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Placenta accreta and percreta: A review of 5 cases
Int. Gynaecol. Obstet., 1981, 19: 337-340 0 International Federation of Gynaecology
PLACENTA
ACCRETA
8 Obstetrics
AND PERCRETA:
A REVIEW OF 5 CASES
ASHA OUMACHIGUI, GITA RAJAGOPALAN, RANI REDDY. R. PRABHAVATHY and A. CHAKRAVARTY Department of Obstetrics and Gynaecology. Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India (Received December 29th. 1980) (Accepted February 11 th, 198 1)
Abstract Oumachigui A, Rajagopalan G, Reddy R, Prabhavathy R, Chakravarty A (Dept. of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India). Placenta accreta and percreta: review of five cases. Int J Gynaecol Obstet 19: 337-340, 1981 Five cases of placenta accreta and percreta are reviewed. Three cases, one a recurrence in the same patient, presented with acute abdominal pain; in one case perforation resulting from placenta percreta was discovered at laparotomy. In another case, placenta accreta was recognized during cesarean delivery. Total or subtotal hysterectomy was performed in three cases; piecemeal removal of placenta1 tissue and closure of the tear was performed in two of the patients. There were no maternal deaths, but the infants were stillborn in three cases of perforation or uterine rupture.
Placenta accreta Trophoblastic tumors
Key words:
creta
Placenta per-
Introduction
Placenta accreta is a rare complication in obstetrics. The reported incidence varies from 1 in 540 to 1 in 70,000 [ ll. High parity, previous retention of placenta that required manual removal, placenta previa, uterine curettage and cesarean delivery have been significantly associated with placenta accreta.
A rise in incidence is expected with the liberalization of abortion law. When the placenta1 adhesion is extensive, no histologie study is necessary for diagnosis. Cases in which adhesions are only focal and where pathologie study is required, however, can present difficulty in diagnosis even to the pathologist. In placenta accreta, a high maternal mortality is expected because of hemorrhage and infection. Perinatal mortality is considerable in cases of spontaneous uterine rupture. Case reports Case 1
A 30-year-old gravida 2 was seen on January 1, 1974. During her first delivery she had a retained placenta, which was removed manually, and postpartum hemorrhage. On examination, her pregnancy was mature and the fetus was found to be in the breech position. A cesarean was performed at the onset of labor, as the cervix was markedly stenotic. Laparotomy revealed a smal1 perforation (1 cm in diameter) at the fundus. The baby was delivered by a transverse, curvilinear incision on the lower segment. The placenta was densely adherent over the entire uterine cavity. A total hysterectomy was performed. One unit of blood was transfused, and the patient was given antibiotics postoperatively. She was discharged on the tenth postoperative day. The uterus was sent for histopathologie examination, at which the presence of placenta increta and percreta was confirmed. Int J Gynaecol Obstet 19
338
Oumachigui et al
Case 2
A 25year-old gravida 2 was first seen on July 14, 1975. Her first pregnancy had ended in a full-term normal delivery. The pdtient’s period of gestation was 32 weeks, and she complained of severe abdominal pain of 24 h duration. She was markedly pale and had a hemoglobin leve1 of 7 g/lOO ml. Her pulse rate was 120 beats/min, and her blood pressure was 90/70 mmHg. Uterine size was consistent with 34weeks gestation and was tender; fetal parts were not palpable, and fetal heart sounds were absent. The cervix was partly effaced and 2 cm dilated; the membranes were present, and the fetus was in a position for vertex presentation. A provisional diagnosis of concealed, accidental hemorrhage was made, and the membranes were ruptured artifically. The patient gave birth spontaneously within 6 h, to a stillborn fetus weighing 1.8 kg. The placenta did not separate as expected. With the patient under genera1 anesthesia, the placenta was found to be adherent and was removed piecemeal. During the procedure, a uterine tear was suspected and laparotomy was performed. There were 500- 1000 ml of clotted blood in the peritoneal cavity. The tear was closed to salvage the uterus, as the patient had only one living child and as most of the placenta1 tissue had been removed. Three units of blood were transfused, and the patient was given antibiotics. She developed an infection in the postoperative period, but it was controlled satisfactorily. She was discharged on the 16th postoperative day. Case 3 A gravida 3, para 1, abortus 1, was admitted on February 10, 1977. She had undergone an evacuation for incomplete instrumental abortion in 1972 and had had a lower segment cesarean for cephalopelvic disproportion in 1973. On examination, the patient was found to be at term and in the early stage of labor. A rupture of the cesarean uterine star was suspected. A laparotomy was immediately Int J Gynaecol Obstet 19
