Beyond the immediate postpartum - scar niche associated placenta accreta spectrum presenting as chronic AUB

Abstract

Placenta accreta spectrum (PAS) is typically diagnosed during pregnancy or in the immediate postpartum period. Delayed presentation years after delivery is exceedingly rare and may mimic chronic abnormal uterine bleeding (AUB), resulting in diagnostic difficulty. We report the case of a multiparous woman with three previous caesarean deliveries who presented with persistent abnormal uterine bleeding (AUB) for two years following her last childbirth. She had been repeatedly managed as a case of unexplained AUB with limited response to medical therapy. Transvaginal ultrasonography revealed a heterogenous lesion within a caesarean scar niche associated with myometrial thinning, scar dehiscence, and focal vascularity, raising suspicion for chronic retained products of conception with invasive placental tissue. Diagnostic hysterolaparoscopy revealed dense bladder adhesions and a hypervascular lower uterine segment lesion with significant intraoperative bleeding, necessitating conversion to total laparoscopic hysterectomy. Histopathological examination confirmed placenta accreta and placenta percreta associated with retained products of conception within a caesarean scar niche. This case highlights that chronic AUB in women with multiple prior caesarean deliveries may rarely be associated with retained invasive placental tissue within a caesarean scar niche.