In recent years, the incidence of placenta accreta and associated complications has increased significantly. The authors report the case of a pregnant woman in the 5th month of pregnancy for premature rupture of the membranes. The placenta was inserted low. The evolution was marked spontaneous work followed by the expulsion of the fetus. The delivery of the placenta was haemorrhagic and incomplete. Ultrasonic testing showed a placental fragment integrated in the thickness of the myometrium. Conservative treatment with methotrexate was published a few days later and MRI showed that the anterior uterine sac was filled with blood clots associated with pelvic effusion. A laparotomy was then performed to resect the pouch and the one-piece fragment. The follow-up was uneventful.
Placenta accreta or abnormally adherent placenta remains a source of concern to any obstetrician despite the progress made in terms of both diagnosis and management during delivery and the postpartum period. Because of the dramatic increase in its incidence in the last few decades, together with the rise in caesarean delivery rates and the still-high maternal morbid-mortality rates, much more vigilance is required. Furthermore, a rescue hysterectomy has a significant psychological impact, mainly because of early permanent loss of fertility. This is why there is a tendency to opt for a conservative treatment whenever possible.
Many authors [
A 26-year-old woman, fourth parity second gesture two abortion (G4 P1 A2), was referred to our hospital for a 24-hour history of premature rupture of membranes. She was at 22 weeks of gestation with a normal pregnancy
On admission, the clinical examination showed a clear amniotic fluid flow, a spaced out uterine contraction pattern, and a one-centimeter dilated and 50% effaced cervix. An ultrasonographic examination revealed an ongoing viable pregnancy, anamnios and a low-lying anterior placenta with multiple lacunae (Figure
Ultrasonography appearance of a lacunary placenta.
The evolution was marked by the expulsion of the fetus after 4 hours and the complete retention of the placenta despite an oxytocin infusion already on for 6 hours without any bleeding. The fetal weight was 560 grams.The patient was then transferred to the operating room for uterine revision under general anesthesia. This was difficult and haemorrhagic due to an abnormally adherent placenta. The initial amount of blood lost was about 1200 ml. To control bleeding, a Sulprostone infusion was required in addition to 4 packed red blood cells and 4 fresh frozen plasma bags. An ultrasound performed immediately postabortion revealed only a 3 cm isthmic and echoic image suggestive of a retained placenta increta (Figure
Ultrasonography aspect of the placenta increta fragment.
Given the patient’s favorable initial evolution, she was discharged on the 5th day with an ultrasound control scheduled in about ten days. The ultrasound showed a swelling of the isthmic region in the form of a hernial sac containing a heterogeneous echoic image of 7 cm along its long axis. There was no associated abdominal effusion. A further exploration by pelvic MRI confirmed previous uterine herniation and revealed a content that was suggestive of an organized hematoma. It also led to a suspected uterine scar dehiscence with possible loss of substance at this level (Figure
MRI aspect of the anterior uterine sacculation containing the placenta increta fragment with blood clots.
A surgical exploration revealed an unruptured isthmic hernial pocket, covered by the peritoneum and traversed by multiple dilated veins (Figure
Operative view of anterior uterine sacculation.
Operative view of the opening of the sac containing placenta increta and blood clots.
Operative view of the hysterorrhaphy after resection of the sac and its contents.
Subsequent follow-up was uneventful without any abnormal bleeding. A pelvic ultrasound was normal and there was an insignificant
Our case illustrates well the progressive continuation of a fragment of placenta increta left in place after delivery in the second trimester of pregnancy on a cicatricial uterus despite the medical treatment with methotrexate. This fragment was at the origin of an anterior and isthmic uterine sacculoform neoformation.
