Renata Passini Junior, Roxana Knobel, Ricardo Barini, Em flio M arussi
Placenta percreta w ith silent rupture of the uterus
Women's Assistance Center, College of Medical Sciences - CMS. Department of Obstetrics and Gynecology. StateUniversity of Campinas - Campinas, Brazil
W e re p o rt a ca se o f p la ce n ta p e rcre ta d ia g n o se d b y u ltra so u n d a n d co lo r d o p p le r im a g e a t th e fo u rte e n th w e e k o f g e sta tio n . In itia l a p p ro a ch w a s a tria l o f 1 M m e th o tre xa te fo llo w e d b y to ta l h yste re cto m y, d u rin g w h ich w a s o b se rve d a ru p tu re o f th e u te ru s w ith th e a d h e re n ce o f th e p la ce n ta to th e p o ste rio r re g io n o f th e b la d d e r. W e a lso p re se n t a lite ra tu re re vie w o n th e in cid e n ce ()~ p la ce n ta p e rcre ta , e tio lo g y, d ia g n o sis, tre a tm e n t, a n d co m p lica tio n s.
U N IT E R M S : P la ce n ta a ccre ta . R u p tu re o f th e u te ru s.
IN T R O D U C T IO N
P
lacen tam o rtality p ercretaan d m o rb id ityis a rarerates fo r th e m o th erco n d itio n w ith h ig han d th e fetu s. E arly d iag n o sis is d ifficu lt an d th ere are v ery few rep o rts o f u ltraso n o g rap h ic d iag n o sis in th e seco n d trim ester.W e rep o rt a case o f p lacen ta p ercreta d iag n o sed b y . u ltraso n o g rap h y d u rin g th e fo u rteen th w eek w h ich w as treated w ith a co m b in atio n o f m eth o trex ate an d su rg ery . D u rin g su rg ery , a silen t u terin e ru p tu re at a p rev io u s
in cisio n w as o b serv ed , th ro u g h w h ich th e p lacen ta h ad p assed an d ad h ered to th e cy stic b lad d er.
Adress for correspondence: Renata Passini Junior
Divisao de ObstetrfciaiDIG/FCM /CAISM
Rua Alexande Flem m ing, 101 - Caixa Postal 6030 Cam pinas/SP - Brasil - CEP 13092-340
C A S E R E P O R T
C .S .O ., m u latto , m arried , h o u sek eep er, th ree p rio r C aesarean sectio n s, o n e ab o rtio n .
O n Jan . I, 1 9 9 5 , th is p atien t p resen ted a h isto ry o f in term itten t v ag in al b leed in g fo r o n e m o n th an d a p reg n an cy d iag n o sed at an o th er h o sp ital. U p o n ex am in atio n sh e w as in g o o d co n d itio n w ith n o h eart, p u lm o n ary , o r ab d o m in al alteratio n s. S p ecu lar ex am in atio n sh o w ed d iscrete b leed in g th ro u g h th e ex tern al o s o f th e cerv ix . V ag in al ex am in atio n sh o w ed an en larg ed u teru s in relatio n to th at ex p ected fo r a fo u rteen th w eek p reg n an cy an d th e ex tern al o s w as im p erv io u s. In itial d iag n o sis w as risk o f ab o rtio n .
U ltraso n o g rap h ic an d d o p p ler flo w ev alu atio n sh o w ed an an terio r m arg in al p lacen ta p rev ia 2 0 m m th ick w ith a u terin e in v asio n reach in g th e sero sa o f th e b lad d er, an d a 1 4 -1 5 w eek -o ld fetu s. C y sto sco p y d id n o t sh o w an y alteratio n s.
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F ig u re 1 - U ltra s o n o g ra m a n d c o lo r d o p p le r s h o w in g p la c e n ta ry flo w o n b la d d e r w a ll. T h e p a tie n t w a s re le a se d o n
Ja n . 2 5 (d u e to so c ia l p ro b le m s) in g o o d c o n d itio n ; sh e w a s re a d m itte d o n Ja n . 3 1 .
A fte r a lite ra tu re su rv e y a n d d isc u ssio n w ith th e p a tie n t, a n d d u e to th e h ig h risk in v o lv e d , th e p ro p o se d tre a tm e n t w a s th e ra p e u tic a b o rtio n w ith a sin g le d o se o f m e th o tre x a te to re d u c e p la c e n ta v a sc u la riz a tio n .
