Placenta Accreta

PLACENTA HARLEY (From

the Department

ACCRETA M.D., OMAHA,

E. ANDERSON,

of Obstetrics and College of Medicine,

Gynecology University

NEB.

of the University Hospital)

of Nebraska

118 authentic 0 NLYaccording to Meyer

cases of placenta accreta have been reported, and Ashworth’s’ tabulation in 1940, after careful perusal of the literature. The incidence of this pathologic condition varies greatly: Tiemeyer’ reports it on two occasions, a ratio of 1 in 2,156 cases; Lawson and Ogin? report that Polak in 34 years’ experience encountered but one case in every 6,000, and that Hirst found this anomaly only once in 40,000 deliveries. The etiology of placenta accreta is found in the partial or complete absence of the decidua basalis, allowing the villi to burrow directly into the uterine musculature, which in turn causes the placenta to be retained within the uterine cavity. Any condition producing a primary atrophy of the endometrium may be a factor in the causation of an accreta. The etiologic factors of prime importance are: previous manual removal of the placenta, too thorough curettage, endometritis, submucous myomas, previous cesarean section, and possibly dyshormonism. The chief symptom is more or less brisk bleeding when delivery of the placenta is attempted. The diagnosis is made after an attempt a,t manual removal has failed to establish a cleavage plane between the placenta and the uterine musculature, thus showing retention of the placenta within the uterine cavity. Thorough search of the literature has shown the agreement of all authorities that immediate hysterectomy is imperative as soon as a diagnosis of placenta accreta has been made. The following report is therefore presented, since treatment in this case varied so greatly from the orthodox management of this anomaly. CASE REPORT Mrs. R. B., aged 44 years, white, gravida xii, para xi, had no history of major illnesses. All the patient’s children had been born at home and labors were easy and uncomplicated except the pregnancy just prior to the present one which had terminated at eight months in a premature stillbirth. The cause of the prematurity was unknown. The present pregnancy was uneventful during the first two trimesters; the expected date was estimated as Sept. 22, 1932. On July 24, 1932, the amniotic sac ruptured spontaneously, and thirty-six hours later the patient was delivered normally of a live premature child at her home with the family physician in attendance. Two hours later, after failure of the placenta to deliver and because of profuse bleeding per vaginam, the patient was sent to the University Hospital. She complained of nausea and a great deal of abdominal pain. Shock was combated by hypodermic injections of morphine and application of external heat. Later the same day, because the bleeding continued, manual removal of the placenta was at545

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tempted. Only very small amounts of placental tissue could be removed and no line of cleavage could be established. At t.his time parenteral fluids were administered and the patient received 500 C.C. of blood by transfusion. Inasmuch as uterine bleeding continued, manual removal was unsuccessfully tried forty-eight hours after the first attempt, and the diagnosis of placenta accreta was confirmed. Because of the continuing poor condition of the patient, hysterectomy was deferred until major surgical intervention should be warranted. A septic course ensued, with a temperature of 104” F. on the fourth post-partum day, accompanied by chills. A copious amount, of foul-smelling discharge was noted throughout her hospitalization. Because of the patient’s generally poor condition, accentuated by a profound anemia which did not respond to blood transfusions and liver and iron therapy, a hysterectomy was at no time thought advisable. On the tenth post-partum day her temperature and pulse began to subside and on the twenty-first post-partum day her condition warranted dismissal from the hospital. She was seen at regular intervals at the out-patient clinic where hematopoietic therapy was continued. Ten weeks later, complaining of marked backache and constant pain in the left lower abdominal tquadrant, she was again admitted to the hospital. Pelvic examination showed marked relaxation of the pelvic floor and a patulous external cervical 0s. The uterine corpus was forward and well involuted, with some induration and tenderness in the region of the left adnexa. A panhysterectomy, bilateral salpingectomy, and unilateral oophorectomy were performed through a midline incision by Dr. E. C. Sage. The uterus was found to be soft, of approximately normal size, and adnexal organs were normal in appearance. Upon gross examination, the cut section of the uterine corpus showed a “quite ragged endometrium but without evidence of inflammatory reaction or material which can be recognized as placental tissue. ” The microscopic section, as reported by Dr. P. Tollman, showed “the endometrial surface to be covered with rather ragged masses of granulating tissue in which there are roughly circumscribed masses of very necrotic tissue which are quite uniformly pink staining. In some places this is definitely papillary in type. In a few places large and rather irregular cells remain about the border of these, which are interpreted as patchily degenerating decidual cells. This necrotic mass strikingly resembles chorionic villi undergoing degeneration. The surrounding tissue is moderately to heavily infiltrated with lymphocytes. There is an unusual amount of rather loose fibrous tissue scattered through the wall and the larger arteries show a prominent endarteritis of the type associated with atrophy of tissue.” Examination of a second section was similar except for the absence of chorionic villi. When last seen, this patient was well and had no pelvic complaints. DISCUSSION

