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Placenta Increta at 14 Weeks with Subsequent Hysterectomy: a Case Report Abigail E Collett1*, Jean Payer1 and Xuezhi Jiang1,2

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Placenta Increta at 14 Weeks with Subsequent Hysterectomy: a Case Report Abigail E Collett1*, Jean Payer1 and Xuezhi Jiang1,2 ISSN: 2378-3656 Collett et al. Clin Med Rev Case Rep 2018, 5:225 DOI: 10.23937/2378-3656/1410225 Volume 5 | Issue 7 Clinical Medical Reviews Open Access and Case Reports CASE REPORT Placenta Increta at 14 Weeks with Subsequent Hysterectomy: A Case Report Abigail E Collett1*, Jean Payer1 and Xuezhi Jiang1,2 1Departments of OB/GYN, The Reading Hospital of Tower Health System, Reading, USA Check for updates 2Departments of OB/GYN, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, USA *Corresponding author: Abigail E Collett, DO., Department of OB/GYN-R1, The Reading Hospital of Tower Health, P.O. Box: 16052, Reading, Philadelphia, PA 19612-6052, USA, Tel: 484-628-8827, Fax: 484-628-9292, E-mail: Abigail.collett@ towerhealth.org Abstract transvaginal ultrasound which showed heterogeneous myo- metrium and a heterogeneous mass-like solid and cystic Background: Abnormal placental implantation (API) is an appearing area in the lower uterine segment. A total ab- uncommon obstetrical phenomenon that is associated with dominal hysterectomy, bilateral salpingectomy and cystos- significant maternal morbidity. Typically, the diagnosis of copy were performed. Intra-operative evaluation revealed a API is made at the time of delivery in the third trimester. firm protruding tissue mass in the left anterior lower uterine However there are reports of API presenting in the second segment that was found to be placenta increta or more on trimester, and rarely in the first trimester. Cesarean Scar final pathology. The patient recovered appropriately during Pregnancy (CSP) can be considered a subset of API. Early her hospital stay and was discharged in stable condition. API rarely occurs in the absence of previous uterine manip- ulation. CSP is always associated with previous cesarean Conclusion: API is an uncommon finding in early preg- delivery. Nonetheless, it has been suggested that CSP and nancy. Although there are few reported cases, the major- early API are histologically indistinguishable and both are ity of documented cases presented similarly to our case. precursors of API. Although specific screening for API or CSP is not recom- mended, it is important to have a high index of suspicion Case Report: A 38 yo G4P2012 with a history of two pre- and proper preparation for patients with multiple risk factors vious cesarean sections underwent a dilation curettage for API, especially previous cesarean sections. It is import- and evacuation (DC&E) procedure at 14w6d gestational ant to consider early API and CSP as differential diagnoses age (GA) dated by last menstrual period (LMP) after ap- when one encounters unexplainable and unexpected hem- proximately one month of expectant management for an orrhage at the time of DC&E procedure. incomplete spontaneous abortion. Beta-hCG on the morn- ing of surgery was 1,936 mIU/mL. In the operating room Keywords (OR), immediately after the bimanual exam was performed Abnormal placenta implantation, Placenta increta, Early heavy bright red vaginal bleeding was noted to be com- second trimester pregnancy, Hysterectomy, Cesarean scar ing from the cervical os. A steady heavy flow of bleeding pregnancy continued throughout the procedure. Intra-operatively the patient became hypotensive and was transfused with two units of packed red blood cells. Uterotonic agents were ad- Introduction ministered and a Bakri balloon was placed to tamponade the bleeding. At the conclusion of the case no further active Abnormal placental implantation (API) occurs in ap- bleeding was noted and the patient was hemodynamically proximately 1 in 533 deliveries in the USA and is associ- stable. Approximately 7-8 hours after the initial DC&E pro- ated with significant maternal morbidity [1]. There are cedure the patient bled around the Bakri balloon and was noted to be tachycardic. About nine hours after the initial varying degrees of abnormal implantation differentiat- surgery the decision was made to return to the OR due to ed by depth of placental invasion. In order of increasing persistent vaginal bleeding, persistent tachycardia, addi- severity, placenta accreta is invasion into the myome- tional blood product requirements, and re-review of early trium, increta is invasion deeper into the myometrium, and percreta is invasion through the myometrium and Citation: Collett AE, Payer J, Jiang X (2018) Placenta Increta at 14 Weeks with Subsequent Hysterecto- my: A Case Report. Clin Med Rev Case Rep 5:225. doi.org/10.23937/2378-3656/1410225 Accepted: July 24, 2018: Published: July 26, 2018 Copyright: © 2018 Collett AE, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Collett et al. Clin Med Rev Case Rep 2018, 5:225 • Page 1 of 5 • DOI: 10.23937/2378-3656/1410225 ISSN: 2378-3656 serosa and potentially into surrounding structures. API occurs in areas where there is a total