An unsuspected case of placenta accreta

Abstract

Case report A 29-year-old school-teacher presented in her second pregnancy at term + 6 in spontaneous labour, with an undiagnosed breech presentation. A detailed ultrasound at 20 weeks had shown the placenta to be fundal. She had had an uneventful antenatal period. Her previous pregnancy had been uncomplicated and ended in a forceps delivery at term. Subsequently she developed postpartum endometritis, which was treated by antibiotics. She had wellcontrolled asthma and was a non-smoker. Vaginal examination revealed that the cervical os was 8 cm dilated. After discussing the mode of delivery she opted for caesarean section, which was performed under spinal anaesthesia. The placenta was removed manually but was apparently complete. The estimated blood loss was 800 ml. Intraoperatively, a slight tear of right uterine angle was noted and was sutured. A drain was left intra-abdominally and syntocinon infusion of 40 units in 500 ml of normal saline was administered. Two hours postoperatively she started bleeding vaginally. On examination abdomen was soft, nondistended and the drain contained only 30 ml of serous blood. Initial management included intravenous oxytocin; bimanual uterine compression and intramuscular prostaglandin F2 alpha (carboprost) did not arrest the bleeding. She was taken back to theatre for laparotomy. There was no intra-abdominal bleeding. The uterus was reopened. No obvious source of bleeding was identified; therefore all uterine and abdominal layers were closed again. The vaginal bleeding ceased, but soon after laparotomy she then started bleeding intra-abdominally due probably to disseminated intravascular coagulation (DIC), and finally a subtotal hysterectomy was performed. The estimated blood loss was approximately 6 l. In total she received 15 units of blood, 12 units of FFP, 9 units of cryoprecipitate and 2 units of platelets. Her postoperative care was managed jointly in the intensive care unit, and the high-dependency area of the labour ward, by the anaesthetist, haematologist and obstetrician. She made a good recovery. Pathological examination showed a uterus weighing 628 g and measuring 15 6 9 6 6 cm. The endometrial cavity contained blood and the endometrial lining was ragged. There was no residual placental tissue identified and there were no leiomyomata or other abnormalities seen. Random blocks were sampled from around the uterine cavity and in the blocks from the fundus two foci of residual chorionic villi were identified, the largest 6 mm across. These chorionic villi were lying in close proximity to the myometrium with some large veins and there was a cytotrophoblastic reaction nearby. There was minimal decidual change in this area, although elsewhere decidua up to 2 mm thick was present. The changes were considered consistent with placenta accreta (Figure 1).