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Abortion hysterectomy at 11 weeks’ gestation due to undiagnosed placenta

accreta (PA): A case report and a mini review of literatures

Article  in  Middle East Fertility Society Journal · September 2014

DOI: 10.1016/j.mefs.2014.03.005

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Middle East Fertility Society Journal (2014) 19, 147–152

Middle East Fertility Society

Middle East Fertility Society Journal

www.mefsjournal.org
www.sciencedirect.com

REVIEW

Abortion hysterectomy at 11 weeks’ gestation due

to undiagnosed placenta accreta (PA): A case
report and a mini review of literatures
a,b,*
Ayman H. Shaamash , Walid M. Houshimi c, El-moutasem M. El-kanzi c,
Ashraf E. Zakaria c

a
Obstetrics and Gynecology, College of Medicine, Assiut University, Assiut, Egypt
b
Obstetrics and Gynecology, College of Medicine, King Khalid University, Abha, Saudi Arabia
c
Obstetrics and Gynecology, Abha Maternity Hospital, Abha, Saudi Arabia

Received 29 January 2014; revised 9 March 2014; accepted 13 March 2014

Available online 22 April 2014

KEYWORDS Abstract First trimester placenta accreta (PA) is a rare event; there are few reported cases world-
First trimester; wide. Herein we report a case of abortion hysterectomy at 11 weeks’ gestation due to undiagnosed
Pregnancy; first trimester placenta accreta. Also, we reviewed medical literatures over the past 20 years for case
Dilation and evacuation; reports of first trimester PA diagnosed after the occurrence of severe bleeding during abortive curet-
Placenta accreta; tage or in the post abortive period.
Hysterectomy Ó 2014 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society.

Contents

1. Introduction . . . . . . . .. ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

2. Case report . . . . . . . . .. ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
3. Discussion and review of literatures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Conflict of interest . . .. ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Disclosure . . . . . . . . .. ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
References . . . . . . . . .. ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

