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Placenta Percreta–Induced Uterine Rupture at 7th Week of Pregnancy After In Vitro Fertilization in a Primigravida Woman: Case Report
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–4, 2017 Ó 2017 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2017.01.041
Clinical Communications: OB/GYN PLACENTA PERCRETA–INDUCED UTERINE RUPTURE AT 7TH WEEK OF PREGNANCY AFTER IN VITRO FERTILIZATION IN A PRIMIGRAVIDA WOMAN: CASE REPORT Moon Kyoung Cho, MD, Hyun Kyung Ryu, MD, and Chul Hong Kim, MD Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, Korea Reprint Address: Chul Hong Kim, MD, Department of Obstetrics and Gynecology, Chonnam National University Medical School, 160, Baekseo-ro, Dong-gu, Gwangju 501-746, Korea
, Keywords—placenta percreta; uterine rupture; first trimester; in vitro fertilization; primigravida
, Abstract—Background: Placenta percreta is the most severe form of abnormal placental attachment. Spontaneous uterine rupture due to placenta percreta is extremely rare and difficult to diagnose in the first trimester. Most prior cases were associated with some risk factor for placenta percreta. We report a case of placenta percreta–induced spontaneous uterine rupture at the 7th week of pregnancy after in vitro fertilization in a primigravida woman who was not otherwise at risk of placenta percreta. Case Report: A 34-year-old, primigravida woman at the 7th week of pregnancy presented with sudden severe abdominal pain. The patient was impregnated by frozen embryo transfer. The patient’s antenatal course was unremarkable and she had no risk factor for placenta percreta. An emergency laparotomy was performed to diagnose the cause of hemoperitoneum and the operative findings included a hemoperitoneum of 2000 mL and a fundal uterine defect of 3 2 cm with placental tissue penetrating through the uterine serosa. Histopathologic examination confirmed the diagnosis of placenta percreta. Why Should an Emergency Physician Be Aware of This?: Placenta percreta is associated with serious morbidity and mortality during pregnancy, but it is quite rare and difficult to diagnosis in the first trimester. Emergency physicians should suspect uterine rupture due to placenta percreta in pregnant women with abdominal pain even in their first trimester of pregnancy and without risk factors of placenta percreta, especially in in vitro fertilization pregnancies. Ó 2017 Elsevier Inc. All rights reserved.
INTRODUCTION Abnormal placentation is characterized by regional or insufficient diffusion of decidua basalis. The abnormality can be classified as placenta accreta, placenta increta, or placenta percreta. Placenta percreta is the most severe form, potentially leading to serious complications due to its infiltration of the serosa and neighboring organs, including the urinary bladder and bowel. The traditional risk factors for placenta percreta include a history of caesarean section, uterine curettage, or manual extraction of placenta, presence of placenta previa, endometriosis, high parity, and advanced maternal age (1). However, higher incidence of placenta percreta after in vitro fertilization (IVF) has been described in recent studies (2,3). Spontaneous uterine rupture can be lethal in pregnant women. Spontaneous uterine rupture occurs mainly during the second or third trimester. Spontaneous uterine rupture in the first trimester is extremely rare, leading to a catastrophic outcome due to massive hemorrhage (4). All previous reports of uterine rupture due to placenta percreta in the first trimester indicated the existence of some risk factors for placenta percreta. There is one
RECEIVED: 7 December 2016; ACCEPTED: 27 January 2017 1
2
M. K. Cho et al.
case report of spontaneous uterine rupture caused by placenta percreta after IVF without other risk factors for placenta percreta, and it occurred at 18 weeks gestation (5). We report the case of a pregnant woman with spontaneous uterine rupture due to placenta percreta at 7 weeks of gestation after IVF who has no traditional risk factor for placenta percreta. CASE REPORT A 34-year-old woman, gravid 0, was admitted to our emergency department at the 7th week of pregnancy because of sudden severe abdominal pain that occurred 3 h before admission. For the present pregnancy, which was her first, the patient was impregnated by frozen embryo transfer at a private infertility clinic. The patient’s antenatal course was unremarkable. She had no operation history except for an appendectomy at 24 years of age. Her general medical history was unremarkable. Findings on admission included a pulse of 94 beats/min, blood pressure of 90/50 mm Hg, respiration rate of 24 breaths/min, temperature of 36.2 C, and abdominal tenderness. The hemoglobin level decreased from 11.2 to 9.9 g/dL during a 1-h period. Transabdominal and transvaginal ultrasound revealed a fetus with a crown–rump length of 15 mm, consistent with a 7-week, 6-day intrauterine pregnancy with cardiac activity (Figure 1). Free fluid in the abdominal cavity was observed. Overall condition of the patient deteriorated within 2 h of admission. The lower abdominal pain progressed throughout the entire abdomen. The patient had a pale appearance and despite of aggressive hemodynamic
Figure 1. Transvaginal ultrasound. Ultrasound examination showing intrauterine pregnancy at 7 weeks gestation.
