PLACENTA PERCRETA.
A CASE REPORT.
Dr. YUDANIA LORENTE BRICUYET
RUNDU. NAMIBIA
2013
The Placenta: is an organ that develops in the uterus during pregnancy. It
is a unique characteristic of the higher mammals. In humans it is a thick
mass, about 18 cm in diameter, liberally supplied with blood vessels. It
usually weighs about 1 to 2 pounds (about 1/6 of the weight of the baby).
The placenta is attached to the uterus, and the fetus is connected to the
placenta by the umbilical cord. The placenta draws nourishment and
oxygen, which it supplies to the fetus, from the maternal circulation. In turn,
the placenta receives the wastes of fetal metabolism and discharges them
into the maternal circulation for disposal. It also acts as an endocrine gland,
producing estrogen, progesterone, and gonadotropin. Shortly after delivery
of the fetus the placenta is forced out by contractions of the uterus. Severe
haemorrhage may occur if the placenta does not emerge in its entirety or if
the uterus fails to contract properly.
A case report.
Name: Murunga Angelina
28 years old.
Previous obstetric history: G 5 P3 (nvd) A1. LMP: 31/1/2012
EDD:7/11/2012
Risk factors: RVI on HAART and Preeclampsia.
This patient came to Rundu Hospital on 26/10/2012 complaint LAP.
On examination was found:
BP 179/109 mm/Hg. Abd. Cephalic, FHR present and normal, no contractions
noticed. Pedal oedema. And in VE. Os was closed, no bleeding per vagina.
Was admitted with follow diagnosis:
1) Gestation of 38.3 weeks.
2) Severe preeclampsia. (treated with methyldopa)
3) RVI on HAART.
On 27/10/2012 during round, the Dr on call, decided to order
labs test ( FBC, U+E, LFT, and Urine analysis) and also to
start induction with Misoprostol, BP was normal and general
condition of the patient was stable.
The patient received 3 doses of Cytotec to tried to induce
labour. The BP was controlled.
On 28/10/2012 the labs results was received: Hb 10.94 g/dl
WCC 5.94x10 l. Platelet 134x10 l.
And Creatinine 74 mmol/l.
Then the Dr was informed and decided to do Caesarean
section due to Severe Preeclampsia with maternal affectation
and failed Induction, and informed immediately to specialist
for assistance.
During surgery ,the anterior wall of the uterus was normal, then the baby
was extracted with good Apgar score by classical segment incision, but
the placenta was on posterior wall and penetrated through the uterus and
some part was attached on the bowels and retroperitoneal tissue.
Obstetric Hysterectomy was done and also removed some placenta tissue
from de bowels with assistance of de general surgeon.
Placenta accreta is a rare but potentially life-threatening
complication of pregnancy that is today an increasingly frequent
cause of maternal morbidity and mortality. The term refers to any
placental implantation that results in its abnormal adherence to
the uterine wall.
CLASIFICATION
The placenta forms an abnormally firm attachment to
the uterine wall. There is absence of the decidua
basalis and incomplete development of the Nitabuch's
layer. There are three forms of placenta accreta,
distinguishable by the depth of penetration.
1.Placenta accreta.
2.Placenta increta.
3.Placenta percreta.
Pathogenesis
Type
Description
Percent
Placenta accreta
An invasion of the myometrium which
does not penetrate the entire thickness of
the muscle.
75-78%
Placenta increta
Occurs when the placenta further
extends into the myometrium, penetrating
the muscle.
17%
Placenta percreta
The worst form of the condition is when
the placenta penetrates the entire
myometrium to the uterine serosa. This
variant can lead to the placenta attaching
to other organs such as the rectum or
bladder.[9]
5-7%
Risk factors
1) Presence of scar tissue:
•Asherman’s Syndrome. (D and C)
•Myomectomy.
•Caesarean section.
2) Trophoblastic invasion.
3) Low lying placenta.
4) Congenital and acquired uterine defects:
• Uterine septa.
• Leiomyoma.
• Cornual pregnancy.
5) Some study suggest that the rate of incidence is higher when the fetus is
female.
Diagnosis
Placenta accreta is very rarely recognised before birth, and is very
difficult to diagnose. A Doppler ultrasound can lead to the diagnosis of a
suspected accreta and an MRI will give more detail leading to further
suspicion of such an abnormal placenta. However, both the ultrasound
and the MRI rarely confirm an accreta with certainty. While it can lead to
some vaginal bleeding during the third trimester, this is more commonly
associated with the factors leading to the condition. In some cases the
second trimester can see elevated maternal serum alpha-fetoprotein
levels, though this is also an indicator of many other conditions. A three
dimensional power color doppler ultrasound scan has been used.
Usually in this case, manual blunt dissection or placenta traction is
attempted but can cause haemorrhage in accreta.
Treatment
•HYSTERECTOMY:
The safest and most common treatment is a planned caesarean
section and abdominal hysterectomy if placenta accreta is
diagnosed before birth.
In cases where there is invasion of bladder, it is treated in similar
manner to abdominal pregnancy and manual placental removal is
avoided. However, this may eventually need hysterectomy and/or
partial cystectomy.
CONSERVATIVE:
Pitocin and antibiotics are used for post-surgical management. When there is
partially separated placenta with focal accreta, best option is removal of
placenta and oversewing the uterine defect. If it is important to save the
woman's uterus (for future pregnancies) then resection around the placenta
may be successful. Conservative treatment can also be uterus sparing but may
not be as successful and has a higher risk of complications.
Techniques include:
•Leaving the placenta in the uterus and curettage of uterus. Methotrexate has
been used in this case.
•Intrauterine balloon catheterisation to compress blood vessels.
•Embolisation of pelvic vessels.
•Internal iliac artery ligation.
•Bilateral uterine artery ligation.
Complications.
1.Haemorrhage (3000mls-5000mls)
2.Disseminating Intravascular Coagulations (DIC)
3.Transfusion reactions.
4.Other
complications
accompanying
blood
transfusion (HIV and Hepatitis)
5.Surgical complications (emergency hysterectomy,
bowel injury, urological injuries etc.)
6.Pulmonary embolism.
7.Adult Respiratory Distress Syndrome (ARDS)
CONCLUSION
Placenta Accreta is a nasty little secret in the world of
Obstetrics and Gynaecology. It is fast on the rise, due to
the primarily dramatic increase in Caesarean Sections,
the majority of which are unnecessary. Any type of
uterine surgery increases your risk of developing
placenta accreta with subsequent pregnancy, no more
than caesarean section. The more caesareans you have,
the greater your likelihood of developing placenta
accreta.
Thank You