* Corresponding author. Address: Obstetrics and Gynecology, Col-

lege of Medicine, Assiut University, PO # 71511, Assiut, Egypt. 1. Introduction
Mobile: +20 01067 000 675.
E-mail address: shamaashayman@yahoo.com (A.H. Shaamash).
First trimester placenta accreta (PA)/percreta is a rare event but
Peer review under responsibility of Middle East Fertility Society.
it can be life-threatening for the mother. At such an early stage of
pregnancy abnormal placentation is mostly diagnosed because
of massive hemorrhage during subsequent uterine curettage
Production and hosting by Elsevier (1). Clinically, however, it is of extreme importance to diagnose
1110-5690 Ó 2014 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society.
http://dx.doi.org/10.1016/j.mefs.2014.03.005
148
PA/percreta prior to delivery or uterine evacuation to allow pre-
vention of expected maternal morbidity or even mortality (2).
Herein, we report the case of a pregnant woman in the
11th week of pregnancy presenting with heavy vaginal bleeding
and dead fetus. Urgent evacuation was performed but severe
bleeding at this stage made an emergency hysterectomy unavoid-
able. It is proved to be (undiagnosed) first trimester PA.
2. Case report
A 37-year old woman, G3 P2, with a history of two previous
Cesarean deliveries, was admitted to the emergency unit at
the Abha Maternity Hospital (Saudi Arabia) because of vagi-
nal bleeding and lower abdominal pain at 11 weeks’ gestation.
On admission, ultrasound examination showed a dead fetus at
week 8 of gestation + 4 days. At the same time, the placenta
was noticed as implanted low and anteriorly and reaching
the internal cervical os, but not covering it. Anteriorly, in the
isthmo corporal region, the placenta showed many and irregu-
lar-shaped hypoechoic and anechoic spaces that infiltrated the
adjacent myometrium. These findings were suggestive of an
underlying placental pathology and early partial molar
changes were suspected (Figs. 1 and 2). The patient was admit-
ted to the in-patient unit for scheduled detailed ultrasound
examination including the Doppler study. Emergency labora-
tory findings were considered normal including b-hcg level
which was in the normal range for the gestational age. How-
ever, within 3 h of admission, the patient suffered of progres-
sive heavy vaginal bleeding and emergency evacuation and
curettage was indicated.
In the initial trials to remove the placenta severe bleeding
occurred that could not be managed conservatively. At the
emergency laparotomy a hemorrhagic mass was seen in the
region of the old Cesarean section scars (± 2–3 cm) and
extending behind the urinary bladder. During exposure of
Figure 1 A trans-abdominal ultrasound scan showing the placenta implanted low and anteriorly with irregular-shaped hypoechoic and
anechoic spaces that infiltrated the retroplacental zone and adjacent myometrium.
A.H. Shaamash et al.
the isthmo corporal region, a bladder injury occurred due to
dense adhesions. The hemorrhagic mass was opened and
showed placental villi invading the anterior uterine wall; we
assumed that as a possible penetration by the PA occurred
in this region. The uterus was opened and adherent placental
tissues were removed by a piece-meal technique with uterine
curettage and packing but heavy bleeding continued. Conser-
vative measures including intra-myometrial injection of oxyto-
cin, uterine compression, and bilateral ligation of the uterine
arteries failed to control bleeding. Emergency supracervical
hysterectomy was done but bleeding continued from the isth-
mus; hence, total hysterectomy had to be performed. Intra-
operatively, the total blood loss was estimated at 3500–
4000 ml, and 9 units of packed RBCs and 4 units of fresh fro-
zen plasma were transfused.
Postoperative hemoglobin was 8.1 gm/dl and the patient
did well and was discharged on postoperative day 7. Histo-
pathology confirmed the diagnosis of PA (Figs. 3 and 4).
There was no evidence of molar changes in the placental
villi. Retrospective analysis of the ultrasonographic finding
that was interpreted as a feature of possible molar changes
could be an evidence of abnormal placental invasion. At
such an early stage of pregnancy, a routine ultrasound gen-
erally does not include a detailed examination of both local-
ization and implantation of the placenta because it is not
important at that stage and technically not obvious. Theo-
retically, it can be assumed that even at this early stage, a
detailed ultrasound examination of the uterine wall, in a
patient with risk factor for placenta accreta, could reveal
abnormal placentation.
3. Discussion and review of literatures
Over the last decade literature reports showed an increased
incidence of abnormal placentation including low implanted
First trimester placenta accreta is a rare event and mostly ends with hysterectomy 149

Figure 2 A trans-vaginal ultrasound scan showing the placenta implanted low and anteriorly with irregular-shaped hypoechoic and
anechoic spaces that infiltrated the retroplacental zone and adjacent myometrium. The arrow indicates the internal os.

Figure 3 Histopathological section shows placental membrane, placental villi with blood clots infiltrating the outer uterine myometrium
(hematoxilin and eosin: X200).