or partial defect in the decidua basalis of the endometrium. Injury to the myometrium causes scarring. As the myometrium heals it forms a fibrous collagen layer rather than regener- ating muscle [1]. The scarred area is weaker and does not form functional decidua basalis, which increases the risk of abnormal placentation [2]. There are various proposed theories to explain exactly how and why API occurs. These include: A primary defect in trophoblast function, secondary decidua basalis defect due to failure of normal decidua formation, and finally abnormal vas- cularization and oxygenation of the scarred tissue [1]. Risk factors for API include previous cesarean sec- Figure 1: Transvaginal dating ultrasound prior to initial obstet- tion, curettage procedure, placenta previa with a his- rical visit. tory of cesarean section, manual removal of placenta, endometritis, myomectomy, Asherman’s syndrome, indistinguishable, but are both precursors to API. submucosal fibroids, adenomyosis, increasing age, and Case multiparity [1-3]. Studies show that cesarean section is the most important risk factor associated with API A 38 yo G4P2012 with a past medical history of hy- and the risk increases with increasing number of prior pothyroidism presented for an initial obstetric (OB) cesarean sections [1]. Despite API typically being asso- appointment to an outside institution. Obstetrical his- ciated with previous uterine injury or a risk factor that tory included two previous cesarean sections and one is associated with a weakening of the endometrium, it previous spontaneous abortion. The patient underwent has been reported that about 7% of API occur in women transvaginal ultrasound (TVUS) the day prior to her visit without risk factors [3]. at 10w0d gestational age (GA) based off last menstru- al period (LMP) (Figure 1). The ultrasound showed an Most cases of API are documented in the third tri- elongated sac-like focus that did not have the appear- mester or at the time of delivery. Less commonly there ance of a normal intrauterine gestational sac. The ul- are reports of API presenting in the second trimester, trasound also did not show a definite yolk sac or fetal often associated with post-abortal hemorrhage and pole. The radiology report pointed out a heterogeneous less commonly uterine rupture [3]. API is an uncom- myometrium and a heterogeneous mass-like solid and mon finding in the first trimester. Papadakis, et al. did cystic appearing area approximately 5.4 cm in the low- a MEDLINE search using key words “placenta accreta”, er uterine segment. Per the report these findings were “placenta percreta”, “early gestation” and “pregnancy” non-specific but may reflect a fibroid, however other from 1966 to 2007 which showed only 14 histological- mass lesions could not be excluded with certainty. Mo- ly proven cases of first trimester API [3]. Most of these lar pregnancy was considered less likely. cases presented with severe hemorrhage precipitated by curettage for induced or spontaneous abortion. All At her initial OB appointment, the patient reported but one case resulted in definitive management with to- menses-like vaginal bleeding for around one week. Per tal abdominal hysterectomy (TAH). The one outlier was the patient she elected for expectant management and treated with bilateral uterine artery embolization (UAE). a referral was made to the clinic at our institution for Rouholamin, et al. published two cases documenting a possible dilation, curettage and evacuation (DC&E) similar presentations; patients with history of cesarean procedure. The next documented patient encounter sections undergoing curettage procedure for first tri- was in our facility’s obstetrical triage department at mester loss, resulting in severe bleeding and ultimately 14w2d, about one month after her initial presentation. requiring total abdominal hysterectomy [4]. The patient presented with abdominal cramping and persistent vaginal bleeding. Review of serum quantita- Cesarean scar pregnancy (CSP) is another uncom- tive beta-hCG (mIU/mL) showed a downward trend con- mon complication seen in patients with prior cesarean sistent with spontaneous abortion: 2/28/2018: 10,181, sections and is also associated with significant mater- 3/9/2018: 5,727, 3/25/2018: 1,854. Repeat TVUS in nal morbidity. The rate of CSP is increasing with the in- triage was consistent with the prior diagnosis, showing creased rate of cesarean deliveries, now affecting ap- an irregular shape and elongated gestational sac and proximately 1 in 800-2500 women [5]. Timor-Tritsch, et no yolk sac or fetal pole. The patient was seen in the al. did a retrospective review of histopathological fea- clinic two days later where she was re-evaluated and tures of patients with a diagnosis of CSP and early ab- consented for a DC&E procedure and blood transfusion. normal placentation (early second trimester API). Their study showed that these two entities are histologically She presented for the procedure two days later at Collett et al. Clin Med Rev Case Rep 2018, 5:225 • Page 2 of 5 • DOI: 10.23937/2378-3656/1410225 ISSN: 2378-3656 14w6d.
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