Placenta accreta

PLACENTA REPORT MICHELE

ACCRETA OF A CASE*

TOMAIUOLI,

WEEHAWKEN,

T

HE literature of pIacenta accreta consists chiefly of persona1 case reports. It was PoIak’s masterfu1 contribution in 1925 that aroused interest in this unusua1 condition, and Arthur C. Tiemeyer further enriched the Iiterature with his noteworthy articIe in 1930. However, in rg33 Phaneuf made a thorough and exhaustive search of the literature coIIecting 82 cases; tabuIated his findings and reported 2 additiona cases. Since his pubIication a case has been reported respectiveIy by E. Capecchi, S. Freitas, G. Giavotto, H. 0. Newman, R. K. Smith, SoIomon and Bourke, making a tota of go. With my case, herein discussed, the number of authentic cases reaches a tota of 91. That this shouId represent the true number of cases which have actuaIIy occurred, no one, I beIieve, seriousIy contempIates. On the other hand, that it is a rarity cannot be denied. Its occurrence ranges between the estimated I in 6000 by PoIak to I in 40,000 by Hirst, with an average of I case in 14,622 deIiveries according to Phaneuf. A distinction must be made between a an adherent pIacenta retained pIacenta, and a pIacenta accreta. The former is a detached pIacenta retained in the uterine cavity by a premature cIosure of the retraction ring; the second is a pIacenta which faiIs to detach itseIf usuaIIy because it is thinned out over a Iarge area but can be easiIy removed manuaIIy and in toto because a Iine of cIevage does exist and is easiIy found by the gIoved fingers; the third, or pIacenta accreta, is one where an intimate union exists between the pIacenta and the uterine muscIe. The term itseIf is derived from the Latin: ad-crescere mean-

M.D.

N. J.

ing “to grow to.” Hence a spontaneous detachment can never occur and a manua1 remova is not onIy impossibIe but laden with deadIy danger. Phaneuf states that in a series of 36 cases treated by manua1 extraction 26 died and IO recovered. “The women who recovered ” he beIieves, “probabIy had partiaI pIacenta accreta . . . for it seems aImost unbeIievabIe that one couId separate an entire pIacenta from the uterine muscuIature without tearing the uterus and without severe hemorrhage and sepsis, the compIications to be feared and which usuaIIy resuIt in death when this method is persisted.” The mechanism by which a pIacenta accreta forms is supposed to be simpIe. It is beIieved that it resuIts from the absence, tota or partia1, or abnorma1 aIteration of the decidua basaIis which leaves the unprotected uterine muscIe waI1 a prey to the penetrating and erosive action of the trophobIasts and chorionic viIIi. An idea of this erosive and penetrating activity can be gained by the case reported by C. E. Tennant, where the autopsy demonstrated that the pIacenta1 attachment not onIy penetrated the peritonea1 coat of the uterus in the fifth month of gestation, but that it actuaIIy invaded the viscera1 cavity. The causes of the absence of the decidua basaIis are protean and, according to the authorities, may be summarized as previous manua1 remova with febriIe reaction, as in the case herein presented, repeated curettages, submucous fibroid (as was one of the cases reported by PoIak), endometritis, and abnorma1 position of the placenta as in pIacenta previa. I confess that I cannot be in compIete accord with this. It seems to me that if

* From the Surgical Service of Christ HospitaI, Jersey City, N. J. 195

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these etioIogica1 factors were true, pIacenta accreta wouId be encountered more frequentIy. It is true that these causes damage the endometrium and that a normal endometrium is necessary for the proper deveIopment of the decidua, stiI1, as Tiemeyer very properIy says, “Other factors, however, enter into the formation of the decidua. . . . It is beIieved that the hormones from the corpus Iuteum contro1 the formation of the decidua, and abnormaIities of the corpus Iuteum may have some bearing on the formation of this condition by producing a defective decidua basaIis.” The foIIowing report is pubIished not onIy because of the rarity of pIacenta accreta, but aIso to stress the dramatic resuIts which may attend the management of such a case. CASE

REPORT

Mrs. A. C., a secundigravida was seen on September

30,

36 years oId, 1934. Her history

is devoid of interesting data except that foIIowing the normaI birth of her previous and first chiId on May I, 1931, the pIacenta faiIed to be expeIIed and was retained for three hours, when a physician caIIed by the midwife in attendance, proceeded to manuaIIy deIiver the pIacenta in toto. The folIowing day, however, the temperature rose to IOZ°F., and persisted with sIight variations for eIeven successive days. Early in the afternoon of September the 30, 1934, the midwife in attendance caIIed me to see this patient. I noticed a proIapse of the cord and an abundance of meconium. Examination revealed a podaIic presentation and in order to obtain a living chiId I proceeded to deIiver the fetus. Some diff&uIty was encountered in the deIiverance of the head especiaIIy since the parturient was extremeIy uncooperative. A ~$8 pounds maie chiId was fInaIIy deIivered but was asphyxiated. The severa procedures for resuscitation were empIoyed and ten minutes afterwards the first cries of Iife were noted. While occupied resuscitating the child I was noticing, nevertheIess, that the patient was having a profuse hemorrhage. My efforts, therefore, were turned to the mother. After severa attempts at expelIing the pIacenta, Crede’s method was tried, but without success,