performed; the star, however, was intact. A live baby was delivered by a repeat lower segment incision. The placenta was morbidly adherent to the entire uterine surface, and a subtotal hysterectomy was performed. The patient was given antibiotics, and discharged on the 11th postoperative day. Histopathologie examination confirmed placenta accreta. Case 4 An 1Syear-old primigravida was admitted on March 8, 1978, with a history of prolonged labor and with severe abdominal pain. The patient was pale and restless. Her pulse rate was 120 beats/min, and her blood pressure was 90/80 mmHg. The uterine contour could not be ascertained by palpation; fetal parts were felt superficially. Uterine rupture was suspected, and a laparotomy was performed. There was a complete rupture in the lower uterine segment extending toward the left broad ligament. A stillborn baby lying partly in the uterus was extracted. The placenta was adherent at the site of the rupture. Results of the biopsy taken from the uterine wal1 and the placenta in the region of the rupture showed placenta percreta. The placenta was removed piecemeal, and the tear was closed. The patient was discharged on the 12th postoperative day. In May, 1979, the same patient was seen again with a gestation of 30 weeks and was scheduled for elective cesarean delivery at term. At 38 weeks, however, she complained of severe abdominal pain. A laparotomy was performed on July 10, 1979. There was no evidente of star rupture. A live baby was delivered by a transverse lower segment incision. Placenta previa (Type 1) was seen; the placenta was morbidly adherent. It was removed piecemeal before the uterine incision was sutured. The patient was given antibiotics and discharged on the 15th postoperative day. Case 5
A 21-year-old gravida 2 was first admitted
Placenta accreta and percreta
as an emergency patient on November 8, 1979, for acute corrosive esophagogastritis. She was known to have had rheumatic heart disease (mitral stenosis and regurgitation). Her fust pregnancy had ended in a full-term, normal delivery. On emergency admission, she was referred to the obstetrician because she was 8 months pregnant, On examination, the patient was pale and hypotensive (blood pressure, 70/50 mmHg). The uterine contour could not be felt; fetal parts were felt superficially, and fetal heart sounds were absent. Blood was aspirated on paracentesis. A laparotomy was resorted to immediately. A dead fetus was lying in the peritoneal cavity, along with about 2000 ml of blood. After the fetus was extracted, the uterine rupture (10 cm) was seen at the fundus (Fig. 1). A subtotal hysterectomy was performed because the placenta adherent. Histopathologie was morbidly
339
examination confirmed the diagnosis of placenta percreta. The patient was treated for corrosive esophagogastritis and discharged on the 20th postoperative day. Discussion Recurrence of placenta accreta was noted in case No. 4. Her first pregnancy was associated with placenta previa. The recurrence may have been a result of the star in the lower segment and the placenta previa (Type 1). These two factors are the ones most commonly associated with placenta accreta [ 5 1. Cesarean delivery star was a factor in case No. 3. Parity
A high parity is said to be a predisposing factor to placenta accreta [23. A low parity however, was a constant feature in al1 our cases. Previous obstetrie difficulties
Previous manual removal of a retained placenta was noted in one case. Edgar [21 noted this condition three times in one patient, and four and five times in two others. A history of instrumental evacuation was obtained in one of our patients. Both these procedures can cause trauma to the endometrium, which plays a role in the occurrence of placenta accreta. Placenta accreta following the treatment of Asherman’s syndrome has been reported [4]. Millar 171 and Luke et al. [61 found that 33% and 28% of their patients respectively, had had curettage previously. Breen et al. 111 have suggested that cytotoxic drugs for trophoblastic tumors may play a role in causing placenta accreta. Diagnosis
Fig. 1.
Uterine rupture at Fundus From case No. 5.
Classically, placenta accreta presents as a complication of the third stage of labor. This was true for only one of our cases (No. 2). Spontaneous perforation giving rise to acute abdominal pain was seen in case NOS. 2, 4 (fust admission) and 5. In case No. 1, the perforation was small and had not manifested Int J Gynaecol Obstet 19
340
Oumachigui et al.
earlier; the diagnosis was made during cesarean delivery. In the cases reported by Millar [7] and Shah and Mehta [ 8 1, spontaneous rupture was noted in 7% and 4% of their patients, respectively.
complain of acute abdominal pain with signs of intemal bleeding, particularly in those who previously have undergone uterine surgery.
