Abstract
Placenta percreta in early pregnancy is an extremely rare but life-threatening complication, for which very few cases have been reported in the literature worldwide, none from the United States. We report a patient with two previous cesarean deliveries, who presented with incomplete abortion at 17 weeks and underwent dilatation and curettage. She was found to have retained, adherent placenta that led to extensive hemorrhage, requiring emergency supracervical hysterectomy. Postoperative course was also complicated by severe consumption coagulopathy, necessitating reexploration after hysterectomy. Pathology revealed a placenta percreta. Patient lost more than 8000 cc blood through the 2 surgeries, received massive transfusions due to severe disseminated intravascular coagulopathy (DIC), and underwent a complicated surgery because of great difficulty in separating lower uterine segment and cervix from the bladder. Abnormal placentation in early pregnancy has increased in prevalence due to marked rise in cesarean deliveries and curettages in recent decades. We reviewed all reported cases of first and second trimester placenta percreta in the literature, to emphasize the early recognition of abnormal placentations in patients with risk factors, consider prenatal evaluation in such patients, anticipate complicated placental implantations during termination procedures, and prevent associated maternal morbidity and mortality.
Highlights
Abnormal placentation during pregnancy is categorized into accreta, increta, and percreta in the order of increasing severity and increasing invasion of placental villi through the uterine wall
Placenta percreta is the most severe form of placentation defect, noted very infrequently in first or second trimester. It can be a lethal problem when encountered during a dilatation and evacuation or curettage performed for the termination of first or second trimester pregnancy loss, leading to extensive hemorrhage within minutes of initiating the procedure
In majority of the studies, predisposing factors for abnormal placentation in early pregnancy were related to thinning of the endometrium at the site of uterine scars from previous cesarean sections
Summary
Abnormal placentation during pregnancy is categorized into accreta, increta, and percreta in the order of increasing severity and increasing invasion of placental villi through the uterine wall. Accreta involves penetration of placental tissue beyond the endometrial lining, into the myometrium, increta is characterized by deep myometrial invasion, and percreta involves placental penetration through the uterine serosa and into adjacent organs in some cases. Placenta percreta is the most severe form of placentation defect, noted very infrequently in first or second trimester. It can be a lethal problem when encountered during a dilatation and evacuation or curettage performed for the termination of first or second trimester pregnancy loss, leading to extensive hemorrhage within minutes of initiating the procedure. Case in point exemplifies the need of aggressive evaluation for placentation defects in patients with history of previous cesarean deliveries or curettages and encourages the physician to employ more conservative methods like uterine artery embolization or methotrexate prior to curettage for termination
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