Placenta accreta complicated by hemoperitoneum

Abstract

P LACENTA accreta is defined as that pathologic condition in which the chorionic villi are in direct contact with and are interspersed among the actual muscle bundles of the myometrium. There is a deficiency of de&dual tissue resulting in a partial or Complete absence of this important structure. Attempts at separating such a placenta can lead only to tearing of the uterine wall itself, as there is no line of cleavage between the placenta and muscle. The incidence of placenta accreta in different clinics varies widely from: The Boston Lying-in Hospital, 1 in 1,956 deliveries to 1 in 17,464 deliveries at the Baltimore City Hospitals. Irving and Hertig stress the fact that cases of partial placenta accreta are often overlooked and are spoken of as densely adherent placentas. The tissues removed should always be examined microscopically when any difficulty is encountered in manually removing a placenta. There are at least 163 cases of placenta accreta reported in the literature to date, in which the diagnosis has been proved by microscopic examination. The case of placenta percreta reported below is remarkable in that it was complicated by massive hemoperitoneum in the absence of gross rupture of the uterine wall. The vaginal bleeding was minimal and the hemorrhage occurred into the .peritoneal cavity from rupture of large subserosal veins. The patient was a 24-year-old, white para 0, gravida ii. Her first pregnancy had ended in a spontaneous incomplete abortion at about six weeks with severe hemorrhage. She gave a history of having had a curettage, blood transfusion, and a febrile but eventually complete convalescence. She became pregnant again six months after this septic illness. Her local physician treated her during the first five months for severe nausea and vomiting and irregular vaginal bleeding. She had no unusual complaints when seen by one of us (M. D. P.) six weeks before her calculated date of delivery. She appeared pale, undernourished, with very poor general hygiene, but her pulse rate, blood pressure, urinalysis, and abdominal examination were normal at that visit. Two weeks later she was admitted to the Albany Hospital with mild irregular uterine contractions. The abdomen was t,ender to the touch but she did not localize the tenderness. The cervix was a finger tip dilated and the fetal heart rate was recorded as 140 per minute. Her symptoms subsided promptly after a night’s sleep and mild sedation. A second admission for apparent false labor with similar findings but intensified pain occurred one week after the first and she was again sent home. She returned twenty-four hours later appearing acutely ill. On this third admission, the uterine contractions were intermittent and the fetal heart was definitely heard. No vaginal bleeding was seen. Very striking were the extreme and increasing pallor, the pinched expression of the face, and the rising pulse rate. The abdomen was tense, tympanitic in its upper half, but there was still no localization of tenderness or palpable abnormality of the uterus. The cervix was still a finger tip dilated. A blood count revealed 1,780,OOO red cells with 4.5 Gm. (31 per cent) of hemoglobin. Compatible blood was obtained and transfusion started. The urine showed a trace of