a patient with placenta percreta

Placenta percreta is a problem encountered with increasing frequency due to the rising rate of cesarean delivery. Conservative management of this condition is associated with decreased perioperative morbidity. When hysterectomy is necessary, a laparoscopic approach can provide additional benefits. We present the case of a woman with placenta percreta with bladder invasion who was undergoing conservative management and then required delayed hysterectomy. Laparoscopic-assisted vaginal hysterectomy was successfully performed. We review the techniques used to ensure a good outcome and the advantages of a minimally invasive approach to hysterectomy in this patient with placenta percreta.     

Acute abdomen at 12 weeks secondary to placenta percreta

With increasing caesarean section rates during the past decades, a rising trend of placenta percreta is observed. Although rare, placenta percreta can present as acute abdomen due to haemoperitoneum during antepartum period. A 24 years old pregnant lady with two previous caesarean sections, presented in emergency at 12 weeks of gestation with syncope, acute abdominal pain and distension. Ultrasonography revealed an ectopic pregnancy in right adnexa with intraperitoneal haemorrhage. On laparotomy, there was moderate hemoperitoneum, both adnexa were normal and placental tissue was protruding through a bleeding previous caesarean scar. Hysterectomy was done. Histopathological report was consistent with the diagnosis of placenta percreta.     

超声及MRI在胎盘植入诊断中的应用现状及评价

胎盘植入是胎盘绒毛因内膜缺陷而直接侵入子宫内膜,或胎盘直接种植到子宫肌层及浆膜层内。根据胎盘绒毛植入子宫肌层的深度,可将胎盘植入分为胎盘粘连、胎盘植入和胎盘穿通。超声和MRI是目前临床最常用于诊断胎盘植入的方法。超声已成为胎盘植入的首选检查方法;但当胎盘位于子宫后壁或需要判断胎盘植入深度时,超声检查结果不可靠。作为超声检查的辅助手段,MRI对于胎盘位于子宫后壁的患者具有较大优势,同时对于胎盘植入的分型(尤其对于胎盘穿通的患者)明显优于超声。对临床怀疑有胎盘植入高危因素的孕妇可先行超声检查;当超声诊断不明确、胎盘位于子宫后壁或不能判断其植入深度时,可进一步行MRI,以优化诊断率。     

A case report of placenta percreta with bladder invasion

A 33-year-old British woman who had undergone caesarean section at 31 years of age was admitted to our hospital at 28 weeks of gestation due to a large amount of genital hemorrhage induced by total placenta previa. Magnetic resonance imaging showed placenta percreta with bladder invasion. To control the sudden hemorrhage at 31 weeks of gestation, we performed an operation emergently. An occlusion ballon was inserted into the bilateral internal iliac arteries by radiologists, caesarian section followed by simple hysterectomy was performed by gynecologists, and then the bladder wall with placenta percreta was removed by urologists. Although the operation was carefully undertaken with multi-department cooperation, 11,550 ml of blood was lost during the 6.5-hour operation. There are few reports of placenta percreta with bladder invasion, about 30 cases including 3 cases in our country have been reported around the world until now.     

Urological Manifestations of Placenta Percreta

Placenta percreta is a condition of pregnancy associated with abnormal decidua placenta. It is characterized by invasion of chorionic villi past the myometrium and serosa, towards urogenital organs. Complications include massive hemorrhage, bladder dysfunction, and severe infections during delivery. Reports suggest an increasing prevalence of this condition. From a urological perspective, this review suggests how early diagnostic modalities, effective treatment plans, and appropriate surgical methods may aid in decreasing the morbidity and mortality of placenta percreta. The importance of maintaining bladder integrity during hysterectomy is emphasized.Key Words: Abnormal placentation, Pregnancy, Hematuria, Placenta, Post postpartum hemorrhage, Shock, Placenta percreta, Pregnancy     

Cesarean section in a pregnant patient with placenta percreta involving the urinary bladder

Placenta percreta involving adjacent structures is serious complication of pregnancy with a high mortality rate. A 32-year-old woman, gravida 4, para 3, who had previously undergone a cesarean section, was admitted to our hospital at 31 weeks' gestation for placenta previa. At 33 weeks' gestation, the diagnosis of placenta percreta with involvement of the urinary bladder was made by ultrasonography and magnetic resonance imaging. At 34 weeks' gestation, an elective cesarean section was scheduled. Anesthesia was maintained with sevoflurane in oxygen before delivery, and with nitrous oxide in oxygen, fentanyl and midazolam after delivery. During the operation, attempts to remove the placenta resulted in massive hemorrhage. Blood loss for the procedure was 13,800 g. Because of the extreme hemorrhage, we encountered hemorrhagic shock and postoperative complications despite the preoperative preparation. In case of placenta percreta, it is essential to prepare adequate volume of blood for transfusion at the start of surgery and secure large bore intravenous lines. A rapid transfusion device may be recommended. Regarding the anesthetic management, general anesthesia is preferable in consideration of the risk of hemorrhagic shock and the length of operation time. Furthermore, we need team approach and preoperative management to prevent the uncontrolled hemorrhage in such a severe case.     