In recent decades there has been a rise in the incidence of placenta accreta and its variants (increta and percreta) coinciding with an increasing number of caesarean sections worldwide [
Several risk factors are described in the literature, the most important of which are caesarean section scars and curettage [
Despite its low incidence, placenta increta continues to be the most feared complication in obstetrics as it is one of the main causes of maternal and fetal/neonatal morbidity and mortality [
The ideal management of this complication remains uncertain although much progress has already been made [
Conventionally, the recommended management consists in a caesarean hysterectomy or hysterectomy scheduled as soon as the diagnosis is retained after the delivery of the fetus, in the presence of a multidisciplinary and experienced team [
Since the publication of the first case managed conservatively by Arulkumaran et al. in 1986 [
Although medical imaging is useful for antenatal diagnosis, findings suggestive of placenta increta are not always obvious. In a recent and extensive review of 167 placenta accreta cases, only 44% of them were suspected on ultrasound [
Ultrasound diagnosis of placenta accreta is suspected when there is at least one of the following signs: placental lacunae, obliteration of the retroplacental clear space, interruption of bladder boundaries, andmyometrial thickness less than 1 mm [
The MRI is not a first intention in screening, but it is of great help in the presence of technical difficulties with ultrasound (posterior placenta, obese women, etc.) or to make an extra uterine lesional assessment when placenta percreta is suspected [
Uterine herniation is a rare and specific complication of pregnancy in which a weakened part of the uterus is transformed into a pouch or hernial sac whose wall contains all the usual uterine layers [
Elsewhere, the retention of a placenta increta fragment is manifested by the delayed onset, in relation to the abortion date, of a heterogeneous echogenic uterine mass. This interval varies from 2 weeks for Ju et al. [
This abnormal placentation also predisposes, as described in our observation, to premature delivery and premature rupture of membranes [
Several therapeutic options for conservative treatment are described in the literature [
The adjuvant therapy was based primarily on the administration of a 50 mg/m2 body surface area dose of methotrexate to promote placental resorption or its secondary delivery. The median timerequired for complete spontaneous resorption of the placenta was 13.5 weeks (range: 4-60 weeks) in the Sentilhes et al. [
Overall, Sentilhes et al. found a conservative treatment failure rate of 22%. In these cases a hysterectomy was performed either immediately or secondarily given the extent or recurrence of bleeding or for severe sepsis [
In our case, despite the prescription of methotrexate, the placental fragment left in place was a source of endometritis and a progressive increase in the volume of the hernial sac probably due to the pressure exerted by bleeding. An exploratory laparotomy was then carried out on the 18th day for fear of imminent uterine rupture and to control the infection. Indeed the excision of the increta fragment allowed us to repair the weakened uterine zone and to control the infection.
Other authors reoperated on their patients to complete the resection of an evolutive placenta increta fragment by laparotomy [
The trophoblastic invasion of a pregnancy implanted on a cicatricial uterus is a situation that has been on the rise in recent years due to the increase in obstetric scars. This invasion may be the source of an abnormal placentation that causes weakening of the isthmic region, which becomes thin, and an abnormal adherence of the placenta. These abnormalities may in turn be responsible for obstetric morbidity caused by premature rupture of the membranes, late abortion, severe postabortion or postpartum hemorrhage, and placental retention. The retention of a fragment of placenta increta after abortion may remain poorly symptomatic initially and may cause, by an excess of pressure on an already thinned and weakened area, an anterior bulge like a hernia sac. Thus a mass made of placenta and embedded blood is made and can be complicated by infection, rupture, and hemorrhage. The diagnosis is guided by systematic ultrasound which should check, in addition to uterine emptiness, the condition of the lower segment to search in the thickness of the uterine wall of an evocative heterogeneous echogenic image. The MRI is a more precise imaging procedure for identifying herniation and its content. To treat this mass, two approaches can be adopted on a case-by-case basis according to the state of the patient and the radiological workup of the lesion. The first treatment modality is medical, based on methotrexate injections and regular monitoring until the involution of the mass. The second is surgical, aiming at either extracting the increta fragment by curettage or better by hysteroscopy or resecting the hernia and its contents followed by complete reconstruction of the lower segment. It seems that the latter solution is the safest and can be performed by laparotomy or laparoscopy. Arterial embolization may be associated with this treatment.
Conservative management of uterine herniation due to placenta accreta should be considered as the first-line approach for women who desire future fertility. Otherwise, hysterectomy may be the ultimate life-saving solution in case of failure of conservative approaches or if required by the workup of the lesion.
The authors declare that there are no conflicts of interestregarding the publication of this paper.