S h e re c e iv e d 5 0 m g /m 2 (6 2 .5 m g ) o f m e th o tre x a te a n d 1 2 0 m g o f e n d o v e n o u s fo lin ic a c id o n F e b .
2 ; e c h o g ra p h ic stu d ie s d o n e a fte r a d m in istra tio n sh o w e d n o c lin ic a l c h a n g e s a fte r se v e n d a y s.
T h e re sp o n se to tre a tm e n t w a s c o n sid e re d in a d e q u a te . S u rg e ry w a s d e c id e d u p o n a fte r fu rth e r d isc u ssio n w ith th e p a tie n t.
O n F e b . 1 4 sh e u n d e rw e n t a to ta l a b d o m in a l e x tra fa sc ic u la r h y ste re c to m y . D u rin g su rg e ry a sile n t ru p tu re o f th e u te ru s th ro u g h th e sc a r o f a p re v io u s C a e sa re a n se c tio n w a s o b se rv e d . T h e p la c e n ta h a d g o n e th ro u g h it a n d re a c h e d th e b la d d e r, a d h e rin g to a n a re a o f a p p ro x im a te ly 2 c m , w h ic h w a s n o t re se c te d , sin c e it p re se n te d n o b le e d in g . D u rin g a n d a fte r th e o p e ra tio n a
2 0 0 0 m l h e m o rrh a g e o c c u rre d , a fte r w h ic h sh e re c e iv e d a tra n sfu sio n o f tw o u n its o f re d b lo o d c e lls.
T h e p a tie n t le ft th e h o sp ita l o n F e b . 2 0 in g o o d c o n d itio n a n d w ith o u t c o m p lic a tio n s.
D IS C U S S IO N
P la c e n ta p e rc re ta is th e m o st se rio u s a b n o rm a l a d h e re n c e to th e u te ru s w a ll (p la c e n ta a c c re ta ), a n d it o c c u rs w h e n th e re is p e n e tra tio n o f th e tissu e th ro u g h th e m y o m e triu m o f th e u te ru s a n d se ro sa , w ith th e p o ssib le in v o lv e m e n t o f o th e r o rg a n s.
T h e in c id e n c e o f p la c e n ta a c c re ta v a rie s fro m 1 :5 4 0 (T h a ila n d ) 1 .2to 1 :9 3 ,0 0 0 p re g n a n c ie s.2 T h e in c id e n c e o f p la c e n ta p e rc re ta v a rie s fro m 1 :3 3 3 3 p re g n a n c ie s3 to
I: 1 ,4 0 0 ,0 0 0 .1
E tio lo g y is n o t w e ll d e fin e d . It is p o ssib ly re la te d to a fa ilu re in th e d e c id u a b a sa lis w h ic h w o u ld a llo w p la c e n ta in v a sio n in to th e m y o m e triu m . S e v e ra l c o n d itio n s th a t
a c c o m p a n y p la c e n ta a c c re ta w e re o b se rv e d : p la c e n ta p re v ia ; 1 .2 a p re v io u s C a e sa re a n se c tio n ; 1 .2 m u ltip le
p re g n a n c ie s;2 .4 a h isto ry o f d ila tio n a n d c u re tta g e ;1 .2 .4 a n d
a h isto ry o f m a n u a l e x tra c tio n o f th e p la c e n ta , w h ic h w o u ld in d ic a te a p re v io u s a d h e re n c e .1 .2 .4
C lin ic a l d ia g n o sis o c c u rs u su a lly d u rin g th e th ird
trim e ste r d u e to e x c e ssiv e b le e d in g a n d /o r d iffic u lty in p la c e n ta e x tra c tio n .2 .5
.6 A lthough it is a rare and difficult
d ia g n o sis, it is p o ssib le to u se u ltra so n o g ra p h y a n d d o p p le r flo w e v a lu a tio n .2 .3 .6 .7 E a rly d ia g n o sis is im p o rta n t sin c e it
a llo w s a sse ssm e n t o f th e e x te n sio n o f th e p la c e n ta in v a sio n , d isc u ssio n a b o u t th e tre a tm e n t, a n d a b e tte r p re p a ra tio n o f th e te a m a t p ro c e d u re (i.e . h e m o th e ra p e u tic su p p o rt).2 .3 .7 T h e re fo re , a th o ro u g h u ltra so n o g ra p h ic e x a m in a tio n is su g g e ste d fo r p a tie n ts w ith risk fa c to rs fo r p la c e n ta a c c re ta .2 .6 .7
S in c e d ia g n o sis u su a lly o c c u rs d u rin g d e liv e ry ,
m e a su re s sh o u ld b e ta k e n a t th a t tim e (w h ic h u su a lly m e a n s h y ste re c to m y ).1 .2 .4 R e c e n tly , th e re h a s b e e n a te n d e n c y
to w a rd s a m o re c o n se rv a tiv e tre a tm e n t/.3 d u e to e a rly d ia g n o sis, w h ic h p e rm its th e p re d ic tio n o f p o ssib le c o m p lic a tio n s a n d a sse ssm e n t o f th e b e n e fits o f e a c h ty p e o f tre a tm e n t. 2 .3 .7C o n se rv a ti v e tre a tm e n t stiII p re se n ts se v e ra l c o m p lic a tio n si
.3 .6.7 and high m orbidity and m ortality ra te s.I.2 .6 T h e re fo re , it re q u ire s p re c ise in d ic a tio n s a n d a
stric t fo llo w -u p .
