Placenta accreta (abnormal placentation) is characterized
by a regional or insufficient diffusion of
decidua basalis. It has three types: placenta accreta
where the villi are superficially attached to, but do
not invade the uterus; placenta increta where villi
invade myometrium; and placenta percreta where
placenta crosses full thickness of myometrium and
reaches the serosa (
Placenta percreta is the most severe form as it
invades the serosal layer of the uterus and has a
potential to invade adjacent pelvic organs. Its incidence
has been increasing with each passing day
as a result of an increase in the number of surgical
We report a patient with placenta percreta who presented with continued vaginal bleeding following curettage for incomplete abortion at 6 weeks of pregnancy.
41-year-old female G3 P2 L1 A1 with history
of 2 previous cesarean deliveries, presented to
our clinic with protracted vaginal bleeding. It
was learnt that she had undergone curettage
for incomplete abortion at an outside center 2
months ago, following which she had persistent
vaginal bleeding. She did not apply to any
healthcare facility because her sociocultural
level was low and she resided in a rural area of
İzmir, Turkey. She could not have any sexual intercourse
as a result of protracted bleeding. Her
hemoglobin was 7.1 g/dl, and beta-human chorionic
gonadotropin (β-HCG) was 130 mIU/ml.
Transabdominal and transvaginal ultrasonography
(USG) was used to rule out abortion imminens
and extrauterine pregnancy. Transvaginal
color Doppler ultrasonography revealed a
20 mm solid mass lesion with smooth contour
compressing endometrium anterior to uterine isthmus
as well as a dense fluid collection within the cavity (
Transvaginal color Doppler interrogation demonstrates a solid mass lesion with smooth contour and a central vascular flow at the anterior wall of the uterine isthmus.
T1W sagittal precontrast image (A) shows residual placental (white arrows) and a hyperintense area consistent with subacute hemorrhage around it at the posterior segment of uterus. T1W sagittal postcontrast image (B) shows contrast uptake in myometrium and placental residue (white arrows). Axial fat suppression T2W image (C) shows placental residue (white arrows) and hemorrhage (arrow heads).
Postoperative hysterectomy material reveals placenta percreta extending to serosa (white arrows) at the level of uterine isthmus and a hematoma opening to endometrial cavity medial to it (arrow heads).
Macrophotography demonstrates hemorrhagic placental residue containing necrotic villi interspersed in muscle tissue.
Placenta percreta is a disorder that results from regional or insufficient diffusion of decidua basalis and is characterized by placenta passing beyond myometrium to reach serosa. Approximately, 5% of the cases with abnormal placentation consist of placenta percreta. Nearly all cases of placenta percreta are diagnosed in 3rd trimester. Its incidence has been on the rise with each passing day as a result of the increase in the number of caesarean section operations (
Risk factors for placenta percreta include previous surgery (caesarean section, myomectomy or curettage), abnormal placental localizations, advanced maternal age, grand multiparity, Asherman’s syndrome, endometritis, adenomyosis, endometriosis, and submucous leiomyoma. Our patient had 2 of these risk factors, including advanced age and previous caesarean sections. Early use of USG and MRI to establish an early and accurate diagnosis, and to determine the appropriate treatment modality are of paramount importance in reducing the morbidity (
Two strategies have been proposed for treatment of placenta percreta, namely hysterectomy and conservative treatment. Although, hysterectomy is the first line treatment modality, it may prove insufficient in achieving hemostasis in cases with advanced and severe invasion of adjacent structures. Thus, hemodynamically stable patients with placenta percreta may be conservatively treated with methotrexate (
Our literature search yielded very few cases with placenta percreta diagnosed in the first and second trimester of pregnancy. Massive bleeding may develop following curettage performed after incomplete abortion and hysterectomy may be required to stop the bleeding (
In our case, incomplete abortion at the 6th week of pregnancy, leading to an early curettage, may have prevented progressive placental growth and further complications. No massive bleeding was observed during curettage and an urgent hysterectomy was not needed. Furthermore, an increased serum β-HCG level in the preoperative period, history of curettage for incomplete abortion 2 months back, no history of sexual intercourse after curettage, history of 2 previous cesarean deliveries and demonstration of placental residue in the uterine cavity on USG and MRI all led to the correct diagnosis. To our knowledge, there is no case diagnosed with placenta percreta as early as 6 weeks of gestation, in English literature.
In conclusion placenta percreta is one of the most important complications of pregnancy with serious morbidity and mortality. First trimester diagnosis is quite difficult. USG and MRI are diagnostic adjuncts. Unexplained protracted vaginal bleeding after curettage for incomplete abortion should raise the suspicion of placenta percreta.
More importantly, uterine rupture may take place in these patients during curettage, leading to shock secondary to abundant hemorrhage. For this reason, it is recommended to perform the curettage in a fully equipped healthcare facility where blood transfusion and hysterectomy can be carried out.