resuscitation, the patient remained hypotensive with a blood pressure of 80/50 mm Hg. An emergency laparotomy was performed to diagnose the cause of hemoperitoneum. Differential diagnosis at the time included ovarian cyst rupture or heterotopic tubal pregnancy rupture. A hemoperitoneum of 2000 mL was found as well as a fundal uterine defect of 3 2 cm with placental tissue penetrating through the uterine serosa. Brisk bleeding was observed from the fundal uterine defect. Both adnexa were grossly normal and all other intraperitoneal organs were intact. Gestational material in the uterine cavity was suctioned with a suction catheter inserted through the rupture site. The edges of fundal uterine defect were excised and uterine reconstruction was performed with layer-by-layer suture. The total blood loss was estimated at 2500 mL, and 4 U blood were transfused operatively and postoperatively. Postoperative hemoglobin was 9.7 g/dL. Postoperatively, the patient did well and was discharged from the hospital on the 4th postoperative day. Histopathologic examination confirmed the diagnosis of placenta percreta, revealing that the chorionic villi had invaded the myometrium and the serosa (Figure 2). DISCUSSION Placenta accreta is an abnormally firm attachment of the placenta to the myometrium. It is called placenta increta when the placenta invades the myometrium, and placenta percreta is characterized by the invasion of the placenta through the myometrium to reach the serosa. Placenta accretes occur at the incidence of 1:2500 to 1:7000 births, and placenta percreta is the rarest form of placental abnormalities accounting for 5% to 7% of all placenta accreta cases (6,7).
Figure 2. Histologic finding. The invasion of chronic villi and trophoblasts into myometrium was identified (arrows). Hematoxylin and eosin stain. Original magnification 100.
Uterine Rupture in IVF Primigravida
Well-known traditional risk factors for placenta percreta include a history of caesarean section or uterine surgery, placenta previa, manual placenta extraction, dilatation and curettage, multiparity, and advanced maternal age (6). However, in recent studies, IVF pregnancy is newly recognized as an independent risk factor for placenta accrete (2,3). Furthermore, cryopreserved embryo transfer was an independent risk factor for accreta among patients using IVF and intracytoplasmic sperm injection (8). Our patient displayed none of the traditional risk factors, but was impregnated by IVF, especially cryopreserved embryo transfer. The reason for the higher incidence of placenta accretes among the IVF population is unclear, but several theories focused on the alterations in the endometrial environment of the IVF population and the stimulation protocols used in the IVF process. The stimulation protocols can induce morphologic and structural changes, and disturb the expression of relevant genes in the endometrium, contributing to abnormal implantation (9). Fertilization and embryo culture in vitro can also influence implantation and early embryo development (10). Uterine rupture due to placenta percreta is very rare, occurring at an incidence of 1 in 5000 pregnancies, and it mainly occurs later in pregnancy. Its occurrence during the first trimester is found in very few reports (11–15). All reported cases during the first trimester featured risk factors, including previous history of caesarean section, history of uterine curettage, history of manual placenta extraction, and multiparity. The present patient lacked these risk factors and the pregnancy was her first. One case of spontaneous uterine rupture during first trimester without definite risk factors has been described (4). In that case, the patient was multiparous and an association between uterine rupture and placenta percreta was not noted. The presenting features of uterine rupture include symptoms and signs of shock, pain in the abdomen, shoulder pain, and vaginal bleeding (14). Early diagnosis is very important, but there is no completely sensitive and specific test for the diagnosis especially in the first trimester. In the case of life-threatening severe bleeding or insufficient hemostasis, total hysterectomy is considered for the treatment of placenta percreta (6). Conservative treatment is considered in a more stable disease, and it includes leaving the placenta in situ, uterine curettage with packing, localized excision and repair, uterine artery ligation, and combinations of these approaches (1). Wedge resection of the ruptured uterine segment and uterine repair along the wedge can arrest the bleeding and avoid the blood loss associated with hysterectomy of a gravid uterus in a patient already hemodynamically compromised, as was done presently.
