Pregnant patients commonly present with abdominal pain. Diagnosis can be challenging as the differential for both obstetric and nonobstetric causes can be extensive, and the physical examination can be altered when a gravid uterus is present. Two rare obstetric causes of acute abdominal pain include uterine rupture and intra-abdominal hemorrhage due to a morbidly adherent placenta. As the rate of cesarean sections increases, these severe complications may become more frequent and should be included in the differential diagnosis for abdominal pain in pregnancy. This case report aims to contribute to the small body of published literature describing these rare complications of pregnancy.
A 32-year-old G5T2P1A1L2, at 21 weeks and 3 days of gestation, was brought to Labour and Delivery Triage at a tertiary care centre by ambulance. The patient had noted abdominal pain that she felt may be bowel related. After attempting to have a bowel movement, she experienced a presyncopal episode that prompted her to call for an ambulance.
Upon arrival, the maternal heart rate was 71, respiratory rate was 18, oxygen saturation was 98% on room air, and blood pressure was 80/40 mmHg. The fetal heart rate was auscultated to be normal at 145 beats per minute. The patient arrived with an intravenous line in situ and was receiving a fluid bolus. She appeared to be in pain but was awake and oriented. On history, the patient did not endorse any change to her bowel habits, fever, nausea, or vomiting. She did not have any vaginal bleeding, contraction-like pain, rupture of membranes, or abnormal vaginal discharge. Her past obstetrical history was significant for a therapeutic abortion, a classical cesarean section for a stillborn infant after preterm premature rupture of membranes and cord prolapse, an elective cesarean section at term, and a subsequent elective cesarean section at term with an incidental finding of uterine dehiscence at the time of surgery. She was otherwise healthy.
In her current pregnancy, she had been referred to the Maternal Fetal Medicine service for investigation of a suspected abnormally adherent placenta, possibly placenta increta or placenta percreta. This was identified at the time of her anatomy ultrasound, when a complete anterior placenta previa was noted, along with concerning findings including loss of the placental-myometrial interface, multiple large and irregularly shaped lacunae, significant vascularity within the myometrium abutting the bladder wall, and a marginal placental abruption measuring 37.5 x 57.6 x 9.5mm. The fetus was appropriately grown and anatomic survey was normal.
Repeat vital signs continued to be stable. Blood pressure improved to 92/51 with an ongoing fluid bolus. The abdomen was soft and tender throughout, with most pain in the right lower quadrant; however, the uterus itself was nontender. In addition, there was rebound tenderness and voluntary guarding.
Laboratory investigations initially revealed a hemoglobin of 87 g/L, leukocytes of 12.0 x 109 per liter, and platelets of 154 x
Doppler ultrasound in the sagittal plane at midline in the pelvis demonstrates turbulent peripheral vascularity in the placenta extending across the myometrium to the posterior wall of the bladder. The bladder contour is otherwise smooth; however, the finding remains highly suggestive of placenta percreta. No defect in the uterine wall could be identified, but given the large volume of hemorrhagic ascites, an emergency diagnostic laparoscopy was subsequently performed.
Blood work was repeated several hours after the initial measurements, once the suspicion of intra-abdominal hemorrhage was reported on ultrasound. Repeat hemoglobin was stable at 87 g/L, leukocytes rose to 15.6 g/L and platelets were relatively stable at 144 x
Upon entry into the peritoneal cavity there was a significant amount of old and new blood, which was immediately evacuated. A small defect on the anterior surface of the uteruswas actively bleeding; it was felt to be the source of the hemoperitoneum. This focal area of the uterine wall was very thin, revealing placenta extending through the level of the serosa. Internal iliac ligation and hysterectomy were performed with the fetus in situ, due to the active bleeding. The estimated blood loss was 2.5 liters, most of which was noted in the abdomen at the beginning of the surgical procedure from prior blood loss. The patient received 3 units of packed red blood cells, 2 units of fresh frozen plasma, and 10 units of cryoprecipitate and 1L of Ringer’s Lactate intraoperatively.
Fresh surgical specimens were forwarded to pathology, including bilateral fallopian tubes, the cervix, and the uterus containing the fetus and placenta. The uterine cornua and fallopian tubes, as well as peritoneal reflections, were anatomically normally in position. The serosal surface was intact, except for a 1.0 x 0.6 cm variegated, slightly ragged area, at the midline of the anterior wall, approximately equidistant from the fundus and cervix (Figure
Intact hysterectomy specimen. Anterior wall demonstrates softened tumescence, with patchy hemorrhagic and congested appearance.
A subchorionic blood clot, continuous with a retroplacental hemorrhage, was noted. A brick-like color indicated that bleeding was remote. Cross-sections of the uterus demonstrated placental infiltration directly under the serosa, with a variegated appearance of the clotted blood admixed with infarcted tissue. Representative sections from the deepest point of placental invasion demonstrated retroplacental hematoma directly abutting serosal uterine surface with adjacent nonviable villi. Overall gross and microscopic findings confirmed the clinical diagnosis of placenta percreta with retroplacental hematoma.
Placenta accreta is defined as an abnormally adherent placenta that invades and is inseparable, from the uterine wall. The term placenta increta is used when the chorionic villi invade only the myometrium, whereas placenta percreta describes invasion through the myometrium and serosa and occasionally into adjacent organs [
Accurate prenatal diagnosis of placental accreta is vital in order to facilitate appropriate antenatal management, delivery planning, and appropriate patient counseling. Ultrasound is the standard modality for assessing the placenta, but MRI has also proven useful [
Uterine rupture or intra-abdominal hemorrhage prior to delivery is a rare complication of placenta accreta. This is the first Canadian case report describing uterine rupture associated with a morbidly adherent placenta in the second trimester. This is also the first reported case of a hysterectomy being performed with fetus in situ for uterine rupture. Unfortunately, our patient presented at a gestational age remote from viability. Prior to surgery, a long discussion with the patient revealed that she did not wish conservative treatment, but rather she preferred definitive management in the case of intra-abdominal hemorrhage due to either uterine rupture or placenta percreta. Due to active hemorrhage intraoperatively, in order to preserve maternal health and well-being and in accordance with the patient’s wishes, we felt it was most prudent not to attempt conservative management to prolong the pregnancy. Conservative measures could be considered with guarded optimism in patients wishing to attempt pregnancy preservation.
There is only one case reported by Aboulafia et al. that describes successful conservative management of a patient with a similar presentation [
In terms of definitive management, a hysterectomy is most commonly performed. Given that significant hemorrhage can occur during this procedure, adjunct procedures can be used to minimize blood loss including internal iliac balloon occlusion and internal iliac ligation. Internal iliac artery occlusion with a balloon has been shown to significantly reduce the blood loss and risk of hysterectomy in patients undergoing nonemergency cesarean section for morbidly adherent placenta [
In summary, there have been case reports describing pregnant patients presenting with acute onset of abdominal pain and a surgical abdomen found to have uterine rupture due to morbidly adherent placenta. This is the first Canadian case report, and the first report to describe a hysterectomy performed with fetus in situ where the diagnosis of hemorrhage due to uterine rupture and morbidly adherent placenta was suspected preoperatively. It is important to consider this rare but morbid and severe diagnosis when seeing an obstetrical patient with acute abdominal pain.
The authors declare that they have no conflicts of interest.