Management of Placenta Percreta with Bladder Invasion

Placenta percreta is an abnormal penetration of placental tissue through the uterine wall with encroachment into surrounding organs such as bladder or rectum. There is a well-known association between repeated cesarean sections, placenta percreta and abnormal placentation [1]. Other risk factors include previous uterine surgery such as myomectomy, dilation and curettage, and endometritis [2, 3]. Bladder invasion with placenta percreta is a rare occurrence, but can be lethal both for mother and fetus. In literature, different management strategies have been mentioned, varying from conservative to radical approaches depending upon the extent of placental invasion, involvement of other organs, intraoperative hemorrhage and expertise of the surgeon [4]. In our case, less radical surgical procedure was adopted with better outcome.

A 29-year-old female gravida 3, para 2, with history of two cesarean sections, was referred to our tertiary care hospital at 36 weeks of gestation with complaints of lower abdominal pain and hematuria. She had pallor with blood pressure 110/70 mm Hg and regular pulse 90/min. Laboratory investigations showed hemoglobin 8.0 gm/dL, and numerous red blood cells and bacteria on urine microscopy. A previous ultrasound report showed a single alive fetus with major placenta previa and color flow Doppler (done after admission) showed placenta previa percreta with urinary bladder invasion. Surgery was planned in collaboration with a multi-disciplinary team including general surgeons, urologist, hematologist and anesthetist. Large vascular channels were visible in the lower segment of the uterus. A live female baby weighing 2.7 kg was delivered through classical scar. As there was no cleavage plane between bladder and lower segment of the uterus to direct surgical dissection, a subtotal hysterectomy with ligation of internal iliac arteries was performed and whole placenta was left in the abdomen after cutting the umbilical cord. Methotrexate therapy was started 48 hours after surgery for placental resorption. Patient was discharged 10 days postoperatively. Follow-up MRI abdomen and beta human chorionic gonadotrophin hormone (beta-HCG) were indicative of adequate placental resorption. Patient was re-admitted with high-grade fever and hematuria associated with urinary incontinence. Urine microscopic examination found numerous pus and red blood cells. A cystoscopic examination found a big hole in the bladder base. Patient underwent bladder repair surgery by urologist during which shrunken placenta was removed. Patient completely recovered and was without any urinary problems at one year of follow-up.

The incidence of placenta percreta has risen substantially due to the increased rate of cesarean sections. A 10-fold rise has been reported during the past 50 years, and incidence rate varies between 1/210 to 1/2500 births [5]. Morbidly adherent placenta occurs when there is abnormally firm attachment of placental villi to the uterine wall with the absence of the normal intervening decidua basalis and Nitabuchʼs layer [6].There are three variants of this condition: 1) accreta: the placenta is attached to the myometrium 75%; 2) increta: the placenta extends into the myometrium 17%; and 3) percreta: the placenta extends through the entire myometrium and uterine serosa 5-7%, this variant can lead to the placental attachment to other organs such as the rectum and bladder [7]. Morbidly adherent placenta remains one of the greatest challenges in modern obstetrics [8]. During pregnancy, adherent placenta may be asymptomatic or may present with antepartum hemorrhage or abdominal pain. Intrapartum adherent placenta is associated with significant maternal morbidity including massive hemorrhage, disseminated intravascular coagulation, hysterectomy, bladder and ureteric trauma, acute respiratory distress syndrome, or acute tubular necrosis. Risk also increases in cases dealt in emergency without proper planning or multi-disciplinary liaison. The risk factors for morbidly adherent placenta include previous uterine surgery e.g. myomectomy [9], dilatation and curettage, and placenta previa following previous cesarean sections. Our case was diagnosed prenatally as placenta previa percreta involving urinary bladder, was properly prepared forsurgery, and managed in collaboration with multi-disciplinary team. Management of placenta percreta invading the urinary bladder usually requires radical surgery, which may include partial or total resection of the bladder [10]. The most influential variable on maternal outcome is not attempting to remove the placenta. A retrospective study by Yap et al showed that placental removal before hysterectomy resulted in increased maternal morbidity [11, 12]. A recent review also advised against attempts at placenta removal before hysterectomy [13]. Antenatal diagnosis and adequately planned cesarean hysterectomy without attempts at placental removal reduce maternal morbidity as seen in our case. All efforts should be made to control both intra- and post-operative hemorrhage; internal iliac artery and uterine artery ligation is performed in some cases to control hemorrhage. Ting-Kai Leng et al used prophylactic uterine artery embolization to reduce intraoperative blood loss for placenta percreta with bladder invasion; however, the success rate was low [14]. We tried internal illiac artery ligation which helped us to reduce hemorrhage. Maternal mortality, as high as 7-10% has been reported in previous cases [15]. Hysterectomy has traditionally been advised in the management of placenta accreta but there has been a recent movement towards conservative management and preservation of fertility. Strategies include leaving the placenta after cesarean delivery with surgical uterine devascularisation, embolization of the uterine vessels, uterine compression sutures and/or over sewing of the placental vascular bed [16]. A conservative approach was first described by Arulkumarran and colleagues in 1986 by using systemic methotrexate [17]. Methotrexate has an important role in conservative management of placenta percreta with bladder invasion and it has been used in many patients. We used methotrexate in our patient after subtotal hysterectomy with placenta in-situ. This required prolonged follow-up during which patient had another laparotomy for repair of bladder fistula and successful repair.