Treatment There is general agreement that the best treatment for placenta accreta is hysterectomy [ 1,251. It should be recognized that removal of the placenta is associated with a high risk of both hemorrhage and sepsis. Nevertheless, the procedure was attempted successfully once in case No. 2 and twice in case No. 4, as it was desirable to preserve the patient’s reproductive capacity. In both these cases. the perforations were also sutured. The increased risk that wil1 be associated with any future pregnancy in these cases must be remembered. Hysterectomy was performed in our other three patients. Maternal mortality has been shown to fa11 drastically when hysterectomy. is resorted to [3]. Total hysterectomy should be done in cases of placenta previa accreta so that placental tissue is not left in the stump. The complication of disseminated intravascular coagulation, a complication of placenta previa percreta, was recorded by Kitchen [5]; hemostasis was a problem even after hysterectomy. The possibility of a placenta percreta should be kept in mind when pregnant women
Breen JL, Neubrecher R, Gregori CA, Franklin JE: Placenta accreta, increta and percreta - A survey of 40 cases. Obstet Gynecol49: 43, 1977. Edgar MJ: In Obstetrics and Gynaecology Annual 1978, (ed. RM Wynn). p 107, AppIetonCenturyCrofts, New York, 1978. Fox H: Placenta accreta 19451969. Obstet Gynecol SUN 27: 475,1972. Georgakopoulos P: Placenta accreta foIlowing lysis of uterine synechiae (Asherman’s syndrome). J. Obstet Gynaecol Br Commonw SI: 730,1974. Kitchen DH: Placenta accreta, percreta and praevia accreta. Aust NZ J Obstet Gynecol18: 238, 1978. Luke RK, Sharpe JW, Greene RR: Placenta accreta: The adherent or invasive placenta. Am J Obstet Gynecol 95: 660,1966. Millar WG: A clinical and pathological study of placenta accreta. J Obstet Gynecol Br Emp 66: 353,1959. Shah JT, Mehta A: Placenta accreta (A review of cases from the Journal of Obstetrics and Gynaecology of India and 3 case reports). J Obstet Gynecol (India) 23: 191, 1973.
Int J Gynaecol Obstet 19
References
Address for reprints: Asha Oumachigui Dept of Obstetrics and Gynaecology lawaharlal Institute of Postgraduate Medicai Education and Research Pondicherry 605006 India
PLACENTA
ACCRETA
8 Obstetrics
AND PERCRETA:
A REVIEW OF 5 CASES
ASHA OUMACHIGUI, GITA RAJAGOPALAN, RANI REDDY. R. PRABHAVATHY and A. CHAKRAVARTY Department of Obstetrics and Gynaecology. Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India (Received December 29th. 1980) (Accepted February 11 th, 198 1)
Abstract Oumachigui A, Rajagopalan G, Reddy R, Prabhavathy R, Chakravarty A (Dept. of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India). Placenta accreta and percreta: review of five cases. Int J Gynaecol Obstet 19: 337-340, 1981 Five cases of placenta accreta and percreta are reviewed. Three cases, one a recurrence in the same patient, presented with acute abdominal pain; in one case perforation resulting from placenta percreta was discovered at laparotomy. In another case, placenta accreta was recognized during cesarean delivery. Total or subtotal hysterectomy was performed in three cases; piecemeal removal of placenta1 tissue and closure of the tear was performed in two of the patients. There were no maternal deaths, but the infants were stillborn in three cases of perforation or uterine rupture.
Placenta accreta Trophoblastic tumors
Key words:
creta
Placenta per-
Introduction
Placenta accreta is a rare complication in obstetrics. The reported incidence varies from 1 in 540 to 1 in 70,000 [ ll. High parity, previous retention of placenta that required manual removal, placenta previa, uterine curettage and cesarean delivery have been significantly associated with placenta accreta.