M e th o tre x a te w a s in itia lly u se d a s c h e m o th e ra p y fo r tre a tm e n t o f g e sta tio n a l tro p h o b la stic d ise a se , sin c e it d im in ish e s tro p h o b la stic a c tiv ity , p la c e n ta v a sc u la riz a tio n
P A S S IN I J r, R .; K N O B E L , R .; B A R IN I, R . & M A R U S S I, E . - P la c e n ta p e rc re ta w ith s ile n t ru p tu re o f th e u te ru s
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Figure 2 - S p o n ta n e o u s ru p tu re o f th e u te ru s o b s e rv e d a fte r s e c tio n o f v is c e ra l p e rito n e u m . 2 A . U te rin e ru p tu re a s s e e n o n a n te rio r h y s te ro rrh a p h y . 2 8 . P la c e n ta a n d o v u la r s a c p a s s in g th ro u g h ru p tu re o f th e u te ru s .
T h e p rin c ip a l c o m p lic a tio n re p o rte d in p la c e n ta
a c c re ta is h e m o rrh a g e , w h ic h m a y o c c u r b e fo re , d u rin g ,
o r a fte r b irth . 1 .3 ,4It m a y a ls o c a u s e h y p o v o le m ic s h o c k a n d
d e a th , 1 .4 .7b e s id e s in c re a s in g th e n e e d fo r b lo o d tra n s fu s io n s
[R E A D4 s h o w s a fo llo w -u p o f 2 2 p a tie n ts , n e c e s s a ry
tra n s fu s io n s = 0 -3 9 u n its / p a tie n t (m e d ia n = 7 .9 u n its )].
O th e r c o m p lic a tio n s m a y b e : c o a g u la tio n p ro b le m s ,4
ru p tu re o f th e u te ru s ,4 .7 a n e m ia ,4 in fe c tio n a n d 4
e n d o m e trio s is .4 M a te rn a l m o rta lity ra te s a re v a ria b le , b u t
m a y s u rp a s s 6 .5 p e rc e n t in c a s e s o f p la c e n ta p e rc re ta w ith
in v a s io n o f th e b la d d e r, o r th e la rg e o r B o w e l's lig a m e n t.7
CONCLUSION
P la c e n ta p e rc re ta is a ra re d is e a s e w ith a d iffic u lt in itia l d ia g n o s is . W e s u g g e s t th a t u ltra s o n o g ra p h y b e
c a rrie d o u t c a re fu lly in h ig h ris k p a tie n ts . E a rly d ia g n o s is
e n a b le s a th o ro u g h d is c u s s io n o f th e p ro c e d u re s , a n d /o r
a s s e s s m e n t o f th e ris k s a n d b e n e fits in e a c h c a s e .
A c o n s e rv a tiv e a p p ro a c h to c h e m o th e ra p y , s u c h a s
m e th o tre x a te , is a re la tiv e ly n e w a n d h a s n o t b e e n te s te d .
