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Placenta accreta
PLACENTA ACCRETA* REPORT
OF THREE
J. IRVING NEW
P
LACENTA
adherence underIying
KUSHNER,
YORK,
accreta is the abnorma1 of the afterbirth to the uterine wall. It is due to a
NEW
ing this time there were PIacenta accreta, therefore, every 3,333 deliveries. CASE
deIiveries. occurred one in
10,000
REPORTS
CASE I. H. J., No. 70574, age 24, gravida III, para I. Her first pregnancy in 1933 resulted in a spontaneous abortion for which a curettage had been performed. The second confinement was comphcated by a manuaI removal of a partiaIIy adherent pIacenta foIIowed by a uterine infection. She had been hospitaIized for fourteen days. The present deIivery on after 4 October I 5, 1936, was spontaneous hours of Iabor, aIthough the membranes had ruptured five days before onset of pains. The
(Dr. Meyer Rosensohn, director),
YORK
FIG. 2. Photomicrograph showing an attachment of the hyaIinized trophoblastic layer directIy to the myometrium. X 20.
compIete or partia1 absence of the decidua basaIis, especiaIIy of its deeP or spongy Iayer which resuIts from the compression of the mucosa1 gIands. The norma separation of the pIacenta is caused by the cIeavage of this spongy Iayer. Absence of the decidua basaIis forces the chorionic viIIi to attach themseIves directIy to the myometrium giving rise to the condition known as placenta accreta. Irving and Hertig,l in 1937, reviewed eighty-six cases by sixty-eight authors, a compIete summary of the Iiterature, and added an additiona twenty cases of their own. The incidence in their cIinic was one case in every 1,956 deliveries. We wish to of Obstetrics
M.D.
add the reports of three cases from the Bronx Hospital embracing a period from JuIy I, 1932, through March I, 1938. Dur-
FIG. I. Photomicrograph showing chorionic villi fused with myometrium. X 20.
* From the Departments
CASES
attending),
Bronx Hospital.
92
and Pathology
(Dr. Joseph
Felsen,
New SEHIES VOL. 1.11. No.
I
Kushner-Placenta
placenta failed to separate and as there was no bleeding the patient was put to bed. Bleeding began twelve hours later and manuaI extraction of placenta was attempted under anesthesia by Dr. A. J. Fleischer. It was impossibIe to determine a cleavage Iine, so the uterus was packed with iodoform gauze, a 500 cc. citrate transfusion given, folIowed by a supravaginal hysterectomy, bilatera1 saIpingectomy and left oophorectomy. ConvaIescence was afebriIe and the patient was discharged on the seventeenth day . The specimen consisted of a postpartum uterus with an entire pIacenta IirmIy adherent to the uterine waII. Attached to the uterus were both tubes and one ovary, the seat of an 0.5 cm. corpus Iuteum. Microscopically (Fig. I) the specimen showed chorionic viIIi fused with the myometrium. Diagnosis: PIacenta accreta. CASE II. J. R., No. 72691, age 37, gravida 11, para I. The patient’s first pregnancy- in 1931 was complicated by a toxemia (pre-ecIampsia). She had at that time a spontaneous deIivery at seven and one-half months of a three pound baby which lived seventeen days. She was admitted as a private patient of Dr. A. J. FIeischer on December 17, 1936, because of a gravidity of two months and a recurrence of the toxemia. Eye and medica consuItation advised interruption of pregnancy because of the presence of nephropathy. On December 28, 1936, a hysterotomy and steriIization under spinal anesthesia was done. The specimen was a 6 by 5 cm. piece of .veIIowish-white tissue, apparentIy a portion of the uterus with an attached adherent pIacenta. MicroscopicaIIy (Fig. 2) there was an attachment of the hyaIinized trophoblastic Iayer directIy to the myometrium. Diagnosis: PIacenta accreta. CASE III. S. G., No. 103993, age 27, gravida I, para o. In 1932, she had what was reported as a subtotal hysterectomy for fibroids with a reconstruction of the stump of the cervix and a part of the isthmus of the uterus. She was admitted to Bronx HospitaI, service of Dr. Irving SmiIey, from a private sanatorium where on September IO, 1939, she had a premature breech iabor of seven months’ gestation necessitating extraction. In the extraction the fetal head was Ieft in the uterus. Her membranes had been ruptured since September 7, 1939, and she now had daily chills and fever. She was put under supportive therapy, sulfaniklmide and transfusions, and on September
Accreta 21, 1939, the ninth day after admission, she had a supravagina1 hysterectomy and bilateral oophorectomy performed. The uterus was
FIG;. 3. Photomicrograph showing direct attachment of villi and hyalinized trophobkic layer directly to the myometrium. X 20.
