Introduction

Placenta Accreta Spectrum (PAS) encompasses a range of abnormal placentation with disruption of the decidual basalis enabling invasion of chorionic villi into or past the myometrium in turn leading to incomplete placental separation and major obstetric hemorrhage.1 PAS is a life threatening condition and a major cause of maternal mortality. It is also associated with maternal morbidity like hysterectomy due to uncontrollable bleeding, large volume of blood transfusion, coagulopathy, ureteral injury, intra-abdominal infection and prolonged maternal admission to intensive care unit. The most important risk factors are the following: previous caesarean delivery, maternal age over 35 and dilatation and curettage. The incidence of placenta accreta spectrum is expected to increase in the coming years due to an increase in the frequency of cesarean sections and advanced maternal age both of which are independent risk factors for placenta accreta spectrum.2, 3

Case Presentation

A 30-year-old woman G3P2L2 previous two LSCS, last childbirth two years ago, and current pregnancy gestational age of 12 weeks and 4 days presented with complaints of spotting per vaginum and lower abdominal pain of one day duration. Her general physical examination was found to be normal, and her vital signs were stable. Per abdomen examination showed a healthy suprapubic transverse scar and an uterine size of 14-16 weeks. On per vaginal examination, cervix pointing downwards, uterus was anteverted and corresponding to 14-16 weeks size, fornices were free and bleeding was present. All baseline investigations were found to be normal. An emergency ultrasound was done, and it was suggestive of Dichorionic Diamniotic (DCDA) twin pregnancy in early gestational failure. After investigations informed consent was obtained from the patient and she was taken up for manual vacuum aspiration.

Operative procedure and findings

During MVA, products of conception were removed; however, abnormal fresh bleeding from the uterine cavity was noted. It could not be controlled with tranexamic acid or uterotonics -oxytocin 40 units, methergine 0.2 mg and carboprost 250mcg. Patient went into shock following a blood loss of about one liter in a few minutes. Immediate resuscitation with intravenous fluids and other supportive management was done. After obtaining informed consent, case proceeded to emergency laparotomy; resuscitation continued with adequate blood and blood products. Intra-operative findings were: Both fallopian tubes were found to be normal, left ovary showed cyst measuring 3cm and uterus corresponds to 12-14 weeks, lower uterine segment appeared vascular and covered with engorged vessels (Figure 1).

Placenta was implanted at the lower uterine segment, adherent to the anterior uterine wall. Absence of cleavage plane between placental bed and endometrium; Inability to remove placenta from the uterus (Figure 2, Figure 3).

Figure 1

Placental invasion into myometrium with increased vascularity and engorged vessels

Figure 2

Bluish bulge can be seen through the myometrium

Figure 3

Placental tissue invading the myometrium and reaching up to serosa with left ovarian cyst

Emergency laparotomy proceeded to subtotal hysterectomy. She was transfused with four units of PRBC and four FFPs. The patient was shifted to ICU. Her postoperative period was monitored for coagulopathy, anaemia, thromboembolism and organ dysfunction and it was uneventful. She was discharged on day 7 in a stable condition. Histopathological report of uterus with cervix showed chronic cervicitis, products of conception and endometrial cavity with decidual cells invading myometrium close to serosa.

Discussion

Placenta increta is abnormally implanted, invasive or adherent placenta with myometrial invasion. PAS occurs when the placenta attaches itself deeply into the uterine wall between the myometrial fibres, excessive capacity of infiltration by chorionic villi or when the decidual reaction is inadequate in containing villi penetration. It is due various other risk factors like advanced maternal age > 35 years, multiparity > 6 pregnancies, prior caesarean delivery, placenta previa, previous caesarean delivery with placenta previa, prior uterine surgery like myomectomy, uterine pathology like Adenomyosis, submucous fibroid, bicornuate uterus, uterine artery embolization, endometrial ablation, uterine curettage, asherman syndrome, manual removal of placenta, puerperal sepsis, postpartum endometritis and previous history of adherent placenta.

In this case previous two caesarean section risk factor was found.

Investigations of choice to diagnose PAS were:

A systematic review and meta-analysis on epidemiology of placenta previa accreta had shown that there is a need to implement standardised protocols for the diagnosis of both placenta previa and PAS.4, 5, 6, 7, 8

Conclusion

As explicit in this case, ultrasound screening in first trimester of pregnancy does not seem to have the high sensitivity to reliably detect PAS. Prospective studies are needed to further refine the techniques in USG to reliably diagnose PAS in first trimester. Prospective studies are also needed to assess the best method/methods (colour doppler/MRI) for routine screening of PAS in first trimester.

The rate of CD increased from 5 to 32.9% in 2009. 45 similar or even higher rates of CDs are reported Elsewhere in the world with countries such as Brazil (45%), Mexico (44%), China (42%), and Italy (38%). In consideration of the epidemiologic emergency, the great maternofetal morbidity and mortality, and the possible medico-legal implications, the prenatal diagnosis Of PAS is extremely important above all for correct management in consideration of the importance of diagnosis and the possible severe consequences in case of misdiagnosis, it is appropriate that all suspected cases are subjected to a careful diagnostic study in a referral centre, where it is possible to benefit from more advanced technology and operators with higher experience.

Recommendations

Our suggestion is that in patients with a prior uterine scar, in the first trimester, the USG may be combined with MRI to optimise diagnostic accuracy in PAS. This will help to optimise management with a planned elective hysterectomy/ other modalities of management whicn in turn will reduce morbidity and mortality in women with PAS.

Consent

Written informed consent was obtained from the patient for this case report.

Source of Funding

None.

Conflict of Interest

There are no conflicts of interest for any of the authors to be declared.