A rise in incidence is expected with the liberalization of abortion law. When the placenta1 adhesion is extensive, no histologie study is necessary for diagnosis. Cases in which adhesions are only focal and where pathologie study is required, however, can present difficulty in diagnosis even to the pathologist. In placenta accreta, a high maternal mortality is expected because of hemorrhage and infection. Perinatal mortality is considerable in cases of spontaneous uterine rupture. Case reports Case 1
A 30-year-old gravida 2 was seen on January 1, 1974. During her first delivery she had a retained placenta, which was removed manually, and postpartum hemorrhage. On examination, her pregnancy was mature and the fetus was found to be in the breech position. A cesarean was performed at the onset of labor, as the cervix was markedly stenotic. Laparotomy revealed a smal1 perforation (1 cm in diameter) at the fundus. The baby was delivered by a transverse, curvilinear incision on the lower segment. The placenta was densely adherent over the entire uterine cavity. A total hysterectomy was performed. One unit of blood was transfused, and the patient was given antibiotics postoperatively. She was discharged on the tenth postoperative day. The uterus was sent for histopathologie examination, at which the presence of placenta increta and percreta was confirmed. Int J Gynaecol Obstet 19
338
Oumachigui et al
Case 2
A 25year-old gravida 2 was first seen on July 14, 1975. Her first pregnancy had ended in a full-term normal delivery. The pdtient’s period of gestation was 32 weeks, and she complained of severe abdominal pain of 24 h duration. She was markedly pale and had a hemoglobin leve1 of 7 g/lOO ml. Her pulse rate was 120 beats/min, and her blood pressure was 90/70 mmHg. Uterine size was consistent with 34weeks gestation and was tender; fetal parts were not palpable, and fetal heart sounds were absent. The cervix was partly effaced and 2 cm dilated; the membranes were present, and the fetus was in a position for vertex presentation. A provisional diagnosis of concealed, accidental hemorrhage was made, and the membranes were ruptured artifically. The patient gave birth spontaneously within 6 h, to a stillborn fetus weighing 1.8 kg. The placenta did not separate as expected. With the patient under genera1 anesthesia, the placenta was found to be adherent and was removed piecemeal. During the procedure, a uterine tear was suspected and laparotomy was performed. There were 500- 1000 ml of clotted blood in the peritoneal cavity. The tear was closed to salvage the uterus, as the patient had only one living child and as most of the placenta1 tissue had been removed. Three units of blood were transfused, and the patient was given antibiotics. She developed an infection in the postoperative period, but it was controlled satisfactorily. She was discharged on the 16th postoperative day. Case 3 A gravida 3, para 1, abortus 1, was admitted on February 10, 1977. She had undergone an evacuation for incomplete instrumental abortion in 1972 and had had a lower segment cesarean for cephalopelvic disproportion in 1973. On examination, the patient was found to be at term and in the early stage of labor. A rupture of the cesarean uterine star was suspected. A laparotomy was immediately Int J Gynaecol Obstet 19
performed; the star, however, was intact. A live baby was delivered by a repeat lower segment incision. The placenta was morbidly adherent to the entire uterine surface, and a subtotal hysterectomy was performed. The patient was given antibiotics, and discharged on the 11th postoperative day. Histopathologie examination confirmed placenta accreta. Case 4 An 1Syear-old primigravida was admitted on March 8, 1978, with a history of prolonged labor and with severe abdominal pain. The patient was pale and restless. Her pulse rate was 120 beats/min, and her blood pressure was 90/80 mmHg. The uterine contour could not be ascertained by palpation; fetal parts were felt superficially. Uterine rupture was suspected, and a laparotomy was performed. There was a complete rupture in the lower uterine segment extending toward the left broad ligament. A stillborn baby lying partly in the uterus was extracted. The placenta was adherent at the site of the rupture. Results of the biopsy taken from the uterine wal1 and the placenta in the region of the rupture showed placenta percreta. The placenta was removed piecemeal, and the tear was closed. The patient was discharged on the 12th postoperative day. In May, 1979, the same patient was seen again with a gestation of 30 weeks and was scheduled for elective cesarean delivery at term. At 38 weeks, however, she complained of severe abdominal pain. A laparotomy was performed on July 10, 1979. There was no evidente of star rupture. A live baby was delivered by a transverse lower segment incision. Placenta previa (Type 1) was seen; the placenta was morbidly adherent. It was removed piecemeal before the uterine incision was sutured. The patient was given antibiotics and discharged on the 15th postoperative day. Case 5
A 21-year-old gravida 2 was first admitted
Placenta accreta and percreta