3
In conclusion, IVF pregnancy should be considered as an independent risk factor in addition to the traditional risk factors of placenta accreta. Uterine rupture should be considered in the differential diagnosis in all IVF pregnancies with acute abdomen and fluid collection in the peritoneal cavity, even during the first trimester and in the absence of traditional risk factors. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? Placenta percreta is associated with serious morbidity and mortality during pregnancy. Prompt and proper diagnosis followed by appropriate interventions is crucial in patients who develop abdominal pain during their pregnancy. However, first-trimester diagnosis is quite rare and difficult. This difficulty in first-trimester diagnosis is that it calls for a high level of clinical suspicion and anticipation of placenta percreta in early pregnancy. Emergency physicians should suspect uterine rupture due to placenta percreta in pregnant women with abdominal pain even in their first trimester of pregnancy and without risk factors of placenta percreta, especially in IVF pregnancies. REFERENCES 1. Morken NH, Henriksen H. Placenta percreta—two cases and review of the literature. Eur J Obstet Gynecol Reprod Biol 2001; 100:112–5. 2. Fitzpatrick KE, Sellers S, Spark P, Kurinczuk JJ, Brocklehurst P, Knight M. Incidence and risk factors for placenta accreta/increta/ percreta in the UK: a national case-control study. PLoS One 2012;7:e52893. 3. Esh-Broder E, Ariel I, Abas-Bashir N, Bdolah Y, Celnikier DH. Placenta accreta is associated with IVF pregnancies: a retrospective chart review. BJOG 2011;118:1084–9. 4. Park YJ, Ryu KY, Lee JI, Park MI. Spontaneous uterine rupture in the first trimester: a case report. J Korean Med Sci 2005;20: 1079–81. 5. Medel JM, Mateo SC, Conde CR, Cabistany Esque AC, Rios Mitchell MJ. Spontaneous uterine rupture caused by placenta percreta at 18 weeks’ gestation after in vitro fertilization. J Obstet Gynaecol Res 2010;36:170–3. 6. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol 1997;177: 210–4. 7. Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012;207: 14–29. 8. Kaser DJ, Melamed A, Bormann CL, et al. Cryopreserved embryo transfer is an independent risk factor for placenta accreta. Fertil Steril 2015;103:1176–11842. 9. Horcajadas JA, Riesewijk A, Polman J, et al. Effect of controlled ovarian hyperstimulation in IVF on endometrial gene expression profiles. Mol Hum Reprod 2005;11:195–205. 10. Leese HJ, Donnay I, Thompson JG. Human assisted conception: a cautionary tale. Lessons from domestic animals. Hum Reprod 1998;13(Suppl 4):184–202. 11. Gardeil F, Daly S, Turner MJ. Uterine rupture in pregnancy reviewed. Eur J Obstet Gynecol Reprod Biol 1994;56:107–10.
4 12. Tanyi JL, Coleman NM, Johnston ND, Ayensu-Coker L, Rajkovic A. Placenta percreta at 7th week of pregnancy in a woman with previous caesarean section. J Obstet Gynaecol 2008;28:338–40. 13. Esmans A, Gerris J, Corthout E, Verdonk P, Declercq S. Placenta percreta causing rupture of an unscarred uterus at the end of the first trimester of pregnancy: case report. Hum Reprod 2004;19:2401–3.