Its e ffe c tiv e n e s s h a s n o t y e t b e e n p ro v e d w ith p la c e n ta
p e rc re ta ; h o w e v e r, its re s u lts w ith e c to p ic p re g n a n c ie s
s h o w th a t it m a y b e a v ia b le p ro c e d u re , a s lo n g a s
p re c a u tio n s a re ta k e n a n d a c a re fu l fo llo w -u p d u rin g
p re g n a n c y o c c u rs , e s p e c ia lly in p a tie n ts w h o w is h to re m a in fe rtile .
a n d h e m o rrh a g e s .3 .5 It h a s a lre a d y b e e n u s e d to
re d u c e tro p h o b la s ts o f e c to p ic g e s ta tio n s (tu b a ria n , a b d o m in a l a n d c e rv ic a l),5 .7 a n d s o m e
re p o rts u s e d m e th o tre x a te fo r tre a tm e n t o f
p la c e n ta a c c re ta a fte r p re g n a n c y .3 .7
W e in itia lly d e c id e d to u s e m e th o tre x a te ,
b a s e d o n re p o rts o f c e rv ic a l g e s ta tio n s in w h ic h
it w a s u s e d s u c c e s s fu lly a n d h y s te re c to m y
a v o id e d ,5 a n d in p la c e n ta a c c re ta c a s e s in w h ic h
it w a s u s e d a fte r p re g n a n c ie s ,3 .7 w ith
h y s te re c to m y b e in g a v o id e d in o n e c a s e .3
H o w e v e r, a fte r th is c h e m o th e ra p y th e re w a s n o c h a n g e in th e p a tie n t's c o n d itio n . A lth o u g h th e
p ro c e d u re c o u ld h a v e b e e n re p e a te d , w e o p te d
fo r s u rg e ry , s in c e re p o rts s ta te th a t d e la y in g
h y s te re c to m y m a y w o rs e n m a te rn a l
p ro g n o s is , L V i a n d im p lic a tin g s u rg e ry b e c o m e s
te c h n ic a lly m o re c o m p le x a s p re g n a n c y
p ro g re s s e s , a n d c o u ld c a u s e m o re c o m p lic a tio n s . Figure3 -U te ru s w ith ru p tu re a n d p la c e n ta .
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RESUMO
A p re se n ta m o s u m ca so d e p la ce n ta p e rcre ta d ia g n o stica d o n a 14!!se m a n a d e g e sta ya o p o r e co g ra fia e d o p p le rflu xo m e tria , d ia n te d o q u a l fo ; te n ta d o , in icia lm e n te , u m tra ta m e n to co m M e th o tre xa te , q u e fo i, a p 6 s u m a se m a n a , co n sid e ra d o in e fica z. F o i e n ta o , re a liza d a u m a h iste re cto m ia to ta l a b d o m in a l co m d ia g n 6 stico in tra -o p e ra t6 rio d e ro tu ra u te rin a su b -c1 fn ica e a d e re n cia p la ce n ta ria a o te to ve sica l. A se g u ir a p re se n ta m o s u m a d iscu ssa o b a se a d a e m d a d o s d e lite ra tu ra so b re in cid e ln cia , e tio lo g ia , d ia g n 6 stico , tra ta m e n to e co m p lica yo e s d a p a to lo g ia .
H ow ever, surgery is the option that leads to the low est m aternal m orbidity, and should not be postponed if conservative treatm ent is ineffective or in case of bleeding, shock or any other com plication.
REFERENCES
I. B reen JL , N eubecker R , G regori C A , F ranklio JE . P lacenta accreta, increta and percreta, a survey of 40 cases. O bstet
G ynecol 1977;49:43-6.
2. C ox S M , C arpenter R J, C otton D B . P lacenta percreta: U ltrasound diagnosis and conservative surgical m anagem ent.
O bstet G ynecol 1988;71 :454-6.
3. L egro R S , P rice F V , H ill L M , C aritis S N . N onsurgical m anagem ent of placenta percreta: A case report. O bstet
G ynecol 1994;83:847-9.
4. R ead JA , C otton D B , M iller F e. P lacenta accreta: C hanging clinical aspects and outcom e. O bstet G ynecol 1980;56:31-4.
5. K aplan B R , B randt T , Javaheri G , S com m egna A . S uccessful
treatm ent of a live cervical pregnancy w ith m ehotexate and
folinic acid - a case report. R epro M ed 1989: 853-6. 6. V ettraino I, G raham C , S hyken J, K hodadoust K , K ivikoski
A . P lacenta percreta: A case of m aternal death. M aternal F etal
M edic 1993;2:276-8.
7. Jaffe R , D uB eshter B , S herer D M , T hom pson E A , W oods
JR . F ailure of m etrotexate treatm ent for term placenta percreta. A m J O bstet G ynecol I994;A ugust:558-9.
P A S S IN I Jr, R .; K N O B E L , R .; B A R IN I, R . & M A R U S S I, E . - P la ce n ta p e rcre ta w ith sile n t ru p tu re o f th e u te ru s