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the hemorrhage continuing with alarming signs. Since the safety of the patient seemed at stake, resort was made to manua1 removal,

El

FIG. I. Photograph of specimen through a plane at right angIes to the Iong axis of the uterus. Sections were cut along the circumference from A to D. but the gloved fingers sought vainIy for the famiIiar line of cIeavage. The patient by now seemed to be rapidIy sinking. She was coId and cIammy perspiration covered her face and Iimbs: her pupiIs were diIated and vision dimmed; the puIse was imperceptibIe and the heart sounds rapid and feeble. A steriIe pack was therefore quickIy inserted, the foot of the bed eIevated, heat applied and hypodermic injections of camphor in oil, adrenaIin and caffein sodium benzoate were given in rapid succession. As her condition was critica she was hospitalized immediateIy. Heroic therapeutic measures were instituted; the foot of the bed elevated, intravenous cIysis of saIine and glucose; black coffee and whiskey per rectum; hot water bottIes and warm blankets-and cardiac stimulents. After an hour or so she improved somewhat temporarily. That evening her condition again became precarious and she was transfused receiving 500 C.C. whole bIood. The improvement in her condition was striking. Twenty hours after her admission the packing was removed; the bIeeding had stopped. In an effort to extract the placenta without much interference, 250 C.C. of steriIe saline was injected into the cord vein, the Iatter clamped and an ampouIe of obstetrical pituitrin administered. The result was negative and a piacenta accreta was accepted as the IikeIiest diagnosis.

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GynecoIogicaI consultation confirmed necessity of supravagina1 hysterectomy. condition, however, justified postponement

FIG. 2. Low Dower microDhotoaraohs greatIy diIated venous c(anneIi. The decidua found in these sections.

the Her for

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1936

favorabIy. She was discharged from the hospita1 fuIIy recovered, 27 days after admission. Pathological Report by Frederick A. Hem-

of celIoidin sections from the areas A to D in Fig. I. Note the bIocked area I, magnified in Fig. 4, shows the thickest portion of

in order that she couId be better prepared for the operation. That night she developed a chill and her chiI1 temperature spiked to 103”~. Another and elevation of temperature occurred the next morning, but even though this was attributed to sapremia, it was evident that no time was to be Iost for the operation. Actuated onIy by the desire to avoid the operation, whiIe the patient was under gas, oxygen and ether anesthesia, a Iast attempt was undertaken to extract the placenta manuaIIy. L+hiIe introducing my fingers in the uterine cavity and as gentIy as possible seeking the edge of the pIacenta, the uterine waI1 at the IeveI of the interna OS posteriorly, suddenly gave way, as if offering onIy a tissue paper Iike resistance, and the peritonea1 cavity was entered. A speedy supravagina1 hysterectomy with drainage was done immediately, while an intravenous infusion of saIine and glucose was being administered concomitantly. The tear was verified by sight and the presence of fresh bIood. Inasmuch as the prognosis was questionabIe, an indirect transfusion of goo C.C. titrated bIood was given her while in bed. After three days of stormy convalescence she began to respond

another day

Accreta

sath, M.D. Specimen consists of a supracervical portion 14 cm. in height, 15 cm. in of uterus measuring Section after width and 12 cm. in thickness. preliminary fixation shows the uterine waI1 3 cm. in thickness aIong the Iower uterine segment and 1.4 cm. at the fundus. A pIacenta is firmly adherent to the midportion of the cavity and the myometrium beneath the pIacenta shows greatly dilated venous channeIs. The uterus shows no evidence of rupture nor hemorrhage into any portion of the Iower uterine segment. Microscopic Examination. Sections from one-haIf circumference of the uterus along the placental implantation (Fig. I, A, B, c, D.) are cut 16 miIIimicrons in thickness after ceIIoidin imbedding and stained by hematoxyIin and Orange G. Examination shows a deficient decidua vera with absence of decidua spongiosum. The chorionic viIIi are separated from the myometrium by a fibrinous Iayer (Nitabusch) of varying thickness beneath which, in many places, there is a Iayer of dense decidua. In other areas the fibrinous Iayer is directIy in contact with myometrium. The onIy endometria1 gIand seen is present in a portion of decidua capsuIaris. Groups of chorionic wander-

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ing cells are found the viIIi

myometrium into

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at short but

distances

actua1

the

myometrium

FIG. 3. A higher Fig. 2 showing myomel rium.

magnification fibrinous layer

within

penetration is

not

of noted.

of bIocked area in direct contact

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CONCLUSIONS

I. The Iiterature of pIacenta accreta is reviewed. To date there are 90 cases

2 of with

Polynuclear infiltration of the pIacenta, decidua and mgometrium is extensive in some areas. Diagnosis: PIacenta accreta, acute placentitis and myometritis.

