A Case of Placenta Prævia Increta

By placenta accreta is meant an abnormal adherence of the whole, or part, of the placenta to the uterine wall due to partial or complete absence of the decidua basalis, especially the spongiosum layer. Placenta increta is an uncommon variant of this condition when, in addition, the plfacenta invades the uterine musculature. The incidence of placenta accreta varies from observer to observer, and is reported as ranging from one in 19.t56 to one in 40,000 deliveries. Irving and Hertig (1937) in their summary of cases in the literature found only about one out of six cases of placenta accreta to be situated in the lower segment. The incidence of placenta praevia increta is rarer still. Chisholm, in 1948, could find only three recorded cases in the previous ten years. The aetiological factors have been classified by McKeogh and D'Errico (1951). They divide them into two groups, uterine and placental. It is interesting that in this case a cause from each group is present, the uterine factor being previous trauma in the form of two Caesarean operations and the placental one being its situation in the lower segment. IThe patient, aged 36 years, a small woman of height 4 feet 9 inches and dystrophic appearance, was first seen in the thirty-first week of this, her fourth, pregnancy. In her first pregnancy in 1947 she had a classical Caesarean operation for disproportion. An early abortion two years ago was followed by curettage. One year ago she had an elective lower uterine segment Casarean section. Apart from a transverse lie, no abnormality was noted at the first antenatal examination in the present pregnancy. At the 36th week the lie was still transverse and she was admitted a few days later for elective Caesarean section in view of the clinical findings and her obstetric history. At no time had she any vaginal bleeding. It had been intended to perform another lower segment operation, but, while the bladder was being displaced with gauze dissection, the uterus ruptured with almost explosive violence, producing very copious haemorrhage and exposing the placenta. The rupture seemed to have commenced in the region of approximation of the two previous uterine scars. The infant was rapidly extracted by the breech through the placenta. It was now discovered that the body of the uterus was attached only behind, and only by about one inch of tissue. The placenta extended almost to the …