Conservative management of placenta previa‐percreta with bladder invasion: A case report

Abstract

Key Clinical Message

Placenta previa, accompanied by placenta percreta, which involves invasion of the bladder, presents a significant risk of excessive bleeding during and after delivery. This case highlights that prophylactic embolization, conservative surgery, and careful monitoring offer an effective approach to avoid hysterectomy in cases of placenta percreta with adjacent organ involvement.

Abstract

Placenta previa complicated by placenta percreta is associated with a high risk of massive intra and post‐partum hemorrhage. We present a case of a 35‐year‐old woman (G2 P1) who was referred to the Akbar‐Abadi hospital at 13 weeks of gestation. Color Doppler ultrasound indicated complete placenta previa‐percreta with bladder invasion. After induction of fetal demise, bilateral uterine and bladder artery endovascular embolization was conducted for the patient. After 48 h, under ultrasound guidance, surgical resection of residual percreta tissue was conducted as much as possible. Eight weeks later, a follow‐up sonography showed the minimum residual placenta tissue and she regained menstrual cycles after 2 months. This case indicated that the combination of prophylactic embolization, conservative surgical management with placenta left in situ, and follow‐up with serial color Doppler monitoring, is an optimum method to avoid hysterectomy in placenta percreta patient with adjacent organ invasion.

1. INTRODUCTION

Placenta previa is an abnormal placenta position (in the lowest part of the uterine) that covers the cervical opening partially or completely. Sometimes previa is complicated by morbid adherence of the placenta to the uterine wall and becomes inseparable, defines as the placenta accreta spectrum (PAS). ¹ According to reported data, the prevalence of PAS is approximately 0.2% of all pregnancies. ² When placenta previa occurs in conjunction with PAS, it can give rise to significant bleeding during both pregnancy and delivery. Also, it increases the risk of fetomaternal morbidity and mortality. ³ Due to the rapidly increasing rate of cesarean delivery, higher maternal age, and using assisted reproductive technology, the number of placenta previa and PAS have significantly raised recently. ⁴ Ultrasonography or magnetic resonance imaging (MRI) can be used for antenatal diagnosis of placenta accreta with appropriate sensitivity. ⁵ Recently studies indicated that the management of PAS by an experienced multidisciplinary team in a referral hospital can improve maternal outcomes. ⁶ Placenta previa‐percreta has the highest risk of severe intra and post‐partum hemorrhage of the placenta accrete spectrum. ⁷

2. CASE HISTORY

A 35‐year‐old woman (G2 P1) was referred to the Akbar‐Abadi hospital for surgical termination because of Omphalocele that was detected at ultrasonography (Figure 1). Her vital signs were stable (Blood pressure = 115/65 mmHg, Pulse rate = 88 beats per minutes, Respiratory rate = 18 breaths per minutes, Body temperature = 36.9°C). However, she reported experiencing minor vaginal bleeding. The gestational age was 13 weeks and 5 days when she was admitted to the hospital. She had a history of elective lower segment cesarean section 8 years ago and she hadn't reported any other abdominal surgery. Ultrasound at 13 weeks and 3 days reported complete placenta previa with suspicion of placenta percreta. In our hospital, color Doppler sonography was performed for the patient and the diagnosis of placenta percreta with bladder invasion was confirmed (Figure 2). Consequently, a medicolegal consultation was conducted for the patient to discuss the case of fetal demise. Following permission, the demise was induced by intracardiac potassium chloride (KCl) injection.

FIGURE 1.

Transabdominal ultrasound demonstrated a mass lesion protruding through the defect measuring 1.3 cm, in the anterior abdominal wall.

FIGURE 2.

Doppler ultrasound at 13 weeks and 5 days revealed several bridge vessels extending from the lower uterine segment to the posterior wall of bladder with loss of retroplacental clear space. The Doppler ultrasound showed placenta percreta with bladder invasion. In addition, complete placenta pevia (a condition where the placenta completely covers the internal cervical os) was detected.

3. INVESTIGATION AND TREATMENT

The patient was given several treatment options, including: cesarean hysterectomy, resection placenta, and conservative treatment. As her family planning was not yet completed, she expressed a desire to preserve her fertility and avoid undergoing a hysterectomy. A multidisciplinary team consisting of an interventional radiologist, a perinatologist, a gynecologic oncologist, and an anesthesiologist, together with the patient decided to combine uterine artery embolization (UAE) with ultrasound‐guided resecting placenta tissue.

Bilateral uterine and bladder artery endovascular embolization was conducted for the patient (Figure 3). Bilateral embolization was performed instead of unilateral embolization to minimize the risk of bleeding from anastomoses between uterine arteries. In cases where there was a significant amount of hemorrhage and the situation was emergent, endovascular embolization was conducted non‐selectively through the internal iliac arteries After 48 h, Doppler sonography showed that the vascularity of the placenta was reduced.

