1 Department of Obstetrics and Gynecology and 2 Department of Pathology, Lindendreef 1, 2020 Antwerp, Belgium
3 To whom correspondence should be addressed. Email: jan.gerris{at}zna.be
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Abstract |
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Key words: hysterectomy/placenta percreta/spontaneous uterus rupture
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Introduction |
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A literature review of reports on placenta percreta followed by a spontaneous rupture of an unscarred uterus in early gestation indicated that the reported case can be considered as extremely rare. This case report aims to contribute to the insight and knowledge of this rare complication of pregnancy.
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Case report |
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Discussion |
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Although the aetiology of placenta percreta is unknown, a number of risk factors have been identified on the basis of previous case reports. These risk factors include a history of Caesarian section resulting in a scarred uterus, placenta praevia, history of manual placenta extraction, multiple pregnancies, dilatation and curettage, endometriosis, high parity and an advanced maternal age (Haider, 1990; Morkon and Henriksen, 2001
). In most cases, a placenta percreta is caused by a combination of factors and it is unlikely that its occurrence can be attributed to one single risk factor. Of the above-mentioned risk factors, a history of a classical Caesarian section leaving scar tissue in the uterine wall is most often reported in association with the development of a subsequent placenta percreta (Clark et al., 1985
; Wax et al., 2000
). In contrast to the many reports in which a placenta precreta was diagnosed in patients with a history of Caesarian section (Woolcott et al., 1987
; Haider, 1990
; Smith and Mueller, 1996
; Endres and Barnhart, 2000
; Höpker et al., 2002
), our patient had no previous Caesarian section and had a normal vaginal delivery some years before. Due to retention of the placenta during the patients' first parturition, a manual extraction was performed which may have altered the risk for developing a placenta percreta. In addition, a less significant risk factor may have been the previous curettage and age of the patient (40 years of age).
Two types of management of a placenta percreta have been proposed: (i) surgical removal of the uterus and of the surrounding tissues; and (ii) conservative therapy. The latter involves (i) leaving the placenta in situ with packing; (ii) uterine curettage with packing; (iii) closing the uterine defect; (iv) localized excision and uterine repair; (v) uterine packing with uterine and even hypogastric artery ligation; and (vi) leaving the placenta in situ with adjuvant chemotherapy (Morkon and Henriksen, 2001). Hysterectomy has been the traditional treatment for placenta percreta given the report by Fox (1972)
that conservative treatment caused a four times higher mortality rate than treatment with an immediate hysterectomy. The choice between hysterectomy or conservative therapy is dependent on the severity of the placenta percreta and the type of additional complications. Reported complications of placenta percreta include severe bleeding that can be life-threatening, and invasion of neighbouring organs by the placental villi such as the urinary bladder (Abbas et al., 2000
). One of the most severe complications is a spontaneous rupture of the uterus with a haemoperitoneum, as was observed in our patient during laparotomy. This type of complication has been reported in a number of cases which all necessitated a hysterectomy (Smith and Mueller, 1996
; Imseis et al., 1998
; Endres and Barnhart, 2000
; LeMaire et al., 2001
).
Cases of spontaneous uterine rupture in early gestation are very rare. In most cases, placenta percreta is diagnosed in the third trimester of pregnancy because of massive post-partum haemorrhage in an attempt to remove the placenta or during subsequent curettage. Reports of spontaneous uterine rupture as a result of a placenta percreta during early pregnancy have been made in weeks 1021 of gestation (Woolcott et al., 1987; Smith and Mueller, 1996
; Zeeman et al., 1999
; Endres and Barnhart, 2000
; LeMaire et al., 2001
; Morkon and Henriksen, 2001
; Norwitz, 2001
). Of these case reports on secondary uterine rupture caused by placenta percreta, only the cases of Morkon and Henriksen (2001)
and LeMaire et al. (2001)
involved healthy patients with a non-scarred uterus.
In the present case, the placenta percreta was diagnosed at week 14 of gestation when a spontaneous rupture of the uterus occurred. Diagnosis of the placenta percreta at an earlier stage of gestation (week 11) was not possible due to the inconsistent presence of the free fluid in the abdomen; the slightly aberrant blood values which were not indicative for massive blood loss; the fact that the patient's obstetric history did not include a Caesarian section or other pathology resulting in a scarred uterus, considered as the main risk factors; and most importantly the early stage of gestation at which the pathology occurred. At such an early stage of pregnancy (week 11), a routine ultrasound generally does not include a detailed examination of both localization and implantation of the placenta because it is not important at that stage and technically not obvious. Theoretically, it can be assumed that even at this early stage, a detailed ultrasound examination of the uterine wall could reveal abnormal placentation. The main lesson to be learnt from this case is that in patients with a history of placenta accreta and subsequent manual extraction of the placenta, a close investigation of the uterine wall and placentation should be performed in the first trimester in order to anticipate a placenta percreta.
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References |
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Submitted on January 20, 2004; resubmitted on May 13, 2004; accepted on June 24, 2004.
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