ABSTRACT

Forms of aberrant placentation are included in the placenta accreta spectrum (PAS), formerly known as the morbidly adherent placenta. They require multidisciplinary therapy for an appropriate and advantageous surgical approach. The most popular theory for the cause of placenta accreta spectrum is that a problem with the endometrial-myometrial interface prevents normal decidualization in the vicinity of a uterine scar, allowing unusually deep placental anchoring villi and trophoblast infiltration. It is the most severe obstetric condition as it can lead to significant bleeding with multiple organ failure, admission to the critical care unit, hysterectomy, and final maternal death. The diagnosis and treatment of PAS, a diverse illness with a high maternal morbidity and death prevalence, offer particular difficulties. This review aims to conduct a retrospective descriptive observational study with a clinical case and bibliographic search.

                                                               keywords

                               Placenta percreta, bladder, ureter, and abdominal wall.

                                                             INTRODUCTION

Placenta accreta is characterized as an aberrant invasion of the placenta, in whole or part, by trophoblasts into the uterine wall's myometrium (1). Placenta increta, placenta percreta, and placenta accreta are all examples of the pathologic adhesion of the placenta that are included in the placenta accreta spectrum, formerly known as the morbidly adherent placenta.

1. Placenta accreta: The villi enter the myometrium directly. 

2. Placenta increta: The villi enter the myometrium's interior. 

3. Placenta percreta: The villi infiltrate nearby organs by penetrating the abdominal cavity and the peritoneal serosa. (1)

Severe and life-threatening bleeding, which frequently necessitates blood transfusion, can cause maternal morbidity and death. Women with placenta accreta spectrum have higher maternal death rates. (2) Furthermore, patients with placenta accreta spectrum are more likely to require a hysterectomy at the time of birth or during the postpartum period, and they stay in the hospital for more extended periods. (3) 

History of cesarean section is one of the risk factors, and as the number of previous cesarean sections rises, so does the incidence of PAS (4). Moreover, Placenta accreta has been closely correlated with the number of uterine operations, occurring more commonly with the number of prior cesarean sections, according to the frequency of cesarean births and whether or not there is placenta previa. (5)

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Table 1: Frequency of placenta accreta according to the number of cesarean deliveries and presence or absence of placenta previa. (5)

Advanced maternal age, multiple pregnancies, prior uterine surgeries or curettage, and Asherman's syndrome are additional risk factors. The most common cause is a defect in the endometrial-myometrial interface that promotes insufficient decidualization, creating a region amenable to villus invasion, infiltration, and trophoblastic growth. It is a joint multidisciplinary management scenario due to the surgical approach to the pathology and the morbidity and mortality linked to the incident and its potential complications. (1)

This problem, whose incidence is rising worldwide, has an impact on the outcomes of maternal-fetal health. The most severe aftereffect of uterine procedures requires a comprehensive approach to enhance the outcome of surgical therapy. The posterior-inferior region of the bladder and the lower parameter is strongly associated with mortality in placenta accreta, which is the primary cause of maternal death globally due to postpartum bleeding (1). “Near-misses” are occurrences where a patient narrowly avoided death but did so due to a condition that developed during pregnancy, childbirth, or within 42 days after the termination of the pregnancy. This idea is used as a gauge for the excellence of obstetrics treatment. The World Health Organization (WHO) defines a near-miss case as five or more units of red blood cells, depending on the volume of blood products the patient gets. (1)

The outcomes depend on detecting it during pregnancy and distinguishing between adherent and invasive types. Irving and Hertig defined the adherent form as adhering to the uterine wall without a cleavage plane, bleeding from the placental bed, and histologically lacking the decidual layer between the placenta and myometrium in the 1930s. Lukes et al. later reclassified it as a spectrum of abnormal placental disorders in the 1960s. These abnormalities include placenta accreta, in which villi adhere to the myometrium's surface without encroaching, placenta increta, in which the villi penetrate deeply into the myometrium to the uterine serosa, and placenta percreta, in which invasive villous tissue penetrates through the uterine serosa and can reach surrounding pelvic tissues, vessels, and organs. (1)

In the past, manual birth has been associated with uterine curettage, prior cesarean sections, and advanced maternal age. According to some writers, the rising prevalence of cesarean sections contributes to the disease known as placentation accreta. (1)

Prenatal diagnostic evaluation

Obstetric ultrasonography should be used to diagnose in the first instance, with the second and third trimesters having the highest diagnostic yield. While clinical variables continue to be crucial, even if ultrasonography is the preliminary study, the absence of recognizable ultrasound findings does not rule out the diagnosis of PAS (1). Resonance's significance and contribution to this condition's diagnosis must be clarified, and doing so a priori would not lead to any significant diagnostic findings (1). 