FIGURE 3.

(A, B) Uterine artery angiography, abnormal blush due to placenta invasion, more prominent in left side. (C, D) Uterine bleeding was significantly decreased after endovascular embolization of the uterine and bladder vessels.

Misoprostol was administered for cervical ripening, then the patient was transferred to the operation room. Under ultrasound guidance, percreta tissue was resected as much as possible and a Foley catheter balloon was placed for the patient. Intraoperative blood loss wasn't significant and there was no need for blood transfusion. After 48 h, she was discharged from the hospital with small residual placenta tissue. Prophylactic antibiotic was administered to prevent infection for 2 weeks.

4. OUTCOME AND FOLLOW‐UP

She had spotting and vaginal bleeding in the first 2 weeks and also, passed placenta tissue. Close monitoring was conducted every 5–7 days using serial color Doppler ultrasonography to assess perfusion to the remaining placental tissue. At 8 weeks, a follow‐up sonography revealed the minimum residual placenta tissue. Her menstrual cycles returned after 2 months and she had experienced regular menstrual cycles. Furthermore, transvaginal ultrasonography performed 8 weeks after her first menstrual cycle indicated no residual placental tissue.

5. DISCUSSION

Placenta percreta previa is a life‐threatening condition due to the high risk of massive bleeding. The most effective intervention for placenta percreta with bladder invasion is still controversial. ⁸ A variety of treatment options were proposed in previous studies, including cesarean hysterectomy, conservative treatment, and one‐step conservative surgery. ⁹

Cesarean hysterectomy is a standard treatment for abnormal placentation, but this approach increases transfusion requirement and maternal morbidity in cases with extensive invasion of adjacent organs. ¹⁰ Several previous studies have indicated that the use of temporary arterial balloon occlusion of the internal iliac arteries can be effective in reducing intraoperative bleeding. This approach can be further enhanced by combining it with endovascular catheterization and UAE, leading to even more substantial reductions in bleeding. ¹¹ , ¹² , ¹³ Whereas in other investigations, it was reported that this intervention makes no difference. ¹⁴ Aryananda et al. by comparing cesarean hysterectomy versus conservative surgery with two types of arterial ligation, indicated that conservative operation with upper vesical, upper vaginal, and uterine artery ligation, is the optimum treatment for PAS with bladder invasion. ¹⁵

Previous investigations have indicated that surgical devascularization can be used as an effective intervention in the management of placenta accreta to reduce the risk of massive uterine bleeding and potentially avoid the need for hysterectomy. ¹⁶ Mehmet S et al by conducting a retrospective study revealed that conservative surgery with partially removing of the placenta has lower operative time and blood loss than surgical hysterectomy. Also, the same result was shown in the severe forms of PAS (increta and percreta). ¹⁷ Conservative management of PAS and fertility preservation increase the short‐term and long‐term hemorrhagic risk, therefore primary or delayed hysterectomy is inevitable in some cases. ⁹ W. Merz et al. in 2008 indicated that close monitoring of remaining placenta tissue by color Doppler after conservative treatment and determining the vascularity and size of placenta tissue is helpful to decide about additional interventions. ¹⁸ Moreover, it is crucial to note that abnormal placental invasion can have both mental and physical effects on mothers. A previous study indicated that psychological counseling appears to be beneficial for these mothers, regardless of whether a hysterectomy was performed or not. ¹⁹

Consistent with our findings, a recent retrospective cohort study demonstrated that PAS should be managed by primary cesarean hysterectomy, except for adjacent organ invasion or the patient's preference to preserve fertility. ²⁰

In this case, as the patient decided to preserve fertility and also the placenta was extended to the bladder, she was successfully managed by a combination of prophylactic embolization, conservative resected surgery with placenta left in situ, and follow‐up with serial color Doppler monitoring. This study proposed that the approach described is an effective strategy to prevent the need for hysterectomy in cases of placenta percreta involving adjacent organs.

AUTHOR CONTRIBUTIONS

Maryam Kashanian: Supervision. Nooshin Eshraghi: Validation; writing – review and editing. Mohammad Reza Babaei: Conceptualization; data curation. Mahdis Mohammadian‐amiri: Data curation; writing – review and editing. Marjan Ghaemi: Validation. Majid Aklamli: Data curation; visualization. Nasim Eshraghi: Writing – original draft.

FUNDING INFORMATION

There is no funding for this report from any agency.

CONFLICT OF INTEREST STATEMENT

No potential competing interest was reported by the authors.

CONSENT

Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

Kashanian M, Eshraghi N, Babaei MR, et al. Conservative management of placenta previa‐percreta with bladder invasion: A case report. Clin Case Rep. 2024;12:e8879. doi: 10.1002/ccr3.8879

DATA AVAILABILITY STATEMENT

The datasets used during the current study available from the corresponding author on reasonable request.