M. K. Cho et al. 14. Jang DG, Lee GS, Yoon JH, Lee SJ. Placenta percreta-induced uterine rupture diagnosed by laparoscopy in the first trimester. Int J Med Sci 2011;8:424–7. 15. Dabulis SA, McGuirk TD. An unusual case of hemoperitoneum: uterine rupture at 9 weeks gestational age. J Emerg Med 2007;33: 285–7.
http://dx.doi.org/10.1016/j.jemermed.2017.01.041
Clinical Communications: OB/GYN PLACENTA PERCRETA–INDUCED UTERINE RUPTURE AT 7TH WEEK OF PREGNANCY AFTER IN VITRO FERTILIZATION IN A PRIMIGRAVIDA WOMAN: CASE REPORT Moon Kyoung Cho, MD, Hyun Kyung Ryu, MD, and Chul Hong Kim, MD Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, Korea Reprint Address: Chul Hong Kim, MD, Department of Obstetrics and Gynecology, Chonnam National University Medical School, 160, Baekseo-ro, Dong-gu, Gwangju 501-746, Korea
, Keywords—placenta percreta; uterine rupture; first trimester; in vitro fertilization; primigravida
, Abstract—Background: Placenta percreta is the most severe form of abnormal placental attachment. Spontaneous uterine rupture due to placenta percreta is extremely rare and difficult to diagnose in the first trimester. Most prior cases were associated with some risk factor for placenta percreta. We report a case of placenta percreta–induced spontaneous uterine rupture at the 7th week of pregnancy after in vitro fertilization in a primigravida woman who was not otherwise at risk of placenta percreta. Case Report: A 34-year-old, primigravida woman at the 7th week of pregnancy presented with sudden severe abdominal pain. The patient was impregnated by frozen embryo transfer. The patient’s antenatal course was unremarkable and she had no risk factor for placenta percreta. An emergency laparotomy was performed to diagnose the cause of hemoperitoneum and the operative findings included a hemoperitoneum of 2000 mL and a fundal uterine defect of 3 2 cm with placental tissue penetrating through the uterine serosa. Histopathologic examination confirmed the diagnosis of placenta percreta. Why Should an Emergency Physician Be Aware of This?: Placenta percreta is associated with serious morbidity and mortality during pregnancy, but it is quite rare and difficult to diagnosis in the first trimester. Emergency physicians should suspect uterine rupture due to placenta percreta in pregnant women with abdominal pain even in their first trimester of pregnancy and without risk factors of placenta percreta, especially in in vitro fertilization pregnancies. Ó 2017 Elsevier Inc. All rights reserved.
INTRODUCTION Abnormal placentation is characterized by regional or insufficient diffusion of decidua basalis. The abnormality can be classified as placenta accreta, placenta increta, or placenta percreta. Placenta percreta is the most severe form, potentially leading to serious complications due to its infiltration of the serosa and neighboring organs, including the urinary bladder and bowel. The traditional risk factors for placenta percreta include a history of caesarean section, uterine curettage, or manual extraction of placenta, presence of placenta previa, endometriosis, high parity, and advanced maternal age (1). However, higher incidence of placenta percreta after in vitro fertilization (IVF) has been described in recent studies (2,3). Spontaneous uterine rupture can be lethal in pregnant women. Spontaneous uterine rupture occurs mainly during the second or third trimester. Spontaneous uterine rupture in the first trimester is extremely rare, leading to a catastrophic outcome due to massive hemorrhage (4). All previous reports of uterine rupture due to placenta percreta in the first trimester indicated the existence of some risk factors for placenta percreta. There is one
RECEIVED: 7 December 2016; ACCEPTED: 27 January 2017 1
2
M. K. Cho et al.
case report of spontaneous uterine rupture caused by placenta percreta after IVF without other risk factors for placenta percreta, and it occurred at 18 weeks gestation (5). We report the case of a pregnant woman with spontaneous uterine rupture due to placenta percreta at 7 weeks of gestation after IVF who has no traditional risk factor for placenta percreta. CASE REPORT A 34-year-old woman, gravid 0, was admitted to our emergency department at the 7th week of pregnancy because of sudden severe abdominal pain that occurred 3 h before admission. For the present pregnancy, which was her first, the patient was impregnated by frozen embryo transfer at a private infertility clinic. The patient’s antenatal course was unremarkable. She had no operation history except for an appendectomy at 24 years of age. Her general medical history was unremarkable. Findings on admission included a pulse of 94 beats/min, blood pressure of 90/50 mm Hg, respiration rate of 24 breaths/min, temperature of 36.2 C, and abdominal tenderness. The hemoglobin level decreased from 11.2 to 9.9 g/dL during a 1-h period. Transabdominal and transvaginal ultrasound revealed a fetus with a crown–rump length of 15 mm, consistent with a 7-week, 6-day intrauterine pregnancy with cardiac activity (Figure 1). Free fluid in the abdominal cavity was observed. Overall condition of the patient deteriorated within 2 h of admission. The lower abdominal pain progressed throughout the entire abdomen. The patient had a pale appearance and despite of aggressive hemodynamic
Figure 1. Transvaginal ultrasound. Ultrasound examination showing intrauterine pregnancy at 7 weeks gestation.