For major placenta previa percreta with bladder invasion, we propose an alternative approach which involves subtotal hysterectomy, leaving the placenta in-situ, prophylactic bilateral internal artery ligation, and adjuvant methotrexate therapy with surgery for bladder fistula later when situation arises. This approach offers the benefit of a less radical, safer surgery by leaving the bladder intact and minimum perioperative hemorrhage with reduced maternal morbidity and mortality.

1. Clark SL, Koonings RP, Phelan JP. Placenta praevia accrete and prior cesarean section. Obstet Gynecol 1985; 66:89-92.
2. Capella-Allouc S, Morsad F, Rongières-Bertrand C, Taylor S, Fernandez H. Hysteroscopic treatment of severe Asherman’s syndrome and subsequent fertility. Hum Reprod 1999;14:1230–3.
3. Usta IM Hobeika EM, Musa AA, et al. Placenta previa-accreta: risk factors and complications. Am J Obstet Gynecol 2005; 193:1045-9.
4. Johnston TA, Paterson-Brown S. Placenta praevia, placenta praevia accreta and vasa praevia: diagnosis and management. London: Royal College of Obstetricians and Gynaecologists.Green-top Guideline No 27; 2011 [updated May 1, 2011]. Available from:http://www.rcog.org.uk/womens-health/clinical-guidance/placenta-praevia-and-placenta-praevia-accreta-diagnosis-and-manageme. [Accessed September 28, 2014].
5. ACOG Committee on Obstetric Practice. ACOG Committee opinion. Number 266, January 2002 : placenta accreta. Obstet Gynecol 2002;99:169–70.
6. Obstetrics: normal and problem pregnancies (4. ed.). New York, NY [u.a.]: Churchill Livingstone. 2002. p. 519.
7. Miller, David A (2 November 2004). Accreta Obstetric Hemorrhage.High Risk Pregnancy Directory at ObFocus [Accessed 25 January 2006].
8. Usta IM Hobeika EM, Musa AA, et al. Placenta previa-accreta: risk factors and complications. Am J Obstet Gynecol 2005; 193:1045-9.
9. Al-Serehi A, Mhoyan A, Brown M, Benirschke K, Hull A, Pretorius DH. Placenta accreta: an association with fibroids and Asherman syndrome. J Ultrasound Med2008; 27:1623–8.
10. Faranesh R,Romano S,Shalev E, Salim R. Suggested approach for management of placenta percreta invading the urinary bladder. Obstet Gynecol 2007; 110(2 Pt 2):512-5.
11. Shukenami K, Hottori K, Nishijima K, Kotsuji F. Transverse fundal uterine incision in a patient with placenta increta. J Matern Fetal Neonatal Med 2004; 16: 355-6.
12. Yap YY, Pervin LC, Pain SR, Wong SF, Chan Y. Manual removal of suspected placenta accreta at caesarean hysterectomy. Int J Gynecol Obstet 2008; 100:186-7.
13. Oyelese Y, Smulian JC. Placenta previa placenta accreta and vasa previa. Obstet Gynecol 2006; 107:927-41.
14. Leung TK,Au HK,Lin YH, Lee CM, Shen LK, Lee WH, et al. Prophylactic transuterine embolization to reduce intraoperative blood loss for placenta percreta invading the urinary bladder. J Obstet Gynaecol Res 2007; 33:722-5.
15. O’Brian JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative stratigies. Am J Obstect Gynecol 1996; 175:1632-1638.
16. Ojala K, Perala J, Karinuemi J, Ranta P, Raudaslosi T, Tekay A. Arterial embolization and prophylactic catheterization for the treatment of severe obstetric haemorrhage. Acta Obstet Gynecol Scand 2005; 84:1075-80.
17. Arukumaran S, Ng CS, Ingemasson I, Ratnam SS. Medical treatment of placenta accreta with methotrexate. Acta Obstet Gynecol Scand 1986; 65:285-6.