found to be the seat of a rupture across the top, and a Iarge amount of placenta1 tissue was attached to the interior of the uterus. The patient expired four days later from sepsis and peritonitis. The specimen was a uterus 16 by 7 cm. in size, removed supracervicaIIy. There was a large perforation at the fundus. The upper haIf of the uterine cavity contained adherent (Fig. 3) one pIacenta1 tissue. MicroscopicaIIy could see the direct attachment of vilIi and hyalinized trophoblastic Iayer directly to the myometrium. Diagnosis: PIacenta accreta. SUMMARY AND CONCLUSIONS I. Three cases of pIacenta accreta are reported. One was a true clinical case. The other two were discovered in the routine examination of surgicaI materia1. 2. The incidence in our cIinic was one in every 3,333 deIiveries. 3. The essentia1 pathoIogica1 condition is partia1 or compIete absence of the decidua basaIis so that the pIacenta is attached directIy to the myometrium. I am indebted to Dr. Meyer Rosensohn for his encouragement and advice, and to Dr. Joseph FeIsen for his stimulating interest in the preparation of t.his report. REFERENCE I. IHVINC,,F. C. Surg., Cynec. I>+Obst., 64: 178, 1037.
OF THREE
J. IRVING NEW
P
LACENTA
adherence underIying
KUSHNER,
YORK,
accreta is the abnorma1 of the afterbirth to the uterine wall. It is due to a
NEW
ing this time there were PIacenta accreta, therefore, every 3,333 deliveries. CASE
deIiveries. occurred one in
10,000
REPORTS
CASE I. H. J., No. 70574, age 24, gravida III, para I. Her first pregnancy in 1933 resulted in a spontaneous abortion for which a curettage had been performed. The second confinement was comphcated by a manuaI removal of a partiaIIy adherent pIacenta foIIowed by a uterine infection. She had been hospitaIized for fourteen days. The present deIivery on after 4 October I 5, 1936, was spontaneous hours of Iabor, aIthough the membranes had ruptured five days before onset of pains. The
(Dr. Meyer Rosensohn, director),
YORK
FIG. 2. Photomicrograph showing an attachment of the hyaIinized trophoblastic layer directIy to the myometrium. X 20.
compIete or partia1 absence of the decidua basaIis, especiaIIy of its deeP or spongy Iayer which resuIts from the compression of the mucosa1 gIands. The norma separation of the pIacenta is caused by the cIeavage of this spongy Iayer. Absence of the decidua basaIis forces the chorionic viIIi to attach themseIves directIy to the myometrium giving rise to the condition known as placenta accreta. Irving and Hertig,l in 1937, reviewed eighty-six cases by sixty-eight authors, a compIete summary of the Iiterature, and added an additiona twenty cases of their own. The incidence in their cIinic was one case in every 1,956 deliveries. We wish to of Obstetrics
M.D.
add the reports of three cases from the Bronx Hospital embracing a period from JuIy I, 1932, through March I, 1938. Dur-
FIG. I. Photomicrograph showing chorionic villi fused with myometrium. X 20.
* From the Departments
CASES
attending),
Bronx Hospital.