resuscitation, the patient remained hypotensive with a blood pressure of 80/50 mm Hg. An emergency laparotomy was performed to diagnose the cause of hemoperitoneum. Differential diagnosis at the time included ovarian cyst rupture or heterotopic tubal pregnancy rupture. A hemoperitoneum of 2000 mL was found as well as a fundal uterine defect of 3 2 cm with placental tissue penetrating through the uterine serosa. Brisk bleeding was observed from the fundal uterine defect. Both adnexa were grossly normal and all other intraperitoneal organs were intact. Gestational material in the uterine cavity was suctioned with a suction catheter inserted through the rupture site. The edges of fundal uterine defect were excised and uterine reconstruction was performed with layer-by-layer suture. The total blood loss was estimated at 2500 mL, and 4 U blood were transfused operatively and postoperatively. Postoperative hemoglobin was 9.7 g/dL. Postoperatively, the patient did well and was discharged from the hospital on the 4th postoperative day. Histopathologic examination confirmed the diagnosis of placenta percreta, revealing that the chorionic villi had invaded the myometrium and the serosa (Figure 2). DISCUSSION Placenta accreta is an abnormally firm attachment of the placenta to the myometrium. It is called placenta increta when the placenta invades the myometrium, and placenta percreta is characterized by the invasion of the placenta through the myometrium to reach the serosa. Placenta accretes occur at the incidence of 1:2500 to 1:7000 births, and placenta percreta is the rarest form of placental abnormalities accounting for 5% to 7% of all placenta accreta cases (6,7).
Figure 2. Histologic finding. The invasion of chronic villi and trophoblasts into myometrium was identified (arrows). Hematoxylin and eosin stain. Original magnification 100.
Uterine Rupture in IVF Primigravida
Well-known traditional risk factors for placenta percreta include a history of caesarean section or uterine surgery, placenta previa, manual placenta extraction, dilatation and curettage, multiparity, and advanced maternal age (6). However, in recent studies, IVF pregnancy is newly recognized as an independent risk factor for placenta accrete (2,3). Furthermore, cryopreserved embryo transfer was an independent risk factor for accreta among patients using IVF and intracytoplasmic sperm injection (8). Our patient displayed none of the traditional risk factors, but was impregnated by IVF, especially cryopreserved embryo transfer. The reason for the higher incidence of placenta accretes among the IVF population is unclear, but several theories focused on the alterations in the endometrial environment of the IVF population and the stimulation protocols used in the IVF process. The stimulation protocols can induce morphologic and structural changes, and disturb the expression of relevant genes in the endometrium, contributing to abnormal implantation (9). Fertilization and embryo culture in vitro can also influence implantation and early embryo development (10). Uterine rupture due to placenta percreta is very rare, occurring at an incidence of 1 in 5000 pregnancies, and it mainly occurs later in pregnancy. Its occurrence during the first trimester is found in very few reports (11–15). All reported cases during the first trimester featured risk factors, including previous history of caesarean section, history of uterine curettage, history of manual placenta extraction, and multiparity. The present patient lacked these risk factors and the pregnancy was her first. One case of spontaneous uterine rupture during first trimester without definite risk factors has been described (4). In that case, the patient was multiparous and an association between uterine rupture and placenta percreta was not noted. The presenting features of uterine rupture include symptoms and signs of shock, pain in the abdomen, shoulder pain, and vaginal bleeding (14). Early diagnosis is very important, but there is no completely sensitive and specific test for the diagnosis especially in the first trimester. In the case of life-threatening severe bleeding or insufficient hemostasis, total hysterectomy is considered for the treatment of placenta percreta (6). Conservative treatment is considered in a more stable disease, and it includes leaving the placenta in situ, uterine curettage with packing, localized excision and repair, uterine artery ligation, and combinations of these approaches (1). Wedge resection of the ruptured uterine segment and uterine repair along the wedge can arrest the bleeding and avoid the blood loss associated with hysterectomy of a gravid uterus in a patient already hemodynamically compromised, as was done presently.
