PLACENTA PREVIA ACCRETA: A CASE REPORT AND …

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Khalta et al. World Journal of Pharmacy and Pharmaceutical Sciences

PLACENTA PREVIA ACCRETA: A CASE REPORT AND

LITTERATURE REVIEW

Soukaina Khalta*2, Manar Rhemimet

1, Najia Zraidi

1, Amina Lakhdar

1, Abdelaziz

Baidada1 and Aicha Kharbach

2

1Gynaecology-Obstetrics and Endoscopy Department, Maternity Souissi, University Hospital

Center IBN SINA, University Mohammed V, Rabat, Morocco.

2Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University

Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco.

ABSTRACT

Summary: Placenta accreta spectrum disorders (PAS) have become an

obstetrical problem potentially fatal due to its increased incidence over

the past 30 years.[1]

This condition is associated with considerable

maternal morbidity and mortality. Recently, several studies have

attempted to identify risk factors for placenta accreta spectrum

disorders (PAS), maternal age (≥ 35 years) and placenta previa were

reported to be Significantly associated with the development of PAS

disorders.[2.3]

Similarly, the increase in the number of previous

caesarean sections was a major risk factor for PAS disorders.[3]

Pre-

antenatal screening is done by a morphological ultrasound in the

second trimester, allows the patient to be directed to an experimental

team and with a high-performance technical tray to ensure optimal

management. We present a case of placenta previa accreta diagnosed

by ultrasound and magnetic resonance imaging techniques, in which we have realised

surgical treatment with abdominal total hysterectomy.

INTRODUCTION

Placenta accreta spectrum disorders is defined by an invasion of the myometrium by

chorionic villi.[4]

Depending on the depth, the penetration of the chorionic villi, it is

described: the accreta form that is characterized by the superficial penetration of chorionic

villi in myometrium, while the increta form is defined by a deep penetration of villi in the

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Volume 10, Issue 7, 83-90 Case Study ISSN 2278 – 4357

*Corresponding Author

Soukaina Khalta

Gynaecology-Obstetrics and

Endocrinology Department,

Maternity Souissi,

UniversityHospital Center

IBN SINA, University

Mohammed V, Rabat,

Morocco.

Article Received on

02 May 2021,

Revised on 23 May 2021,

Accepted on 13 June 2021

DOI: 10.20959/wjpps20217-19339


84


myometrium without passing the myometrial serosa, and percreta where the Penetration of

villi up to the peritoneal coat and even beyond the pelvic organs and their

vascularizations.[5.6]

As the incidence of Caesarean have increased, Placenta accreta also has increased, there is a

run-up in the frequency of placenta accreta 3%, 11%, 40%, 6 1% and 67% in first, second,

third, fourth and fifth caesarean it seem to be parallel to the increasing caesarean delivery

rate.

CASE REPORT

A 39-year-old woman, no pathological antecedents, gravida 3 par3 2 (G3P3), two living

child, with previous two caesarean section for pelvic dystocia. For the third pregnancy,

antenatal period was not well followed until she was referred to our hospital due to abnormal

placentation diagnosed during a sonographic examination at 33 weeks of gestation. On

admission, The clinical examination found a pulse at 80 beats per minute, blood pressure at

120/65 mm Hg, Temperature at 37, the obstetric examination objectified a fundal height at

26cm, fetal heart tones perceived, the vaginal examination showed a closed cervix, an

abdominal ultrasound examination showed a viable fetus with appropriate biometrical

parameters and normal amniotic fluid, while transvaginal Eco-Doppler images suggested the

diagnosis of placenta previa accreta pelvic non contrast magnetic resonance imaging (MRI)

confirmed the ultrasound diagnosis found the myometrium very thinned with focal

interruption of the basal line at the level of its anterior and upper part of the placenta, given

the age of the patient and the number of child, an elective caesarean delivery was planned at

35 weeks of gestation. After opening the abdominal wall, intra-abdominal inspection showed

hypervascularisation at level of the lower uterine segment. a transverse uterine incision was

made above the lower uterine segment in order to avoid placenta. Total hysterectomy was

performed with the start of bleeding, a healthy female baby, with weight 3000 g was

delivered. During the surgery, the patient lost 1500 ml of blood, she was transfused

intraoperatively. The post-operative suites were good. Patient declared outgoing on d + 6 of

the postoperative period accompanied by her baby. the resulting material was sent to

histological examination.