Despite the lack of agreement on the recommended number of ultrasounds, they can be done between weeks 18-20, 28-30, and 32-34, depending on the placenta's ongoing assessment and any potential bladder intrusion. Although preoperative ultrasound examination is an excellent diagnostic tool, there is no connection between the pictures and the technical issues that crop up during surgery, mainly since the effectiveness of ultrasound depends on the operator's knowledge and expertise. (1)

The most accurate method for confirming the spectrum of placenta accreta is histology. The existence and severity of trophoblastic invasion through the myometrium into the placenta accreta, increta, or percreta determines how these illnesses are categorized. Although retrospective clinical-pathological staging differs from oncological diseases in that it does not have a long-term effect on the patient's survival, pathologists and surgeons both seem uninterested in identifying adherent and invasive forms. (1)

Surgical approach

The surgical teams' expertise, ongoing training, and interdisciplinary collaboration are evident in an increase in conservative procedures, a decrease in event-related morbidity, and more. These births can be planned, and the parameters can be optimized for better management thanks to the prenatal presumption of these diagnoses. When performing these births, highly sophisticated care facilities should form teams with obstetricians with comprehensive experience in the field and vast management of the female pelvis, urologists, interventional radiologists, anesthesiologists with expertise in obstetrics, therapists, and neonatologists, among others. Nurses must also be knowledgeable about postpartum hemorrhage and access sufficient protocols for large transfusions. (1)

Clinical Case

A 40-year-old patient was taken to the Hospital Clinica y Maternidad Suizo Argentina, in the Federal Capital, Buenos Aires, Argentina, with a pregnancy diagnosis at 28 weeks of gestation and total placenta previa with ultrasonographic data suggestive of accreta (at week 27 ). The patient's gynecological history was: two previous cesarean sections, the first due to breech presentation, the second due to the risk of uterine rupture due to contractions and non-existence of dilation. At week 26, she was diagnosed with a total placenta previa and a pregnancy with a normal embryo concordant at the week in reference (6). 

Doppler ultrasound reported: pregnancy at 28 weeks of gestation, balanced growth, and total placenta previa, with ultrasonographic data suggestive of placental incretism (6).

In the magnetic resonance, the placenta percreta is found with severe infiltration of the myometrium in its anterior and right lateral part, with extension to the mesentery of the abdomen and infiltration of the roof of the bladder and the proximal portion of the urethra and the soft tissues of the perineum, especially on the right side (6) (Figures 1 and 2) (7). 

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At week 28, the patient collapsed due to severe bleeding and was taken to be hemodynamically compensated for preparing for an emergency delivery. Once compensated, she underwent an emergency cesarean section to save the near-miss. Asepsis and antisepsis were performed with a supra infra umbilical incision with dissection of the wall until reaching the abdominal cavity. During the revision, a “jellyfish head” image (placental infiltration) was observed that took the bladder, the broad ligament in all its right thickness, and the pelvic hollow in the posterior fornix. A traditional hysterectomy was performed in the fundic region. A live girl weighing 1,380 grams was born. (6)

The internal iliac artery bifurcation is seen at the level of the fourth lumbar vertebra, where the retroperitoneum is dissected to get the hysterectomy margins. (8) 

Along with a thorough obstetric hysterectomy, bilateral ligation of both hypogastric arteries was carried out. Both the utero-ovarian and round ligaments were clamped and ligated. The broad ligament and bladder mucosa were separated after confirming the placental bed invasion that took the bladder wall. At the location of the placental bed, the uterine arteries were severed, ligated, and vasopressin was injected. Dissection of the bladder segment revealed placental infiltration, followed by ligation and cutting of the cardinal (uterosacral) ligaments and dissection and cutting of the cervix to complete the total obstetric hysterectomy. The bladder wall and vaginal vault were closed at the placental penetration location. A suprapubic catheter and drainage lines were inserted to assure active bleeding and wall closure using the standard procedure after both patent ureteral meatuses were confirmed to be present. (6)

With 11 globular packs and replenishment of 3,000 mL of crystalloids and 1,500 mL of colloids, bleeding quantification was about 9,700 mL. A 90/40 mmHg arterial hypotension that responded well to fluids without vasopressors emerged. (6)

With a 152 mmHg blood pressure (hypertension) and 97 mmHg, oxygen saturation of 92%, a heart rate of 70 beats per minute, a respiration rate of 16 beats per minute, and a neurological examination while sedated and anesthetized, the patient was transported to the critical care unit. (6)

At 56 hours, his blood pressure was 130 and 96 mmHg, his heart rate was 80 beats per minute, his breathing rate was 15 breaths per minute, his oxygen saturation was 96%, his mean blood pressure was 114 mmHg, his blood sugar level was 100 mm/dL, and his central venous pressure was 7.8 mmHg. He later left intensive care. (6)

Twenty days after being admitted, she was released from the hospital with typical vital signs, food tolerance, ambulation, diuresis and bowel motions, a clean surgical cut on her belly, peristalsis, pelvic limbs free of edema, and normal osteotendinous reflexes. She was released ten days later with a clean surgical incision. She had her suprapubic catheter removed, and seven days later, without any issues, she removed her urethral catheter. (6)

                                                               DISCUSSION

An obstetric risk is associated with the diagnosis of placenta percreta; some writers state that this condition is associated with significant maternal morbidity and death. The placenta Previa's features, the uterine scar on the anterior face, the invasion of other organs, and its problems all play a significant role in the symptoms. The primary symptom is bleeding during the antepartum, intrapartum, or postpartum periods. In the instance described here, it occurred at this time, but the surgical intervention managed it well and without any problems.

