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CASE REPORT Table of Contents  
Ahead of print publication
Unusual case of placenta accreta - A Case Report


 Department of Obstetrics and Gynecology, JSS Medical College and Research Institute, Mysore, Karnataka, India

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Date of Submission03-Feb-2022
Date of Decision10-Jul-2022
Date of Acceptance26-Jul-2022
Date of Web Publication01-Sep-2022
 

  Abstract 


Introduction: Placenta accreta is a rare and life-threatening condition. The incidence is increasing with increasing cesarean section rates. Detection and management in early gestational weeks are difficult. Conclusion: Here, we have one such case of 39-year multigravida presented with repeated episodes of bleeding per vagina. Keeping differential diagnosis, we investigated further, and it was managed with total abdominal hysterectomy. The diagnosis was confirmed with a histopathology report as placenta accreta.

Keywords: First trimester, hysterectomy, placenta accreta, suction evacuation


How to cite this URL:
Poornima M, Anupama Marnal B A, Sapna H P. Unusual case of placenta accreta - A Case Report. Apollo Med [Epub ahead of print] [cited 2022 Sep 27]. Available from: https://apollomedicine.org/preprintarticle.asp?id=355257





  Introduction Top


Placenta accreta is a rare condition characterized by abnormal invasion of the chorionic villi in the myometrium. It is a life-threatening condition causing massive blood loss and requiring obstetric hysterectomy.[1],[2],[3] Such patients should be managed in a tertiary care center with an in-house blood bank and intensive care unit facilities. The incidence is rising with increasing cesarean section rates, other issues such as multiple terminations of pregnancies, and Asherman's syndrome. It is not easy to diagnose in the first trimester.[4] However, at 10–12 weeks, if the following findings are seen on ultrasound while assessing the fetus, one should strongly suspect placenta accreta – increased myometrial thickness presence of placenta lacunae, loss of clear space between – the interface of the placenta and myometrium.[5]

We report the case of a 39-year-old female with placenta accreta with unusual presentation.


  Case Report Top


A 39-year-old female was seen in the gynecology outpatients department (OPD) with a repeated episode of bleeding per vagina for 1½ months. She had no other symptoms such as pain abdomen and fever. She had a suction evacuation 6 weeks ago for a missed miscarriage at 12 weeks. She had one lower-segment cesarean section 8 years ago. She also gave a history of two miscarriages in the past, followed by suction evacuation.

General physical examination was regular. Vital signs were typical.

Per speculum examination, the cervix was expected, and there was bleeding through the cervical os. The uterus was bulky and soft; fornices were free.

Differential diagnosis of:

  1. Residual products of conceptions
  2. Molar pregnancy
  3. AV malformations and
  4. Placenta accreta was considered.


Her investigations revealed a hemoglobin level of 11gm%. Serum beta-human chorionic gonadotropin (β-HCG) level of 637 international units.

Her transvaginal ultrasound revealed an endometrial thickness of 11 mm – a uterine size of 10.9 cm × 6.2 cm × 7.8 cm. There was a heterogeneous mass lesion measuring 8.5 cm along the anterior wall of the uterus in the intramural portion with increased vascularity, suggesting a hemangiomatous malformation in the uterus. However, color Doppler ultrasonography showed increased vascularity and prominent vessels situated along the anterior wall of the uterus [Figure 1], strongly suggestive of placenta accreta.
Figure 1: Color Doppler ultrasonography

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The patient and the family were informed about the diagnosis and further management in the form of uterine artery embolization (UAE) or hysterectomy with the need for blood transfusion and admission to intensive care. She opted for a hysterectomy. A total abdominal hysterectomy was done. The Pfannenstiel incision was taken. The intraoperative findings were as follows:

Bulky uterus, a vascular mass of 5 cm × 4 cm [Figure 2] in the anterior wall of the uterus extended up to the ureterovesical fold of the peritoneum. There was increased vascularity around the round ligaments, ovarian ligaments, and  Fallopian tube More Detailss. There was no involvement of the bladder. The fallopian tubes and ovaries were healthy.
Figure 2: Cut section of the uterus showing a vascular mass on the anterior uterine wall

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Postoperatively, her hemoglobin level was 9 gm%, and a one-pint blood transfusion was done. Her postoperative period was uneventful. The patient was discharged on the postoperative day 7. Two weeks following the hysterectomy, the patient visited the hospital for follow-up with repeat serum β-HCG showing 3 mIU/ml. HPE report showed placenta accreta spectrum disorder – Grade 3A.

