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 Table of Contents  
Year : 2019  |  Volume : 26  |  Issue : 1  |  Page : 61-64

Undiagnosed placenta praevia percreta: A rare case report and review of management

Department of Obstetrics and Gynecology, College of Medicine, University of Lagos, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria

Date of Web Publication12-Mar-2019

Correspondence Address:
Adeyemi Adebola Okunowo
Department of Obstetrics and Gynecology, College of Medicine, University of Lagos, Lagos University Teaching Hospital, P.M.B. 12003, Idi-Araba, Lagos
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_191_18

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Placenta accreta spectrum disorders, especially placenta percreta (PP) and placenta praevia (PLP), are major risk factors for massive obstetric haemorrhage which is a common cause of maternal morbidity and mortality in our environment. This risk becomes exponential and life-threatening when the two conditions co-exist in the same patient. Even in advanced countries with readily available expertise and state of the art resuscitative and supportive facilities, these conditions are associated with grave maternal and perinatal morbidity and mortality. We present a challenging case of PP co-existing with major PLP, which was diagnosed intraoperatively and the patient had total abdominal hysterectomy and bilateral internal iliac artery ligation to control haemorrhage.

Keywords: Morbidly adherent placenta, placenta accreta spectrum disorders, placenta percreta, placenta praevia

How to cite this article:
Okunowo AA, Ohazurike EO, Habeebu-Adeyemi FM. Undiagnosed placenta praevia percreta: A rare case report and review of management. Niger Postgrad Med J 2019;26:61-4

How to cite this URL:
Okunowo AA, Ohazurike EO, Habeebu-Adeyemi FM. Undiagnosed placenta praevia percreta: A rare case report and review of management. Niger Postgrad Med J [serial online] 2019 [cited 2020 Nov 24];26:61-4. Available from: https://www.npmj.org/text.asp?2019/26/1/61/253982

  Introduction Top

Placenta accreta spectrum disorder (PASD) is a spectrum of disorders that occurs when the placenta becomes unduly attached to the uterus with varied degree of uterine invasion as a result of an incomplete or total absence of decidua basalis and poor development of the Nitabuch layer.[1] This condition is commonly referred to as placenta accreta,[1] placenta accreta syndrome,[2] PASD,[3] morbidly adherent placenta,[4],[5] placenta accretism,[6] placenta adhesive disorder[7] or invasive placenta[8] in different literatures. There are three types of PASD, depending on the extent of uterine invasion. Placenta accreta (also called placenta creta or adherenta), when the chorionic villi are superficially attached to the myometrium, placenta increta, when the chorionic villi extensively invade the myometrium; and placenta percreta (PP), when the chorionic villi invade the whole myometrial layer up to the uterine serosa layer with or without involvement of the contiguous structures and organs.[2],[9],[10]

Though PP accounts for approximately only 5% - 7% of all the PASD,[4],[6],[8] it is the most severe and dangerous of the three conditions. It has great potential of causing life threatening haemorrhage and surgical complications with grave maternal and perinatal morbidity and mortality.[4],[6],[8],[9],[10] The clinical outcome becomes worse, when PP coexist with placenta praevia (PLP) and when the condition is diagnosed at surgery and not preoperatively.[9],[10]

There has been a steady rise in the incidence of PASD in modern-day obstetric practice.[1],[4],[5],[6],[8] And this has made the knowledge of the management of this life-threatening condition and the skills involved in its surgical management imperative among practising Obstetricians. We report a rare and challenging case of PP diagnosed intraoperatively in a patient with major PLP and how she was managed with total abdominal hysterectomy and bilateral internal iliac artery ligation (BIIAL).