The most accurate method of diagnosis is color Doppler ultrasound, which identifies numerous placental lacunae with the strenuous or turbulent flow that extends from the placenta to neighboring tissues. In this clinical case, the Doppler ultrasound suggested placental incretism, and the MRI affirmed it.

The earlier diagnosis that led to the patient being referred to the hospital was vital because it allowed for the possibility of performing an emergency operation with a lesser risk of catastrophic bleeding, thanks to the ability to diagnose placental incretism before birth.

Returning to the clinical scenario, patients with placenta percreta require a multidisciplinary approach that includes a team of qualified obstetrician-gynecologists, urologists, surgeons, anesthesiologists, and intensivists. For this reason, the pregnancy must be terminated in a tertiary care facility.

It is essential to have compatible blood products and coagulation factors on hand and the cooperation of urologists, given the involvement of the posterior bladder wall and surgeons if there is intestinal infiltration. These factors include the complete blood count, coagulation times, blood group, and Rh, as described by some auth like. This is due to the complexity of the surgical techniques used in this circumstance.

There are several critical considerations, such as early awareness of this ailment, since it can stop additional complications and worsen. Similarly, ultrasonography methods for finding or identifying placenta percreta (the quality of the image, for example). Hospitals' blood types are another consideration since the opposite may preclude an early transfusion of whole blood and result in a late transfusion.

                                                               CONCLUSION

Given the high likelihood of placenta percreta-related mortality and the incomplete understanding of its natural history, early detection is essential to preventing a catastrophic result. Firstly, to prevent the physicians' carelessness in failing to recognize that the patient did not need to become pregnant again after two complex cesarean procedures like the ones this patient underwent subsequently. Secondly, the hospital department must also take into account its ability to handle situations like this, including having the necessary equipment, infrastructure, and human resources; engaging in interdisciplinary work that must involve the gynecologist, anesthesiologist, urologist, radiologist, hematologist, and intensive care; all with the shared objective of preventing morbidity and mortality of the mother and her child.

                                                               LIMITATIONS

The lack of comprehensive knowledge on placenta accreta and locating information on the patient were two limitations of this case study.

                                                       ACKNOWLEDGEMENT

I am grateful to Mariano Sertori, my mentor, for his assistance with this inquiry's analysis, investigation, and completion. In the same vein, I'd like to thank my mother, Veronica Demasi, the case study patient, for lending me her perspective and sharing her epicrisis.

                                                               REFERENCES

Dr. Luis Daniel Hernández Mendoza, Dr. Javier Edmundo Herrera Villalobos, Dr. Freddy Mendoza Hernández, Dr. Enrique Adalberto Adaya Leythe (2018, january-july) “Acretismo placentario: Experiencia en Obstetricia Crítica”

                         medigraphic.com/pdfs/veracruzana/muv-2018/muv181g.pdf

Ihab M Usta 1, Elie M Hobeika, Antoine A Abu Musa, Gaby E Gabriel, Anwar H Nassar (2005, September) “Placenta previa-accreta: risk factors and complications.”

                         pubmed.ncbi.nlm.nih.gov/16157109/

Cynthia S Shellhaas 1, Sharon Gilbert, Mark B Landon, Michael W Varner, Kenneth J Leveno, John C Hauth, Catherine Y Spong, Steve N Caritis, Ronald J Wapner, Yoram Sorokin, Menachem Miodovnik, Mary J O'Sullivan, Baha M Sibai, Oded Langer, Steven G Gabbe, Eunice Kennedy Shriver National Institutes of Health and Human Development (NICHD) Maternal–Fetal Medicine Units Network (MFMU) (2009, August) “The frequency and complication rates of hysterectomy accompanying cesarean delivery.”

                         pubmed.ncbi.nlm.nih.gov/19622981/

Dr. Luis Daniel Hernández Mendoza, Dr. Javier Edmundo Herrera Villalobos, Dr. Freddy Mendoza Hernández, Dr. Enrique Adalberto Adaya Leythe (2018, january-july) “Acretismo placentario: Experiencia en Obstetricia Crítica”

                         medigraphic.com/pdfs/veracruzana/muv-2018/muv181g.pdf

Publications Committee, Society for Maternal-Fetal Medicine, with the assistance of Michael A. Belfort, MBBCH, MD, PhD (2010, November 1st) “Placenta Accreta”

                         ajog.org/action/showPdf?pii=S0002-9378%2810%2901159-2

 Hospital Clinica y Maternidad Suizo Argentina (2007, June-July) “Epicrisis” of patient of clinical case.

Diplomado en Ultrasonografía Médica (2017, October 4th) “Placenta percreta con invasión a la vejiga, el uréter y la pared abdominal”

                         diplomadomedico.com/placenta-percreta-invasion-la-vejiga-ureter-la-pared-abdominal/

Matthew Hoffman, MD (2021, Febraury 4th) “Hysterectomy”

                         webmd.com/women/guide/hysterectomy