Minimally Invasive Management of Second Trimester Placenta Percreta

Abstract

<h3>Study Objective</h3> To describe the diagnostic and surgical challenges in the management of second trimester placenta percreta. <h3>Design</h3> Case Review, review of surgical technique and video documentation. <h3>Setting</h3> Laparoscopic hysterectomy at a tertiary care centre. <h3>Patients or Participants</h3> The patient was a 39-year-old female, G7P3 at 17+2 weeks gestation who presented with acute abdominal pain to a community hospital. Imaging such as CT and ultrasound were inconclusive during initial work up for appendicitis. She experienced a drop in her hemoglobin, received a unit of pRBC and was taken to the operating room for exploratory laparoscopy. In the OR, acute hemoperitoneum was visualized with placenta like tissue invading through the anterior lower uterine segment. She was then transferred to our centre for urgent work up which confirmed the diagnosis of second trimester placenta percreta with active bleeding. <h3>Interventions</h3> Laparoscopy. <h3>Measurements and Main Results</h3> Once the patient was transferred to our centre an urgent MRI was done and this confirmed placenta percreta with invasion at the level of bladder and lateral parametrial involvement. An extensive discussion was had with our multidisciplinary team and given that were was ongoing bleeding from the invading placental tissue, pregnancy continuation was not possible. Second trimester placenta percreta is a rare entity with very few case reports in the literature. Our video demonstrates the challenges of a minimally invasive approach, which has not been previously described. We describe five main challenges and a step wise approach to mitigating these challenges. In addition, we combine the use of a dilatation and evacuation technique to allow for a complete minimally invasive approach. <h3>Conclusion</h3> Placenta accrete spectrum disorders pose significant challenges in diagnosis and management. A minimally invasive approach has not been described in the literature. We demonstrate that a minimally invasive approach to hysterectomy in management of midtrimester placenta percreta is a feasible option.