placenta and PA. Placenta accreta is a major obstetric problem Although the etiology of PA is unknown, a number of risk
associated with serious surgical co-morbidities; particularly factors have been indentified on the basis of previous case
massive hemorrhage (P3L). Now, PA is a common reason reports. Of these known risk factors, a history of prior Cesar-
for peripartum hysterectomy in P9% (3). ean section, especially cases with repeated lower segment or
150
Figure 4 Histopathological section showing islands of placental trophoblastic cells within the uterine myometrium (hematoxilin and
eosin: X400).
classical Cesarean section leaving scar tissue in the anterior
uterine wall are most often reported in association with the
development of PA (4).
In accordance to many reports (5–10) in which PA was
diagnosed early in pregnancy, in patients with a history of
Cesarean delivery, our patient had 2 previous Cesarean deliv-
eries. However, of these case reports on PA a few cases
involved healthy patients with a non-scarred uterus, but other
risk factors were present as parity, previous D & C, . . .etc. (11–
14).
When placenta previa is present, the probability of PA
increases from 5% without previous Cesarean section to
>24% with one, and up to 67% with four or more prior sec-
tions (15).
By far to our knowledge, on reviewing medical literatures
over the past 20 years, the reported cases of PA during the first
trimester of pregnancy (612 weeks) were mostly discovered
after the occurrence of severe bleeding either during the abor-
tive curettage (1,5,6,9,11,12,14,17,19,21,22,24,26,28) or in the
post abortive weeks (10,13,16,18,20,23,25,27,29). These reports
included 23 cases and are summarized in Table 1. Similarly,
our case was not suspected until evacuation and curettage were
performed. Nevertheless, the clinical presentation includes also
spontaneous rupture of the uterus with acute abdomen and
haemoperitoneum. These cases were reviewed by Jang et al.
(30).
The diagnosis of PA is known to be difficult during the first
trimester, with a lower accuracy compared with those obtained
in the 2nd and 3rd trimesters. The currently known prenatal
sonographic characteristics of PA in the first trimester are:
low-lying gestational sac and diffuse dilatation of the intra-pla-
cental vessels called ‘‘lacunae’’ (12,21). Additionally, PA could
be suspected if a part of the lining of the gestational sac was
A.H. Shaamash et al.
embedded in the previous Cesarean section scar with an irreg-
ular decidual layer and thinning of the underlying uterine wall
(31).
The earliest reported detection of a low-lying gestational
sac, known retrospectively to be associated with PA, was at
5 and 6 weeks’ gestation. The sac was discovered near the
internal os and a diagnosis of Cesarean scar pregnancy was
made. This suggested a direct implantation of the trophoblast
over the scar. After follow up, Cesarean section and subtotal
hysterectomy were performed with the final diagnosis of ante-
rior placenta previa/accreta (8,32). However, these cases are
difficult to differentiate from ectopic pregnancies developing
in the LSCS scar (33).
Similar retrospective studies reported prenatal diagnosis of
8 cases of PA, after previous Cesarean deliveries, in which
ultrasound examination was performed between 8–10 weeks’
gestation. These cases all showed gestational sac located in
the lower uterine segment at the site of the Cesarean section
scar and were all proven to have PA by histopathological
examination (5,7,31).
Regarding intra-placental lacunae, this characteristic fea-
ture of PA is the presence of multiple hypoechoic or anechoic
areas within the placenta with two dimensional ultrasonogra-
phy. Prenatal sonographic screening in the 2nd and 3rd trimes-
ters using this finding was found to have an excellent sensitivity
and specificity (80% and 95%, respectively) (34–36).
Using this ultrasonographic finding Buetow, Shih et al. and
Chen et al. reported transvaginal sonographic diagnosis of PA
as early as 8 and 9 weeks’ gestation. They also had to perform
hysterectomy owing to heavy bleeding, either immediately or
few weeks later, with histopathological confirmation of PA
(5,12,21). Recently, Stirnemann et al. (33) implemented these
first trimester signs of placenta PA in a prospective screening
First trimester placenta accreta is a rare event and mostly ends with hysterectomy 151

Table 1 A summary of 23 Case Reports of first trimester placenta accreta presented during uterine evacuation and postabortive period
(between 1990 and 2011) (diagnosed before 612 weeks).
Presentation during uterine evacuation (n = 14) Presentation during post-abortive period (n = 9)
Author Year Treatment Author Year Treatment
Ecker et al. (17) 1992 Hysterectomy Harden et al. (16) 1990 Hysterectomy
Arredondo et al. (11) 1995 Hysterectomy Walter et al. (18) 1999 Hysterectomy
Gherman et al. (1) 1999 Hysterectomy Chanrachakul et al. (20) 2001 Hysterectomy
Haynes et al. (19) 2000 Hysterectomy Kim et al. (23) 2005 Hysterectomy
Shih et al. (12) 2002 Hysterectomy Son et al. (13) 2007 Hysterectomy
Höpker et al. (6) 2002 Hysterectomy Ju and Kim (25) 2007 UAE
Chen et al. (21) 2002 Hysterectomy Sedigheh et al. (27) 2009 Hysterectomy
Buetow MP (5) 2002 Hysterectomy Takeda et al. (10) 2010 UAE
Liu et al. (22) 2003 UAE Wang et al. 2011 (29) 2011 Lap. Resect.
Ismail and Toon (24) 2007 MTX
Papadaskis et al. (26) 2008 Hysterectomy
Yang et al. (9) 2009 Hysterectomy
Soleymani et al. (14) 2009 UAE
Kim et al. (28) 2010 Hysterectomy
UAE: uterine artery embolization.
MTX: methotrexate.
Lap. Resect.: laparoscopic resection.