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Figure 1: MRI of a placenta previa accrete: absence of hypoechogenous zone between

placenta and myometrium.


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Figure 2: Longitudinal section of a hysterectomy piece with placenta invading the

myometrium (placenta accreta).

Figure 3: chorionic villi adhere abnormally to the myometrium.


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DISCUSSION

The incidence of placenta accreta continues to increase in recent years. This progression

seems to be directly correlated with the increase in alterations of the uterine mucosa during

the genital life of the patients and more particularly to the increase in the caesarean section

rate over the past five decades.[7-8]

Baldwin and Patterson report that one pregnancy on 403-

533 is now complicated by PAS disorders.[9]

Other predisposing conditions for placenta

accreta are instrumentation of the endometrium, placenta praevia, uterine malformations,

septic endometritis, previous manual removal of placenta and multiparity.

Clinically, Placenta accreta is a pathology with little symptoms during pregnancy. The main

symptoms reported are the metrorrhagia of the second and third trimester, and which are

mainly related to placenta praevia.[7][10]

Macroscopic hematuria may occur in cases of

placenta percreta with invasion of the bladder. However, the most frequent mode of

presentation of the placenta accreta is the failure of natural and manual delivery of the

placenta.

Screening is an essential means of improving maternal prognosis in optimizing management,

thus reducing the risk of morbidity, particularly hemorrhagic morbidity, The diagnosis is

usually made by ultrasound, then MRI in patients with risk factors.[11][12][13]

Ultrasound is the reference examination to detect a placenta accreta. His sensitivity varies

from 77% to 93%[14]

and its specificity is 95%.[6]

The classically described ultrasound signs

are the presence of placental gaps, the absence of a hypoechoic border between the placenta

and the myometrium, an interruption of the hyperechoic zone at the interface of the uterine

serosa and the bladder, and the presence of a pseudotumoral aspect of the placenta opposite

the uterine serosa.[15]

Placental MRI is an important means for the diagnosis of placenta accreta but is indicated

only in the event of high ultrasound suspicion, It appears to be complementary to ultrasound,

particularly in posterior-insertions,and confirms a diagnosis of placenta accrete.[16]

Lax et al

have tried to define diagnostic criteria and especially retained: the presence of Dark

intraplacental bands, the presence of a mass effect on the uterus with a localized bulge, the

appearance of a heterogenous placenta in low signal, thinning of the myometrium with

disappearance of the internal border in low signal.[17]


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Some recent studies have studied the contribution of MRI with gadolinium injection and have

been able to demonstrate that this would improve the specificity of MRI.[18]

It should be

noted that there is a discrepancy between ultrasound results and MRI in 30% of cases.

The choice of management strategy depends mainly on the anatomical type of placenta and

desire of patients to preserve their fertility.

If the diagnosis of is made antenatally, there are essentially three options for the management

of placenta accreta:

Caesarean section-hysterectomy without attempted artificial delivery is currently

recommended in case of strong prenatal suspicion of placenta accreta by the American

College of Obstetrics and Gynecology (ACOG).[19]

The extirpative method, this procedure consists of performing a forcible manual removal of

the placenta delivery in an attempt to obtain an empty uterus but it is associated with a higher

rate of massive PPH resistant to non-radical hemostatic techniques leading to

hysterectomy.[20,21,22-23]

Conservative treatment with placenta left in place, Allows to avoid a hysterectomy in about

75–80% of cases but is associated with a risk of transfusion, infection and severe maternal

morbidity, required women to undergo treatment for a long period of postpartum.[18,24,25]

If the diagnosis of is made intraoperatively, in case of moderate bleeding, arterial ligation

possibly associated with uterine padding (in case of cesarean section) or arterial embolization

(in case of vaginal delivery) can be performed but a hysterectomy must be performed in case

of failure or severe hemorrhage from the start.

CONCLUSION

The placenta accreta is a pathology at risk of serious hemorrhagic complications during

pregnancy and postpartum. Antenatal screening is essential by allowing an optimization of

the treatment. Multidisciplinary management consists of either a hysterectomy for prevent a

PPH, or a conservative approach, but it imposes a rigorous follow-up until complete

resorption of the placenta.


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