3
In conclusion, IVF pregnancy should be considered as an independent risk factor in addition to the traditional risk factors of placenta accreta. Uterine rupture should be considered in the differential diagnosis in all IVF pregnancies with acute abdomen and fluid collection in the peritoneal cavity, even during the first trimester and in the absence of traditional risk factors. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? Placenta percreta is associated with serious morbidity and mortality during pregnancy. Prompt and proper diagnosis followed by appropriate interventions is crucial in patients who develop abdominal pain during their pregnancy. However, first-trimester diagnosis is quite rare and difficult. This difficulty in first-trimester diagnosis is that it calls for a high level of clinical suspicion and anticipation of placenta percreta in early pregnancy. Emergency physicians should suspect uterine rupture due to placenta percreta in pregnant women with abdominal pain even in their first trimester of pregnancy and without risk factors of placenta percreta, especially in IVF pregnancies. REFERENCES 1. Morken NH, Henriksen H. Placenta percreta—two cases and review of the literature. Eur J Obstet Gynecol Reprod Biol 2001; 100:112–5. 2. Fitzpatrick KE, Sellers S, Spark P, Kurinczuk JJ, Brocklehurst P, Knight M. Incidence and risk factors for placenta accreta/increta/ percreta in the UK: a national case-control study. PLoS One 2012;7:e52893. 3. Esh-Broder E, Ariel I, Abas-Bashir N, Bdolah Y, Celnikier DH. Placenta accreta is associated with IVF pregnancies: a retrospective chart review. BJOG 2011;118:1084–9. 4. Park YJ, Ryu KY, Lee JI, Park MI. Spontaneous uterine rupture in the first trimester: a case report. J Korean Med Sci 2005;20: 1079–81. 5. Medel JM, Mateo SC, Conde CR, Cabistany Esque AC, Rios Mitchell MJ. Spontaneous uterine rupture caused by placenta percreta at 18 weeks’ gestation after in vitro fertilization. J Obstet Gynaecol Res 2010;36:170–3. 6. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol 1997;177: 210–4. 7. Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012;207: 14–29. 8. Kaser DJ, Melamed A, Bormann CL, et al. Cryopreserved embryo transfer is an independent risk factor for placenta accreta. Fertil Steril 2015;103:1176–11842. 9. Horcajadas JA, Riesewijk A, Polman J, et al. Effect of controlled ovarian hyperstimulation in IVF on endometrial gene expression profiles. Mol Hum Reprod 2005;11:195–205. 10. Leese HJ, Donnay I, Thompson JG. Human assisted conception: a cautionary tale. Lessons from domestic animals. Hum Reprod 1998;13(Suppl 4):184–202. 11. Gardeil F, Daly S, Turner MJ. Uterine rupture in pregnancy reviewed. Eur J Obstet Gynecol Reprod Biol 1994;56:107–10.
4 12. Tanyi JL, Coleman NM, Johnston ND, Ayensu-Coker L, Rajkovic A. Placenta percreta at 7th week of pregnancy in a woman with previous caesarean section. J Obstet Gynaecol 2008;28:338–40. 13. Esmans A, Gerris J, Corthout E, Verdonk P, Declercq S. Placenta percreta causing rupture of an unscarred uterus at the end of the first trimester of pregnancy: case report. Hum Reprod 2004;19:2401–3.
M. K. Cho et al. 14. Jang DG, Lee GS, Yoon JH, Lee SJ. Placenta percreta-induced uterine rupture diagnosed by laparoscopy in the first trimester. Int J Med Sci 2011;8:424–7. 15. Dabulis SA, McGuirk TD. An unusual case of hemoperitoneum: uterine rupture at 9 weeks gestational age. J Emerg Med 2007;33: 285–7.