Unusual Presentation of Placenta Increta Prepared by: Dr. Howaida Zahhar OB/Gyn Consultant KFAFH, Jeddah K.S.A

KING FAHD ARMED FORCES HOSPITAL, JEDDAH

Jeddah, K.S.A

Introduction Usual presentation of Placenta Accreta, Increta Unusual presentation of Placenta Accreta, Increta Case report in KFAFH, Jeddah Discussion Conclusion

INTRODUCTION Placenta Increta is considered rare complication of pregnancy, though it is life-threatening with high morbidity and mortality. It is defined as abnormal attachment or invasion of the chorionic villi into the underlying myometrium

CONT - INTRODUCTION Placenta accreta (with different varieties) occurs in approximately 1:2500 deliveries (ACOG 2002). Stafford & Belfort (2008) cite the incidence of accreta 1:2500 in 1980 to 1:210 in 2006, which is due to rising trends of caesarean section.

CONT - INTRODUCTION Histologically: Complete absence of decidua baselis → placental villi being attached to or invading the myometrium Varieties: Placenta Accreta Placenta Increta Placenta Percreta – the most severe form

The Usual Presentation of Placenta Increta To be associated with significant risk factors Placenta Previa Scarred Uterus: Previous C/S, previous myomectomy, uterine perforation during D&C.

2. Due to association with risk factors, its probably will be looked for by ultrasound and the sonographic findings may raise the suspicion of the diagnosis.

IN THE UNUSUAL PRESENTATION Absence of significant risk factors. Association with less significant risk factor? Not diagnosed or had suspicion upon ultrasound, until complications happened. which complications?

CASE REPORT We reported a 36 year old lady, G11P9+ with history of previous all SVDs and are uncomplicated D&C, who presented at 27 weeks gestation to emergency room with complain of watery vaginal gush and the examination confirmed the diagnosis of PPROM.

CONT - CASE REPORT The plan of management of PPROM had been made and she had been admitted to the hospital. While in hospital, she started to complain of non-specific symptoms: Generalized abdominal pain, generalized fatigue, and her pulse ↑ to 140bpm and her Hb dropped to 6.4 (was 11.00).

CASE REPORT What the clinician expected? On that day, ultrasound requested and the findings… Medical team consulted, their work up...

CASE REPORT Blood transfusion started and received 2 units along with I.V. fluid. On second day, we received the case as P.E.! But…Why there was significant drop of Hb? Can we start therapeutic heparin while there is unexplained drop in hemoglobin?

CASE REPORT Bedside scan done immediately showed significant pelvic abdominal collection. So, suspicion of rupture uterus raised. Emergency laparotomy decided. Good resuscitation. Blood products preparation. Anesthesia consultation.

CASE REPORT Intraoperative. Complete uterine rupture of the whole superior fundal area. Dead fetus lying in the uterine cavity extracted out of the uterus. Hemoperitoneum about 1500ml of blood was in the peritoneal cavity. The placenta firmly adherent and invading the myometrium through the whole fundal area.

CASE REPORT Decision for emergency subtotal hysterectomy made and the uterus along with placenta sent for histological diagnosis BI transfusion of 6 units PRBCs and 4 units of FFP Patient was hemodynamically stable post op and discharged on 6th post-operative in good condition.

CASE REPORT Histology: Revealed that the chorionic villi was invading the inner third of myometrium which confirmed the diagnosis of placenta increta.

DISCUSSION A literature review of reports on placenta increta followed by rupture of unscarred uterus in second trimester showed few cases only indicated that it is rare situation.

CONT - DISCUSSION In our case, placenta increta presented in unusual way and non-specific symptoms with no major risk factors. Standing as a challenge for the clinician who should decide for immediate surgical intervention which is essential to save the patient’s life.

CONT - DISCUSSION Less significant risk factors for placenta increta should be considered: Generalized multiparity, previous D&C (even uncomplicated)

CONT - DISCUSSION The clinical features of placenta increta, such as hemorrhage , uterine rupture and invasion of urinary bladder, are related to the site of placental implantation, the depth of myometrial invasion and which of abnormally adherent placental tissue.

CONT - DISCUSSION Rupture of unscarred uterus in our case is believed to be in part due to placenta increta which per se caused weakness of the myometrium particularly when the invasion is deep and involving large service area.

CONCLUSION Association of two major obstetric life-threatening situation (Rupture of unscarred uterus induced by placenta increta) is extremely rare.

High index of suspicion should be raised to initiate prompt surgical intervention timely and therefore saving the maternal life.