  Case Report Top

A 40-year-old woman (gravida 4 para 3, 3 alive) presented for routine antenatal care at the antenatal clinic of Lagos University Teaching Hospital, Idi-Araba, Lagos, at 11 weeks gestational age. Her last menstrual period was on 22 September 2013 and her expected date of delivery was 29 June 2014. She had a history of three previous caesarean deliveries (CDs); two emergency CD for severe preeclampsia at 42 weeks gestation and failed attempt at vaginal birth after caesarean section due to failure to progress at 39 weeks in the first two confinements respectively. Her third delivery was through an elective CD at term for two previous CDs. She had no complications during surgery or in the postpartum period. She was a known hypertensive, diagnosed 11 years prior to booking with poor drug compliance. Her booking parameters were normal except for elevated blood pressure of 160/100 mmHg. Obstetric examination revealed a large for date uterus at 16 weeks size. Early obstetric scan done at 10 weeks showed a viable foetus compatible with menstrual age with fundal uterine fibroids. She was reassured and counselled on compliance with her antihypertensive medication (oral methyldopa 500 mg 8 hourly), the need for regular antenatal visits and for a repeat CD at term. She was also counselled on family planning options, and she consented to bilateral tubal ligation during CD.

She had a repeat obstetric scan evaluation at 28 weeks gestation due to increasing wide disparity between her estimated gestational age and fundal height measurements. The scan showed a viable fetus at 28 weeks gestation with low lying posterior placenta covering the os, adequate liquor and coexisting anterior fundal fibroid measuring 8.27 cm by 4.84 cm. There was no history of bleeding per vaginam, haematuria or abdominal pains. She was counselled on the ultrasound findings, the risk of vagina bleeding that may necessitate preterm delivery; the need for regular antenatal monitoring and repeat obstetric scan at later gestation to confirm placenta location. Antenatal care progressed normally without any complaints; however, there was persistent fetal mal-presentation during obstetric examinations. Her blood pressure was well controlled, and her haematocrit level ranged between 30% and 32%.

Repeat obstetric scan at 36 weeks confirmed placenta location in the posterior lower uterine segment and completely covering the internal os with coexisting large anterior fundal fibroid. There was no other abnormality detected on the scan. She was subsequently admitted into the lying in ward for elective CD at 37 completed weeks after adequate counselling on the risk of intra-operative haemorrhage and hysterectomy if indicated. She consented and written informed consent was obtained. Her pre-operative haematocrit level was 31%, and four units of whole blood were made available for the surgery.

Intraoperative findings included dense anterior abdominal wall and intraperitoneal adhesions involving posterior aspect of the anterior abdominal wall, uterus and the bladder; prominent multiple tortuous blood vessels on the serosa of the anterior wall of the uterus extending to its right posterolateral aspect. Other findings included a male neonate in breech presentation, completely adherent placenta invading the whole layers of the uterus including the serosa (anteriorly and in the right posterolateral aspect), the cervix, bladder peritoneum and its superficial layer [Figure 1]. A transverse uterine incision was made above the vessels on the uterine serosa to deliver and the baby was delivered by breech extraction. The attempt at delivery of the placenta by controlled cord traction and manual removal was impossible with placenta tissue infiltrating the whole uterine wall. Due to uncontrolled bleeding from the placenta beds and the difficulty in delivering the placenta, the decision was taken to carry out total abdominal hysterectomy. Pressure was applied on the abdominal aorta, and pressure packing of the uterine cavity was done to minimize blood loss, while hysterectomy was carried out taking care to dissect the bladder away from the uterus and the placenta tissues. Estimated blood loss was 2.8 litres, and an abdominal drain was left in situ after haemostasis was achieved. She was transfused with four units of whole blood intraoperatively. She had a re-exploration 3 h after the initial surgery due to significant intraabdominal bleeding. Pre re-exploration post transfusion full blood count result showed a haematocrit of 25%, haemoglobin of 8.1 g/dl and platelet count of 90,000/μl with normal clotting profile. Findings at re-exploration were one litre of haemoperitoneum, multiple bleeding from raw areas on the bladder base, right uterine pedicle and vaginal angle. Obvious bleeding points were identified and ligated and BIIAL done. Haemostasis was secured, another abdominal drain was left in situ and EBL was 1.4 litres (including haemoperitoneum). The urethral catheter was slightly stained with blood. She was transfused with additional four units of whole blood, two units of platelet concentrate and two units fresh frozen plasma. She was admitted into the High Dependency Unit for close monitoring. Her post-operative recovery was uneventful; post-transfusion haematocrit level was 28%, and she was transferred to the lying in ward on the 2nd post-operative day. Abdominal drain and urethral catheter were removed on the 3rd and 7th post-operative day respectively and she was discharged home on the 8th post-operative day. Puerperal events were unremarkable.
Figure 1: Uterus after delivery of the baby with placenta tissue in situ completely invading the whole myometrium and uterine serosa

