Placenta accreta not previa: a rare case report of placenta accreta in an unscarred uterus
Keywords:Caesarean hysterectomy, Placental spectrum disorders, Placenta accreta
Placenta accreta spectrum disorders are usually associated with direct surgical scar such as caesarean delivery, surgical termination of pregnancy, Dilatation and curettage, Myomectomy, Endometrial resection and Asherman’s syndrome. It can also be associated with non-surgical scar and uterine anomalies. Rarely it can be encountered in unscarred uterus. Mrs X, 35-year female, unbooked patient, G7P2L2A4 with nine months of amenorrhoea reported in emergency of RML Hospital on 30/07/2019 with history of labour pains since 2 days. Patient gave history of four dilatation and curettage for incomplete abortion. On examination patient was found to be severely anaemic (Hb -6 gm). 2 Packed RBC were transfused preoperatively. There was no progress in labour beyond 6 cm for 4 hours. Patient was thus taken for LSCS for NPOL, with blood on flow. Intraoperatively, after delivery of the baby placenta which was fundo-posterior did not separate. In view of parity and morbidly adherent placenta (clinical grade III), subtotal hysterectomy was done. Patient was transfused 4 PRBC, 4 FFP and 2 platelets. Uterus with placenta in situ was sent for histopathology. Patient was in ICU for 2 days and recovered well. Post-operative period was uneventful. Placenta accreta is defined as abnormal trophoblast invasion of whole or a part of placenta into myometrium of uterine wall. Caesarean delivery is associated with increased risk of placenta accrete and the risk increases with each caesarean section, from 0.3% in woman with one previous caesarean delivery to 6.47% for woman with five or more caesarean deliveries. Placenta accreta spectrum disorders occur in 3% of woman diagnosed with placenta previa and no prior caesarean. In the developing world, the obstetrician should be prepared to encounter un diagnosed placenta accrete even in absence of previous LSCS. Curretage following MTP is also a risk factor, so vigourous currettage should be avoided to prevent endometrial damage.
Jauniaux E, Jurkovic D. Placenta accreta: Pathogenesis of a 20th century iatrogenic uterine disease. Placenta. 2012;33:244-51.
Belfort M. Placenta accreta. Ame J Obstet Gynaecol. 2010;203(5):430-9.
Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. J Matern Fetal Neonatal Med. 2011;24:1341-6.
Jauniaux E, Chantraine F, Silver RM, Langhoff-Roos J. For the FIGO placenta accreta diagnosis and management expert consensus panel. FIGO consensus guidelines on placenta accreta spectrum dis-orders: Epidemiol. Int J Gynecol Obstet. 2018;140:265-73.
Jauniaux E, Grobmann W. Caesarean section: Introduction to the “World’s No 1. Surgical Procedure ”, Textbook of Caesarean Section. Oxford: Oxford University Press; 2016:1-8.
Allen L, Jauniaux E, Hobson S, Paillon-Smith J, Belfort MA. for the FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum dis-orders: Nonconservative surgical management. Int J Gynecol Obstet. 2018;140:281-90.
Esakoff TF, Handler SJ, Granados JM, Caughey AB. PAMUS: Placenta accreta management across the United States. J Matern Fetal Neonatal Med. 2012;25:761-5.
Matsubara S, Kuwata T, Usui R. Important surgical measures and techniques at cesarean hysterectomy for placenta previa accreta. Acta Obstet Gynecol Scand. 2013;92:372-7.
Weiniger CF, Kabiri D, Ginosar Y, Ezra Y, Shachar B, Lyell DJ. Suspected placenta accreta and cesarean hysterectomy: Observational cohort utilizing an intraoperative decision strategy. Eur J Obstet Gynecol Reprod Biol. 2016;198:56-61.
Tam KB, Dozier J, Martin JN. Approaches to reduce urinary tract injury during management of placenta accreta, increta, and percreta: a systematic review. J Matern Fetal Neonatal Med. 2012;25:329-34.