Careful search of the literature shows that all outstanding authorities without exception recommend immediate supravaginal hysterectomy as the treatment of choke after diagnosis of placenta accreta has been established. This procedure is augmented by transfusion both before and after surgery. Meyer and Ashworth’s’ tabulations show a mortality of 58 per cent in manual extraction or curettage; 36.4 per cent in partial manual extraction and vaginal hysterectomy; 18.9 per cent in partial manual extraction and supravaginal hysterectomy; and no mortality in supravagind hysterectomy with no attempt at extraction. From the mortality standpoint, this latter procedure would seem to be the method of choice. However, if no attempt at extraction is made, diagnosis is impossible because the inability to establish a line of cleavage is what differentiates placenta accreta from the simple adherent placenta. It would seem extremely radical to perform a supravaginal hysterectomy on each and every retained placenta that is not bleeding

ANDERSON

:

PLACENTA

547

ACCRETA

that has not been expelled within two hours’ time, as some writers have suggested. Stander4 warns that if a prompt hysterectomy is net done directly following the diagnosis, death from hemorrhage usually follows. In the case presented after the diagnosis of accreta had been made, and measures to combat the acute anemia and shock resorted to, at no time during the immediate puerperium was the patient’s condition The writer sufficiently good to warrant supravaginal hysterectomy. feels confident that surgical intervention would have been fatal. At the time of the patient’s readmittance to the hospital, because of her previous condition, removal of the uterus was thought advisable. Rut, postoperative examination of the uterine corpus and the pathologic report showed that very likely no further pathologic condition of the placenta needed to be feared. This case is reported to emphasize the successful outcome of unorthodox treatment in the immediate puerperium of placenta accreta. and

REFERENCES

(2) (1) Meyer and Ashworth : Virginia M. Monthly 67: 36, 1940. 6. : South. M. J. 31: 608, 1938. (3) Lawson and 0gin.z: Am. J. Sung. (4) Williams Obstetrics (Stander), ed. 8, New York, D. Appleton-Century

Campbell,

Meredith

F.:

Vulvar

Fusion,

J. A. 7%.A.

115:

513,

Tiemeyer, A. 41:

70, 1938. Co.

1940.

Fused vulva designates the condition eharaeterized by an embryonal midline sealing together of the labia minora. As a rule an unfused area is left well forward and through this orifice the child urinates. This condition is either congenital, or acquired through inflammatory changes. The most rational explanation for t,he embryologic type is fusion in the midline of the labial folds, similar to that which the two scrotal folds undergo in the male, but the fusion usually lacks the density of scrotal fusion. Acquired vulvar fusion is said to follow local inflammation consequent to acute infectious diseases sue.11 as cholera, smallpox, diphtheria, scarlet fever, pneumonia, typhoid, and typhus. The clitoris is likely to he completely covered, and the entire area appears to be all perineum. In cases of complete fusion the expulsion of urine can take place only through a congenital vaginorectal fistula or a urethrovaginoreetal fistula. In other words, complete vulvar fusion in the absence of an adequate urinary exit means an unviable fetus or child. The line of fusion is well exterior to the hymenal structure. The condition is confused chiefly with hermaphroditism and pseudohermaphroditism. Hematocolpos, hematometra, and pyuria may complete the condition. Treatment consists in separation of the vulva by an incision in the cleavage line or midline of fusion. WILLIAM

BERMAN.