trial. They suggested that the rationale for 11–14 weeks’
screening in the high-risk group allowed early diagnosis and
planning for optimal management.
With color Doppler sonography and power Doppler imag-
ing evidence of the first trimester PA are similar to those seen
in the 2nd and 3rd trimesters including: diffuse turbulent flow
in the placental lacunae and increased peripheral vascularity.
These findings could be seen as early as 8 and 9 weeks’ gesta-
tion (12,21).
Furthermore, Magnetic Resonance Imaging (MRI) with or
without gadolinium can be used as a supplementary diagnostic
modality for further improving the prenatal diagnosis. During
2nd and 3rd trimesters scanning cohort studies compared
sonography and MRI with gadolinium and found high sensi-
tivity (77% and 88%, respectively) and very high specificity
(96% and 100%, respectively) for both modalities (34,35).
They should be considered complimentary when one modality
is inconclusive.
First trimester diagnosis of placenta previa/ accreta using
MRI was described by Thorp et al. (37). In some other case
reports of PA, which were diagnosed in the post abortive
weeks, MRI was used as precise diagnostic imaging technique
to identify the invading placental tissues (14,25).
Hysterectomy has been the traditional treatment for PA
given the report by Fox (1972) that conservative treatment
caused a four times higher mortality rate than the treatment
with an immediate hysterectomy (38). However, there is only
a little experience in treatment of the disease during first tri-
mester. So, the choice between hysterectomy or conservative
therapy is dependent on the severity of bleeding.
In a survey of medical literatures over the past 20 years (23
cases), we found that regarding first trimester PA, which was
diagnosed during the abortive curettage or in the post abortive
period (before 12 weeks’ gestation), hysterectomy was the stan-
dard treatment (Table 1).
Yang et al. (9) performed a ‘‘prophylactic’’ first trimester
hysterectomy (at 12 weeks’ gestation) after diagnosis of low
implanted PA in a 33-year-old woman, with a history of two
previous Cesarean deliveries. Bilateral uterine artery emboliza-
tion was performed preoperatively to reduce expected bleeding
during hysterectomy.
Recent reports indicated that conservative invasive proce-
dures have also been described in order to preserve fertility;
these procedures included angiographic uterine artery emboli-
zation (10,14,22,25) and laparoscopic or surgical resection of
the affected area of the uterus (29). Generally all these methods
must be critically considered.
In some settings, uterine conservation, with the placenta left
in situ may be considered. Adjuvant therapy with methotrexate
has also been used to expedite resorption of the placenta (39).
It was found that there was a reduction in the hysterectomy
rate from 85% to 15% when placental retention was allowed.
Morbidities associated with leaving the placenta in situ mainly
included infection and coagulation disorder, which may neces-
sitate subsequent hysterectomy (3). Ismail and Toon reported
successive use of methotrexate in treatment of first trimester
PA (24).
In conclusion, women at high risk of PA could be consid-
ered for detailed sonographic examination during the first tri-
mester. Early diagnosis may allow earlier elective intervention
that prevents maternal morbidity and mortality. Clear evi-
dence guiding screening, diagnosis and management are
needed. Considering the rising rate of Cesarean deliveries,
the incidence of PA in early gestation will increase.
Conflict of interest
The authors declare no conflict of interest.
Disclosure
The authors confirm that, they do not have any relationships
with companies that may have a financial interest in the infor-
mation contained in the manuscript.
 152
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