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  Discussion Top

The combination of PLP and PP is not a common occurrence in obstetrics, and it is one of the most deadly complications encountered by the obstetrician during surgery especially when it is undiagnosed prior to surgery. It is frequently associated with massive life-threatening haemorrhage and its related complications, multiple viscera injuries due to frequent involvement of other contiguous organs such as bladder and bowels.[3]

The incidence of PASD including PP has been increasing over the years[1],[5] from the first time it was report by Irving and Hertig[11] in 1937 through a very low rate of 1 in 7,000 deliveries reported by Breen et al.[12] in 1977 to a recent alarming rate of 1 in 533 deliveries reported by Wu et al. in 2005.[13] This increase has been associated with the rising trend in CD.[1],[4],[5],[13] PP accounts for just 5%–7%[4],[6],[8] of these disorders, making it the rarest of the three but the most dangerous of them with a reported maternal morbidity rate of 9.5%,[5] maternal mortality rate of 7%–10%[14] and perinatal mortality rate of 24%.[5]

The major risk factor for PASD is the presence of previous CD.[1],[2],[6],[9],[13] The higher the number of repeated CD, the higher the risk of PASD. This risk increases from 0.2% in patients with 1 previous CD to 2.1% in patients with 4 previous CD.[1],[15] The second major risk factor is the presence of PLP, especially when the placenta implants over the scarred portion of the uterus.[1],[6],[9],[13] PLP is associated with a 1%–4% risk of developing any of the PASD.[1],[15] The presence of both previous CD and occurrence of PLP give the highest risk of developing PASD.[1],[6],[9] This risk also increases progressively as the number of previous CD increases. The risk of developing PASD in a woman with one previous CD with PLP increases exponentially from 3.3% to 61% in a woman with four previous CD and PLP.[15] The other associated risk factors are scarring of the uterus due to myomectomy, uterine curettage, endometrial ablation and endometritis; multiparity, advance maternal age, uterine fibroids, uterine artery embolization, hypertensive disorders and smoking.[1],[5],[8],[9],[13] Most of these risk factors were present in the case reported.

The presence of these risk factors should raise suspicion of PASD and prompt further evaluation. This will aid antenatal diagnosis and allows for planned multidisciplinary management which has been shown to reduce maternal and perinatal morbidity and mortality.[1],[5],[9],[10] Prenatal diagnosis of PP and indeed PASD is usually based on ultrasonography (either grayscale or Doppler) and occasionally on magnetic resonance imaging (MRI) when ultrasound findings are debatable, as clinical diagnosis is usually difficult.[1],[5],[6] Ultrasound findings suggestive of PASD include appearance of multiple intra-placenta lacunae, turbulent flow of blood in the lacunae, loss or absence of the retro-placental clear space between the uterus and placenta, disruption of the posterior bladder wall-myometrial interface, reduction in myometrial thickness to < 1 mm, hyper-vascularity and irregularity of the adjacent bladder wall.[1],[5]

Unfortunately, the suspicion of PASD was not heightened in the case presented despite the presence of risk factors due to ultrasound findings that was not suggestive of any of the PASD and the fact that the placenta did not implant anteriorly over the previous caesarean scar.[1],[10] This scenario is similar to that observed in many cases of PASD that were undiagnosed antenatally, where the absence of ultrasound findings suggestive of PASD precluded diagnosis despite the presence of risk factors. The use of MRI in such suspicious cases is highly recommended.[5]

The surgical management of PP and PASD include non-conservative surgery, such as subtotal or total hysterectomy and conservative uterus sparing surgery such as placental resection or leaving of the whole placenta in situ with or without planned interval hysterectomy.[1],[4],[6],[10] Conservative management is usually followed by uterine and pelvic devascularization in order to reduce risk of bleeding.[1],[4],[6] Placental tissue is either allow to undergo autolysis spontaneous or aided with the administration of methotrexate.[4],[6] These patients are however at high risk of emergency peripartum hysterectomy due to uncontrolled secondary postpartum haemorrhage, severe sepsis due to uterine infection and placental necrosis.[4],[6]

