Total abnormal invasive placenta in a woman with a history of placental abruption and severe hemorrhage

Haruka Imai; Junichi Hasegawa; Yuki Suzuki; Haruhiro Kondo; Nao Suzuki

doi:10.1515/crpm-2017-0037

Article Publicly Available

Total abnormal invasive placenta in a woman with a history of placental abruption and severe hemorrhage

Haruka Imai , Junichi Hasegawa , Yuki Suzuki , Haruhiro Kondo and Nao Suzuki

Published/Copyright: November 23, 2017

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From the journal Case Reports in Perinatal Medicine Volume 7 Issue 1

Abstract

Abnormal invasive placenta (AIP) is subdivided into total, partial and focal types. A diagnosis of total AIP is made when the entire placenta adheres to the uterine myometrium. We experienced a patient with total AIP who had a history of an emergency cesarean section at 36 weeks of gestation due to placental abruption, and massive hemorrhage due to severe uterine atony treated conservatively with blood transfusion. From our experience with the present case, we hypothesize that total AIP resulted from thinning of the entire endometrium, as can occur with an ischemic change of the entire uterus after disruption of Nitabuch’s layer in severe placental abruption and intramuscular extravasation with uterine atony. This situation might adversely affect placental implantation in the current pregnancy.

Keywords: Abnormal invasive placenta; placenta accreta; placental abruption; previous cesarean section

Case presentation

The patient was a 39-year-old pregnant woman, gravida 2, para 1. She had hypothyroidism treated with levothyroxine, and had a small leiomyoma measuring 30 mm on the right side of the uterine corpus. She had a past history of emergency cesarean section at 36 weeks’ gestation 3 years prior due to placental abruption, with the placenta normally located on the anterior wall of the uterus; she had no history of hypertensive disorder. Uterine atony was marked and complicated by disseminated intravascular coagulation (DIC), resulting in a massive hemorrhage requiring blood transfusion. Her other obstetric history included a dilation and curettage due to an early spontaneous abortion 1-year prior.

The current pregnancy was assisted by an intracytoplasmic sperm injection (ICSI) at the clinic. The patient initially visited our hospital for a routine pregnancy checkup at 9 weeks’ gestation. Throughout the pregnancy, no complications were observed, with normal fetal growth/well-being. The patient had no uterine contraction or vaginal bleeding. An ultrasound examination showed that the placenta was located on the posterior uterine wall without any remarkable abnormal findings and was independent of the previous uterine operative scar.

At 37+2 weeks of gestation, we performed a cesarean section due to her history of a previous cesarean section. A female infant was delivered, weighing 3018 g, with Apgar scores of 9 and 10 at 1 and 5 min, respectively. After delivery, there were no symptoms of placental detachment and bleeding. We found that the lowest edge of the placenta was strongly adherent to the posterior wall of the uterus. Additionally, a transparent invasive placenta into the myometrium was observed from the uterine serosa at the right fundus (Figure 1). Therefore, a diagnosis of abnormal invasive placenta (AIP) was made and a subtotal hysterectomy was performed. The total amount of blood loss was 1271 mL during the operation; a blood transfusion was not performed.

Figure 1:

Picture of abnormal invasive placenta at the uterine tubal interstitium during cesarean section: transparent placenta was observed from the uterine serosa at the right fundus (arrow).

The postoperative period was uneventful, and the patient was discharged on postoperative day 7. We followed her until 1 month after the cesarean section, with no complications after the operation.

A pathological examination demonstrated trophoblastic tissue strongly invading into the myometrium without intervening decidua between almost the entire maternal surface of the placental attachment and the myometrium; thus, the pathological diagnosis of AIP (placenta increta) was confirmed (Figure 2).

Figure 2:

Macroscopic findings of total abnormal invasive placenta in the removed uterus: the placenta was thoroughly adherent to the posterior wall of the uterus.

Discussion

Any surgery that damages or transects the endometrium increases the rate of subsequent AIP [1]. The risk of AIP with prior cesarean deliveries in women with placenta previa was reported as 3%, 11%, 40%, 61% and 67% for the first, second, third, fourth and fifth or more cesarean deliveries, respectively [2]. In the present case, the only known risk factor for AIP was a previous cesarean section. Even though in the present case the placenta was without previa, located on the posterior wall and independent of the previous uterine operative scar, the entire placenta was strongly invading into the uterine myometrium.

AIP has attracted wider attention. In some, AIP occupies the entire maternal surface of the placenta, whereas in others AIP only partly occupies it, with remaining placental parts being free from AIP. In a more detailed manner, AIP can be categorized into three types, “total” (involving the whole placenta), “partial” (involving one or more lobes) and “focal” (involving isolated areas in a lobe) [3]. Although many reports characterized the “invasion-depth degree” of AIP, i.e. accreta, increta or percreta, few focused on the “invasion-area degree” i.e. total, partial or focal. The latter is clinically important: e. g. “focal uterine wall resection with uterine repair” may be possible in some focal AIP [4], whereas it may be difficult in total AIP [5]. Partial placental separation may be less likely to occur during the surgery in total AIP. As such, we think characterizing focal vs. total AIP is of paramount clinical importance in dealing with AIP.

The present case represents total AIP. To our knowledge, there are no previous reports comparing the etiology of partial and total AIP. We suspected that partial AIP is due in part to endometrial damage, thus previous surgery, such as a myomectomy, is likely to result in partial AIP, while total AIP might be due to global endometrium ischemia. Such clinical situations include grand multiparous or arterial embolization of the uterus for postpartum hemorrhage. In fact, it is reported that the fertility rate in patients attempting another pregnancy reaches 70%–80%, and AIP occurs more frequently after arterial embolization than in the general population, although arterial embolization plays a major role in preventing a response to conservative treatment [6].

Couvelaire uterus is a known hemorrhagic process in the uterine musculature accompanying severe placental abruption. Extravasated blood effuses between the muscle fibers and under the uterine peritoneum. In the normal uterus, trophoblasts stop invading the uterus when the Nitabuch’s layer is reached in the decidua; this fails to occur in cases of AIP, possibly as a result of a damaged or deficient Nitabuch’s layer [1]. Placental abruption originates from bleeding into the decidua from ruptured blood vessels in the Nitabuch’s layer, resulting in major obstetric hemorrhage [7]. In the present case, a previous cesarean section was performed due to severe placental abruption, and uterine atony after placental removal was treated conservatively with a blood transfusion. Uterine arterial embolization was not attempted, but such a history might lead to severe, total placental increta. Although the presence of AIP due to the previous cesarean section cannot be ruled out, we speculate that an ischemic change of the entire uterus after disruption of the Nitabuch’s layer with severe placental abruption and intramuscular extravasation with uterine atony might adversely affect the placental implantation in the current pregnancy.

In conclusion, the case presented here suggests that the destructed endo-myometrium accompanied with abruption might be a culprit for the current total AIP.

Author’s Statement

Conflict of interest: The authors have no conflicts of interest.

Material and Methods

Informed consent: Informed consent has been obtained from all individuals included in this study.
Ethical approval: The research related to human use has been complied with all the relevant national regulations, institutional policies and in accordance the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.

References

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Received: 2017-07-11

Accepted: 2017-10-09

Published Online: 2017-11-23

Articles in the same Issue

https://doi.org/10.1515/crpm-2017-0037

Keywords for this article

Abnormal invasive placenta; placenta accreta; placental abruption; previous cesarean section