Interventional radiology in women with suspected placenta accreta undergoing caesarean section

Placenta praevia in the presence of a previous uterine scar is associated with increased risk of placenta accreta, which could lead to major haemorrhage at delivery. Major haemorrhage is one of the leading causes of maternal mortality in the UK. Interventional radiology with trans-catheter balloon occlusion or arterial embolisation is a recognised technique for the management of intractable obstetric haemorrhage. Between December 2002 and May 2007 thirteen women in our institution with sonographic findings of anterior placenta praevia and suspected placenta accreta or percreta underwent caesarean sections with peri-operative bilateral internal iliac artery catheterization with or without balloon occlusion or embolisation. This case series describes our experience of anaesthetic and radiological techniques, surgical procedures and outcomes. The obstetricians and anaesthetists in our institution are of the impression that the use of peri-operative, preferably pre-operative, internal iliac artery catheterization with or without balloon occlusion or embolisation, in women with placenta accreta or percreta, improves the operative field and potentially reduces blood loss and transfusion requirements. We were unable to find evidence that this technique reduces the need for caesarean hysterectomy. Through our experience, we have developed a unit protocol for the management of women with suspected placenta accreta undergoing caesarean section.     

Placenta percreta with bladder invasion as a cause of life threatening hemorrhage

PURPOSE: Abnormal placental penetration through the myometrium with bladder invasion is a rare obstetric complication with potential for massive blood loss. Urologists are usually consulted after a life threatening emergency has already arisen. Their familiarity with this condition is crucial for effective management. We describe 2 cases of placenta percreta with bladder invasion to highlight the catastrophic nature of this clinical entity, and review the literature on current diagnostic and management strategies. MATERIALS AND METHODS: Between 1986 and 1998, 250 cases of adherent placenta (0.9%) were identified in 25,254 births at our institution, including 2 (0.008%) of placenta percreta with bladder invasion. We treated these 2 multiparous women who were 33 and 30 years old, respectively. Each had undergone 2 previous cesarean sections. RESULTS: Presenting symptoms were severe hematuria in 1 patient and prepartum hemorrhage with shock in the other. Ultrasound showed complete placenta previa in each with evidence of bladder invasion in 1 patient. Hysterectomy, bladder wall resection and repair, and bilateral internal iliac artery ligation were required to control massive intraoperative hemorrhage. The patients received 22 and 15 units of packed red blood cells, respectively. Fetal death occurred in each case. Convalescence was complicated by disseminated intravascular coagulation in patient 1 but subsequent recovery was uneventful. CONCLUSIONS: A high index of suspicion for placenta percreta with bladder invasion is required when evaluating pregnant women with a history of cesarean delivery and placenta previa who present with hematuria and lower urinary tract symptoms. Ultrasonography and magnetic resonance imaging may assist in establishing the diagnosis preoperatively. With proper planning and a multidisciplinary approach fetal and maternal morbidity and mortality may be decreased.     

Anestesia y reanimación en un caso de placenta pércreta

Placenta percreta is a sub-type of placenta accreta in which this organ invades the whole uterine wall and affects the adjacent organs. It is a condition with a high surgical risk which generally requires an obstetric hysterectomy.We present the case of a 36 year-old pregnant woman diagnosed with placenta percreta with bladder and intestinal invasion. She suffered a hypovolaemic shock during surgery which required a massive transfusion of blood products and inotropic support. Three further successive surgeries were required due to the bleeding, with selective embolisation of the hypogastric arteries being performed in one of them. She required 13 days in intensive care. The total volume of blood products transfused was, 43 units of red cells, 28 units of plasma, and 8 platelet pools.The importance of early prenatal diagnosis is emphasised in order to adequately plan the operation, and should include a multidisciplinary team (general surgeons, urologists, vascular surgeons), as well as experienced anaesthesiologists and obstetricians.     

Massive obstetric haemorrhage on post caesarean subtotal hysterectomy due to late detection of occult placenta percreta: A case report

IntroductionPlacenta accreta syndrome is a significant cause of maternal mortality and morbidity. Therefore, a multidiscipline approach is essential to overcome this life-threatening disorder for the mother and fetus.Presentation of caseA 32-year-old women gravida 3 parity 2, 34 weeks gestation come due to recurrent antepartum haemorrhage. She had twice prior caesarean section. Ultrasound assessment suggests total placenta previa and elevating suspicion to placenta accreta. However, intraoperatively its sign is unavailable. Although we have done subtotal hysterectomy, massive bleeding still occurring. Therefore, we present management of unexpected placenta percreta.DiscussionManagement of unexpected placenta percreta involves prenatal diagnosis, haemoglobin optimization, surgical management anticipating haemorrhage, dedicated maternal ICU, blood bank providing massive transfusion and blood component.ConclusionClose monitoring is important in catastrophe management of Placenta Accreta Syndrome.     

Haemoperitoneum due to placenta percreta. A case report

A case of haemoperitoneum due to placenta percreta occurring at approximately 22 weeks' gestation is presented. The diagnosis and treatment are discussed.     

An unusual case of Youssef's syndrome (vesicouterine fistula) and its relationship with placenta percreta

A pregnant lady, on antenatal ultrasound examination, was found to have placenta percreta involving the bladder. After cesarean section, she developed the typical triad of Youssef's syndrome i.e. cyclic hematuria and amenorrhea without vaginal leakage of urine. Cystoscopy showed a vesicouterine fistula which was treated through the transabdominal approach.     

Placenta Accreta and Percreta

The incidence of abnormally adherent placenta (accreta/percreta) has increased 10-fold in the past 50 years, predominantly due to the increased use of cesarean section delivery. The causes, clinical correlates, and pathology of these conditions are discussed in this article.     

Placenta percreta invading the bladder: report of 2 cases

We report 2 cases of placenta percreta with invasion of the bladder that resulted in massive hemorrhage at cesarean section. Control was achieved by hysterectomy, bilateral internal iliac artery ligation, suture ligation of bleeding vessels and bladder repair, with no fetal or maternal mortality.