Placenta Percreta - A Rare Yet Serious Pregnancy Complication

Introduction

Placenta percreta is a pregnancy complication that is uncommon but can be severe. It happens when the placenta attaches deeply and firmly to the uterine wall. In some cases, the placenta can even invade nearby organs like the bladder. This condition carries significant risks during childbirth and often needs specialized medical treatment, including surgery to address potential bleeding and other complications.

What Is Placenta Accreta?

Placenta accreta is a medical condition characterized by the abnormal growth of the placenta into the uterine wall. Unlike a normal pregnancy, where the placenta detaches easily after childbirth, in placenta accreta, the placenta remains attached to the uterine wall and does not separate easily. This can result in dangerous vaginal bleeding, which may necessitate a blood transfusion and the removal of the uterus through a hysterectomy. Pregnancy care providers can diagnose placenta accreta during pregnancy or delivery. The standard treatment for this condition typically involves an early C-section followed by a hysterectomy to minimize the risk of severe complications.

What Are the Types of Placenta Accreta?

There are three distinct classifications of placenta accreta, which are determined by healthcare providers based on the level of attachment between the placenta and the uterus.

• Placenta Accreta: This is the most common type, where the placenta firmly attaches to the uterine wall without penetrating it or affecting the uterine muscles.

• Placenta Increta: In this type, the placenta is deeply embedded within the uterine wall, but it still does not breach the uterine wall. Instead, it remains firmly attached to the uterine muscle. Placenta increta accounts for approximately 15 % of cases.

• Placenta Percreta: Among the three types, placenta percreta is the most severe. It occurs when the placenta penetrates through the uterine wall. In some cases, the placenta may even grow beyond the uterus and impact other organs, such as the bladder or intestines. Placenta percreta is relatively rare, accounting for about 5 % of cases.

What Is Placenta Percreta?

• Placenta accreta is a range of serious placental disorders that can be life-threatening for pregnant women. Placenta percreta is a specific type of placenta accreta, accounting for approximately five percent of cases.

• This subtype is associated with higher maternal morbidity due to its extensive invasion compared to other subtypes like placenta accreta vera and placenta increta. Placenta percreta is characterized by villous invasion throughout the myometrium and surrounding structures, such as the bladder.

• This condition can cause severe complications like hemorrhage, disseminated intervascular coagulopathy, adult respiratory distress syndrome, and kidney failure. The cause of placenta percreta is unknown, but it is linked to previous cesarean section, placenta previa, grand multiparity, uterine curettage, and Asherman syndrome.

• The gold standard treatment for placenta percreta is cesarean hysterectomy immediately after childbirth. Conservative management involves leaving the placenta attached to the uterus, but this requires long-term monitoring for bleeding, thrombotic complications, and infections.

• One-step conservative surgery is another option that involves resecting the invaded area, including the bladder, before removing the placenta and reconstructing the myometrium. Managing placenta percreta is challenging and can lead to fatal complications.

What Causes Placenta Percreta?

• Placenta percreta is caused by abnormalities in the lining of the uterus. These abnormalities can occur due to previous uterine surgeries, which can cause damage or scarring to the uterine lining. However, it is important to note that placenta percreta can also occur in individuals who have not undergone any uterine surgeries.

• There are several risk factors associated with placenta percreta.One of the main risk factors is having multiple C-sections. People who have had multiple C-sections are at a higher risk of developing placenta percreta due to scarring of the uterus from these procedures. The risk increases with the number of cesarean sections a woman has had over time, and it is estimated that multiple cesareans are present in over 60 % of placenta percreta cases.

• Another risk factor is a history of uterine surgeries. If a person has had a uterine fibroid removed or has undergone procedures such as curettage or endometrial ablation, the scarring that occurs as a result of these surgeries can increase the risk of placenta percreta.

• Additionally, individuals with placenta previa, a condition where the placenta blocks the cervix, and a history of prior C-section deliveries are at an increased risk of placenta percreta. The risk further increases with the number of C-sections they have had.

How Is Placenta Percreta Managed?

Surgical procedures are commonly used as a primary treatment option in the majority of cases. Nevertheless, excessive bleeding during the procedure can be a significant issue, particularly when neighboring organs like the bladder or bowel are affected. In such situations, a more cautious approach known as conservative management is favored. Additionally, in specific cases, embolization techniques have also been employed.

In severe cases where the placenta is deeply attached or invading other organs, a hysterectomy (removal of the uterus) may be the safest option. A cesarean hysterectomy is when the uterus is removed during a C-section delivery. In this situation, the doctor will deliver the baby, uterus, and placenta all at once. Removing the uterus with the placenta still attached helps minimize the risk of excessive bleeding.

What Are the Complications of Placenta Percreta?

• Excessive Hemorrhaging - Retained placenta, which has a rich blood supply, leads to heavy bleeding.

• Disseminated Intravascular Coagulopathy (DIC) - The retained placenta releases tissue thromboplastin, resulting in the development of DIC.

• Presence of Blood in Urine - The invasion of the placenta into the bladder leads to bleeding, causing hematuria.

• Inadequate Lactation - The significant blood loss results in the depletion of hormones, including prolactin, which is essential for lactation.

• Formation of Fistulas - Trauma and inflammation can give rise to fistulas. In the case of bladder trauma, a vesicovaginal fistula may occur.

• Loss of Ovarian Function - The scar tissue from the hysterectomy covered the ovary, necessitating its removal.

• Ileus - A well-documented surgical complication that can occur. The bowel's normal functioning is disrupted in the condition known as ileus.

• Perforation of the Bladder - The use of bladder staples to control severe bleeding causes repeated micro trauma to the bladder during its expansion and contraction.

Conclusion

Placenta percreta is a rare and serious condition that occurs during pregnancy when the placenta deeply penetrates the uterine wall. It poses significant risks to both the mother and baby, which calls for careful management and often requires medical intervention, such as surgical procedures. Detecting it early and closely monitoring the mother's health are essential to minimize potential complications and ensure the best outcomes for both the mother and baby.