At this time some pertinent remarks on the history as given become evidently necessary. It is known that pIacenta accreta does not cause any postpartum hemorrhage. How then can the serious hemorrhage sustained by this patient be expIained? I believe the answer is simpIe. The patient was “ uncooperative ” during the somewhat difficult extraction of the head, and reaIizing that no undue effort was exercised in introducing the hand in my last effort to extract the pIacenta, it becomes evident that the bIeeding came from a tear in the cervix caused whiIe derivering the head, and it was this tear that made the subsequent perforation so effortless. The bleeding couId aIso have occurred from a partia1 separation of the pIacenta but Doctor F. A. Hemsath in examining the specimen toId me that “the pIacenta and its membranes were firmly adherent to the myometrium and at no point couId separation be found.”

FIG. 4. Nigher magnification of bIocked arca I of Fig. z showing, from above downward, chorionic villi, fibrinous layer, decidua compacta and myomctrium.

reported. My case brings the tota to 91. 2. Placenta accreta is not we11 known. The lack of knowIedge of this condition pIus the Iack of hospital facilities in many regions must of necessity keep many other cases from the Iiterature. 3. The role of the corpus luteum in the etioIogy of placenta accreta shouId be more thoroughI!: investigated. 4. Postpartum hemorrhage does not occur in pIacenta accreta. When it does occur it is due either to cervica1 tear or to partia1 pIacenta accreta. 5. If after dehvery of the fetus the pIacenta is not expeIIed the known maneuvers to promote this should be tried. As a Iast resort, under asepsis, the gloved fingers shouId be inserted into the uterine cavity in an attempt to expe1 the placenta

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manuaIIy. If no Iine of cIeavage can be found the project shouId be abandoned for a pIacenta accreta then exists. RemovaI to a hospita1 and supravagina1 hysterectomy usuaIIy give favorabIe prognosis. 6. Any persistent attempt to manuaIIy remove a pIacenta accreta is fooIhardy. FataI hemorrhage, sepsis and perforation are the usua1 outcome. 7. A case of pIacenta accreta is reported in detai1. The writer wishes to express his gratitude and appreciation to Dr. W. L. Yeaton, Jr., for his assistance and heIpfu1 suggestions.

REFERENCES I. ANDREWS, C. J. Report of a case of retained pIacenta, cIinicaIIy placenta accreta. Jour. Am. Med. Assn., 82: 1780, 1924. 2. PHANEUF, LOUIS, E. PIacenta accreta; a review of the literature and the report of two persona1 cases. Surg., Gynec. Obst., 57: 343, 1933.

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3. POLAK, J. 0. and PHELAN, G. W. PIacenta accreta; its incidence, pathoIogy and management. Surg., Gynec. Obst., 181, (Feb.) 1924. 4. TENNANT, C. E., WILSON, R. E. and CRAIGSULLIVAN H. Placenta accreta; report of a case. Colorado Med., (April) 1925. 5. TIEMEYER, A. C. A case of pIacenta accreta. Am. J. Obst., Gynec., 22: 106, 1931. 6. WILSON, R. A. Report of a case of pIacenta accreta; with a discussion of its treatment and the unusuaI sequeIae. Am. J. Obst. Gynec., I 7:58, 1929. 7. NEWMAN, H. 0. AbnormaIIy deep growth of chorionic viIIi; anatomicropathoIogic studies of causes of pIacenta accreta, increta or destruens, Ztscbr. j. Geburtsb. u. Gynak., 108: 25-69, 1934. 8. CAPECCHI. E. Abandonment DIacenta accreta in uterus of patient who had had Cesarian section previously; return of uterus to norma state without compIication; case. Policlinico, 40: (sez-prat), 347-349, 1933. g. GIAVOTTO, G. PIacenta accreta partialis; case. Folia Gynec., 29: 269-300. 1932. IO. FREITAS SIMOES. PIacenta accreta in muItiparous woman; surgica1 therapy; case. Lisboa Med., IO: 414-427, 1933. I I. SOLOMONS, B. and BOURKE, F. S. Case of pIacenta accreta with pathoIogica1 description. J. Obst. fl Gynec., Brit.-Emp., 4;: 855-858, 1933. 12. SMITH, R. K. PIacenta accreta; report of a case with review of Iit. Southwest-Med., 17: 55-58, 1933.