The patient visited our OPD a month back for a follow-up and is doing well.


  Discussion Top


The placenta can present as vaginal bleeding starting from irregular bleeding or massive bleeding. Symptoms may be seen during the intra or postoperative period. In the first trimester, diagnosis of placenta accreta is a challenge. Always gestational trophoblastic disease and arterial venous malformations (AVM) should be ruled out. The first investigation for the diagnosis of AVM is ultrasonography. Ultrasonography usually shows normal endometrium, and myometrium contains numerous hypoechoic spaces. Cystic spaces show mosaic patterns of color signals representing turbulent flow in color Doppler.[6]

For first-trimester placenta, accreta definitive treatment is hysterectomy.[7] If future childbearing is desired, can opt for conservative treatment.[8] For postpartum and postabortal abnormal placentation, UAE[8] and cytotoxic therapy with methotrexate (MTX)[9] have been used recently as conservative measures for treatment. UAE helps to achieve immediate hemostasis. Still, revascularization of the retained placental tissue may cause persistent or secondary hemorrhage, resulting in treatment failure, and finally, ending in hysterectomy.[9] MTX can be used when there is no active bleeding from retained placental tissue. Hence, placenta accreta can be managed from observation to total hysterectomy. If the conservative methods fail, then hysterectomy is considered the best method. The current treatment of choice is UAE in patients wanting fertility preservation. Because placenta accreta is usually diagnosed among reproductive-age women. However, hysterectomy is the treatment of choice for women with complete family and life-threatening emergencies. As in our case, when childbearing-age women presented with repeated vaginal bleeding after suction evacuation, placenta accreta should always be suspected and investigated further and managed accordingly.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

Thanks to my teachers and friends for helping me to publish this. Special thanks to the patient for giving us consent to publish this case report.

Conflicts of interest

There are no conflicts of interest.

Authors contribution

Dr. Poornima M: conception of an idea, drafting of the article, final approval of the version to be published.

Financial support and sponsorship

Nil.



 
  References Top

1.
Breen JL, Neubecker R, Gregori CA, Franklin JE Jr. Placenta accreta, increta, and percreta. A survey of 40 cases. Obstet Gynecol 1977;49:43-7.  Back to cited text no. 1
    
2.
Berchuck A, Sokol RJ. Previous cesarean section, placenta increta, and uterine rupture in second-trimester abortion. Am J Obstet Gynecol 1983;145:766-7.  Back to cited text no. 2
    
3.
Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol 1985;66:89-92.  Back to cited text no. 3
    
4.
Wang YL, Weng SS, Huang WC. First-trimester abortion complicated with placenta accreta: A systematic review. Taiwan J Obstet Gynecol 2019;58:10-4.  Back to cited text no. 4
    
5.
Heiskanen N, Kröger J, Kainulainen S, Heinonen S. Placenta percreta: Methotrexate treatment and MRI findings. Am J Perinatol 2008;25:91-2.  Back to cited text no. 5
    
6.
Ecker JL, Sorem KA, Soodak L, Roberts DJ, Safon LE, Osathanondh R. Placenta increta complicating a first-trimester abortion. A case report. J Reprod Med 1992;37:893-5.  Back to cited text no. 6
    
7.
Liu X, Fan G, Jin Z, Yang N, Jiang Y, Gai M, et al. Lower uterine segment pregnancy with placenta increta complicating first trimester induced abortion: Diagnosis and conservative management. Chin Med J (Engl) 2003;116:695-8.  Back to cited text no. 7
    
8.
Arulkumaran S, Ng CS, Ingemarsson I, Ratnam SS. Medical treatment of placenta accreta with methotrexate. Acta Obstet Gynecol Scand 1986;65:285-6.  Back to cited text no. 8
    
9.
Liao CY, Huang HW, Tsui WH. Unusual imaging findings of placenta accreta resulting in early hysterectomy in first trimester – Two case reports. Taiwan J Obstet Gynecol 2016;55:910-2.  Back to cited text no. 9
    

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Correspondence Address:
BA Anupama Marnal,
D/O. Meenakshi Ashok, Bakki Village, Bettagere Post, Mudigere Taluk, Chikmagalur District - 577 136, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_20_22



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