The option of surgical management depends largely on need for fertility preservation, presence or absence of uncontrolled haemorrhage during surgery, patient's stability and the skills or expertise available.[1],[4],[5],[6] Elective caesarean hysterectomy with placenta in situ is considered as the gold standard surgical management of PP and PASD especially in developing countries where the capacity for close follow up, and prompt management of complications of conservative management is suboptimal.[1],[3] This procedure is usually challenging due to the presence of dense intraperitoneal adhesion from previous CD, a hypervascular lower uterine segment that is adherent to the bladder base, pelvic neovascularization and the possibility of placenta invading contiguous structures such as bladder, bowels and cervix.[3] This may be associated with persistent haemorrhage necessitating bilateral internal iliac artery ligation (BIIAL) to control bleeding even after hysterectomy has been done, as seen in the case reported. It is the authors' afterthought opinion that BIIAL should have been performed during the first surgery even when haemostasis seemed to have been achieved, as this would have prevented the return to theatre for re-exploration due to bleeding and its attendant morbidities. Placenta invasion of the bladder and bowel may occur with PP and this will require the surgical assistance of the Urologist and General surgeon for partial cystectomy and bowel resection respectively.[8],[10] In the absence of this expertise, conservative management is advised as much as possible.

Declaration of patient consent

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

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Wortman AC, Alexander JM. Placenta accreta, increta, and percreta. Obstet Gynecol Clin North Am 2013;40:137-54.  Back to cited text no. 1
O'Connor D, Berndl A. Placenta percreta. Can Med Assoc J 2018;190:E168.  Back to cited text no. 2
Allen L, Jauniaux E, Hobson S, Papillon-Smith J, Belfort MA; FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management. Int J Gynaecol Obstet 2018;140:281-90.  Back to cited text no. 3
Armstrong-Kempter S, Kapurubandara S, Trudinger B, Young N, Arrage N. A case of placenta percreta managed with sequential embolisation procedures. Case Rep Obstet Gynecol 2018;2018:7213689.  Back to cited text no. 4
Malnar A, Suranyi A, Jako M, Nemeth G. Intraoperative surgical treatment of undiagnosed placenta percreta. J Clin Case Rep 2016;6:910.  Back to cited text no. 5
Paniza LR, Durán SR, Hita MM, Paniza MR, Villaverde GR, Armenteros MB, et al. Placenta percreta a case study and literature review. Int J Pregnancy Child Birth 2018;4:232-5.  Back to cited text no. 6
Srisajjakul S, Prapaisilp P, Bangchokdee S. MRI of placental adhesive disorder. Br J Radiol 2014;87:20140294.  Back to cited text no. 7
Koukoura O, Lialios G, Garas A, Sveronis G, Nidimos A, Gkorezi I, et al. Macroscopic hematuria due to placenta percreta: Report of two cases and short review. Case Rep Obstet Gynecol 2017;2017:9863792.  Back to cited text no. 8
Saraví PG, Patiño NK, Juana ML, Mariano J, Reyna E, Tizzano R. Doppler ultrasound in the diagnosis of placenta percreta: Our experience. Rev Argent Radiol 2014;78:149-55.  Back to cited text no. 9
Jauniaux E, Alfirevic Z, Bhide AG, Belfort MA, Burton GJ, Collins SL, et al. Placenta praevia and placenta accreta: Diagnosis and management: Green-top guideline no 27a. BJOG 2019;126:e1-e48.  Back to cited text no. 10
Irving F, Hertig A. A study of placenta accreta. Surg Gynecol Obstet 1937;64:178-200.  Back to cited text no. 11
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. 12
Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: Twenty-year analysis. Am J Obstet Gynecol 2005;192:1458-61.  Back to cited text no. 13
Chandraharan E, Rao S, Belli AM, Arulkumaran S. The triple-P procedure as a conservative surgical alternative to peripartum hysterectomy for placenta percreta. Int J Gynaecol Obstet 2012;117:191-4.  Back to cited text no. 14
Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107:1226-32.  Back to cited text no. 15


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