as an emergency patient on November 8, 1979, for acute corrosive esophagogastritis. She was known to have had rheumatic heart disease (mitral stenosis and regurgitation). Her fust pregnancy had ended in a full-term, normal delivery. On emergency admission, she was referred to the obstetrician because she was 8 months pregnant, On examination, the patient was pale and hypotensive (blood pressure, 70/50 mmHg). The uterine contour could not be felt; fetal parts were felt superficially, and fetal heart sounds were absent. Blood was aspirated on paracentesis. A laparotomy was resorted to immediately. A dead fetus was lying in the peritoneal cavity, along with about 2000 ml of blood. After the fetus was extracted, the uterine rupture (10 cm) was seen at the fundus (Fig. 1). A subtotal hysterectomy was performed because the placenta adherent. Histopathologie was morbidly
339
examination confirmed the diagnosis of placenta percreta. The patient was treated for corrosive esophagogastritis and discharged on the 20th postoperative day. Discussion Recurrence of placenta accreta was noted in case No. 4. Her first pregnancy was associated with placenta previa. The recurrence may have been a result of the star in the lower segment and the placenta previa (Type 1). These two factors are the ones most commonly associated with placenta accreta [ 5 1. Cesarean delivery star was a factor in case No. 3. Parity
A high parity is said to be a predisposing factor to placenta accreta [23. A low parity however, was a constant feature in al1 our cases. Previous obstetrie difficulties
Previous manual removal of a retained placenta was noted in one case. Edgar [21 noted this condition three times in one patient, and four and five times in two others. A history of instrumental evacuation was obtained in one of our patients. Both these procedures can cause trauma to the endometrium, which plays a role in the occurrence of placenta accreta. Placenta accreta following the treatment of Asherman’s syndrome has been reported [4]. Millar 171 and Luke et al. [61 found that 33% and 28% of their patients respectively, had had curettage previously. Breen et al. 111 have suggested that cytotoxic drugs for trophoblastic tumors may play a role in causing placenta accreta. Diagnosis
Fig. 1.
Uterine rupture at Fundus From case No. 5.
Classically, placenta accreta presents as a complication of the third stage of labor. This was true for only one of our cases (No. 2). Spontaneous perforation giving rise to acute abdominal pain was seen in case NOS. 2, 4 (fust admission) and 5. In case No. 1, the perforation was small and had not manifested Int J Gynaecol Obstet 19
340
Oumachigui et al.
earlier; the diagnosis was made during cesarean delivery. In the cases reported by Millar [7] and Shah and Mehta [ 8 1, spontaneous rupture was noted in 7% and 4% of their patients, respectively.
complain of acute abdominal pain with signs of intemal bleeding, particularly in those who previously have undergone uterine surgery.
Treatment There is general agreement that the best treatment for placenta accreta is hysterectomy [ 1,251. It should be recognized that removal of the placenta is associated with a high risk of both hemorrhage and sepsis. Nevertheless, the procedure was attempted successfully once in case No. 2 and twice in case No. 4, as it was desirable to preserve the patient’s reproductive capacity. In both these cases. the perforations were also sutured. The increased risk that wil1 be associated with any future pregnancy in these cases must be remembered. Hysterectomy was performed in our other three patients. Maternal mortality has been shown to fa11 drastically when hysterectomy. is resorted to [3]. Total hysterectomy should be done in cases of placenta previa accreta so that placental tissue is not left in the stump. The complication of disseminated intravascular coagulation, a complication of placenta previa percreta, was recorded by Kitchen [5]; hemostasis was a problem even after hysterectomy. The possibility of a placenta percreta should be kept in mind when pregnant women
Breen JL, Neubrecher R, Gregori CA, Franklin JE: Placenta accreta, increta and percreta - A survey of 40 cases. Obstet Gynecol49: 43, 1977. Edgar MJ: In Obstetrics and Gynaecology Annual 1978, (ed. RM Wynn). p 107, AppIetonCenturyCrofts, New York, 1978. Fox H: Placenta accreta 19451969. Obstet Gynecol SUN 27: 475,1972. Georgakopoulos P: Placenta accreta foIlowing lysis of uterine synechiae (Asherman’s syndrome). J. Obstet Gynaecol Br Commonw SI: 730,1974. Kitchen DH: Placenta accreta, percreta and praevia accreta. Aust NZ J Obstet Gynecol18: 238, 1978. Luke RK, Sharpe JW, Greene RR: Placenta accreta: The adherent or invasive placenta. Am J Obstet Gynecol 95: 660,1966. Millar WG: A clinical and pathological study of placenta accreta. J Obstet Gynecol Br Emp 66: 353,1959. Shah JT, Mehta A: Placenta accreta (A review of cases from the Journal of Obstetrics and Gynaecology of India and 3 case reports). J Obstet Gynecol (India) 23: 191, 1973.
Int J Gynaecol Obstet 19
References
Address for reprints: Asha Oumachigui Dept of Obstetrics and Gynaecology lawaharlal Institute of Postgraduate Medicai Education and Research Pondicherry 605006 India