Placenta Percreta in Early Gestation

A 35 year old, gravida 6, para S + 0 with four live children and one infantile death was admitted at 12 weeks gestation as a case of missed abortion. She had four uncomplicated vaginal deliveries at term and a lower segment Caesarean section 4 years back for fetal distress. The current pregnancy had been uneventful until the 9th week when she started bleeding per vaginum which continued intermittently for 19 days. Physical examination revealed a uterus of 10 weeks gestation and slight spotting-otherwise the examination was normal. The pregnancy test on urine was negative and ultrasound showed an irregular gestational sac of approximately 10 wks. size. A diagnosis of missed abortion was made and the patient was admitted for evacuation of uterus. Initial haemoglobin was 8.5 gms which was corrected with two pints of blood transfusion. The serum fibrinogen on two occasions was found to be within the nortial range. During dilatation anti evacuation procedure, the products were found tobe abnormally adherent in the lower part of the anterior wall and following curettage, brisk haemorrhage started. The patient went into hypovolaemic shock with no pulse and an unrecordable blood pressure. Syntocinon infusion and ergomterine failed to bontrol the blood loss and an emergency laparotomy was decided keeping uterine perforation in mind. On opening the abdomen there was no evidence of perforation. The uterus was found to be adherent to the posWuior surface of the bladder at the site of previous scar. The area had grayish purple hue and appeared haemorrhagic and ecchymosed. Adhesions were divided and total abdominal hysterectomy was performed. Cut surface of the specimen revealed placenta deeply penetrating the wall of the uterus. The patient thereafter made an uneventful recovery and was discharged on the 8th postoperative day. Histopathological examination of the uterus showed trophoblast deeply invading the myometrium of the anterior wall involving the serosa consistent with placenta percreta.