Navigating Complexity:A Comprehensive Case Study of Placenta Praevia Percreta Management
About the Patient
A 35 year old female patient, G5P2L2A2, presented at 24 weeks of gestation with chief complains of pain abdomen.The ultrasound performed was s/o central placenta praevia with placenta percreta. She had previous 2 caesarean section and two D&C.She did not complain of any bleeding per vaginum and was managed conservatively.Follow up Ultrasounds were s/o similar findings.MRI at 30 weeks confirmed the sonographic findings of central placenta praevia with percreta.Placental extensions were seen extending upto the posterior wall of the urinary bladder.It was decided to deliver the patient electively by caesarean section at 35 weeks.Steroid coverage was done for the baby’s lung maturity.
Case Scenario
The patient was admitted at 35 weeks of gestation.A multidisciplinary team ,consisting of a gynaecologist ,a uro-surgeon, an anaesthetist, haematologist and an interventional radiologist was sought.Adequate blood products were reserved.On the day of the surgery, balloon catheters were inserted in bilateral uterine arteries, for embolisation through the femoral artery.This was followed by a cystoscopy which showed a hyperaemic posterior wall mucosa.Further we proceeded with the classical cesarean section.The lower part of the uterus was occupied by the placenta.A vertical incision was given on the fundus and the baby was delivered by breech extraction.A 2.4 kg baby was delivered.Uterine incision sutured.Placenta seen encroaching upto the bladder serosa.Bilateral Retrograde pyelography, ureteric catheterisation and open bilateral ureterolysis done.A stepwise total hysterectomy was performed.2 unit PRBC and 4 FFP transfused intraoperatively.She was shifted to ICU and 2 unit PRBC transfused postoperatively.The patient was haemodynamically stable and recovered well in the post-operative period.The patient was discharged on POD 5.The histopathology confirmed the diagnosis of placenta accreta..
World-wide Scenario
Placenta praevia percreta is a serious pregnancy complication where the placenta invades the uterine wall, sometime extending into the nearby organs.The risk increases with the number of previous cesarean sections.The complications include severe life threatening bleeding, damage to local organs(bowel,bladder and ureters) and neurovascular structures in the retroperitoneum and lateral pelvic sidewalls from placental implantation and its removal,dilutional coagulopathy,consumptive coagulopathy,acute transfusion reaction, transfusion associated lung injury,ARDS,and electrolyte abnormalities caused by transfusion of large volumes of blood products.Postoperative thromboembolism ,infection, multi system organ failure and maternal death..
Expertise at Apollomedics Hospital, Lucknow