92
and Pathology
(Dr. Joseph
Felsen,
New SEHIES VOL. 1.11. No.
I
Kushner-Placenta
placenta failed to separate and as there was no bleeding the patient was put to bed. Bleeding began twelve hours later and manuaI extraction of placenta was attempted under anesthesia by Dr. A. J. Fleischer. It was impossibIe to determine a cleavage Iine, so the uterus was packed with iodoform gauze, a 500 cc. citrate transfusion given, folIowed by a supravaginal hysterectomy, bilatera1 saIpingectomy and left oophorectomy. ConvaIescence was afebriIe and the patient was discharged on the seventeenth day . The specimen consisted of a postpartum uterus with an entire pIacenta IirmIy adherent to the uterine waII. Attached to the uterus were both tubes and one ovary, the seat of an 0.5 cm. corpus Iuteum. Microscopically (Fig. I) the specimen showed chorionic viIIi fused with the myometrium. Diagnosis: PIacenta accreta. CASE II. J. R., No. 72691, age 37, gravida 11, para I. The patient’s first pregnancy- in 1931 was complicated by a toxemia (pre-ecIampsia). She had at that time a spontaneous deIivery at seven and one-half months of a three pound baby which lived seventeen days. She was admitted as a private patient of Dr. A. J. FIeischer on December 17, 1936, because of a gravidity of two months and a recurrence of the toxemia. Eye and medica consuItation advised interruption of pregnancy because of the presence of nephropathy. On December 28, 1936, a hysterotomy and steriIization under spinal anesthesia was done. The specimen was a 6 by 5 cm. piece of .veIIowish-white tissue, apparentIy a portion of the uterus with an attached adherent pIacenta. MicroscopicaIIy (Fig. 2) there was an attachment of the hyaIinized trophoblastic Iayer directIy to the myometrium. Diagnosis: PIacenta accreta. CASE III. S. G., No. 103993, age 27, gravida I, para o. In 1932, she had what was reported as a subtotal hysterectomy for fibroids with a reconstruction of the stump of the cervix and a part of the isthmus of the uterus. She was admitted to Bronx HospitaI, service of Dr. Irving SmiIey, from a private sanatorium where on September IO, 1939, she had a premature breech iabor of seven months’ gestation necessitating extraction. In the extraction the fetal head was Ieft in the uterus. Her membranes had been ruptured since September 7, 1939, and she now had daily chills and fever. She was put under supportive therapy, sulfaniklmide and transfusions, and on September
Accreta 21, 1939, the ninth day after admission, she had a supravagina1 hysterectomy and bilateral oophorectomy performed. The uterus was
FIG;. 3. Photomicrograph showing direct attachment of villi and hyalinized trophobkic layer directly to the myometrium. X 20.
found to be the seat of a rupture across the top, and a Iarge amount of placenta1 tissue was attached to the interior of the uterus. The patient expired four days later from sepsis and peritonitis. The specimen was a uterus 16 by 7 cm. in size, removed supracervicaIIy. There was a large perforation at the fundus. The upper haIf of the uterine cavity contained adherent (Fig. 3) one pIacenta1 tissue. MicroscopicaIIy could see the direct attachment of vilIi and hyalinized trophoblastic Iayer directly to the myometrium. Diagnosis: PIacenta accreta. SUMMARY AND CONCLUSIONS I. Three cases of pIacenta accreta are reported. One was a true clinical case. The other two were discovered in the routine examination of surgicaI materia1. 2. The incidence in our cIinic was one in every 3,333 deIiveries. 3. The essentia1 pathoIogica1 condition is partia1 or compIete absence of the decidua basaIis so that the pIacenta is attached directIy to the myometrium. I am indebted to Dr. Meyer Rosensohn for his encouragement and advice, and to Dr. Joseph FeIsen for his stimulating interest in the preparation of t.his report. REFERENCE I. IHVINC,,F. C. Surg., Cynec. I>+Obst., 64: 178, 1037.