A Rare Cause of Massive Hematuria: Placenta Percreta With Bladder Invasion

Abstract

Background/Aim: Placenta percreta is a rare event, but it poses serious problems due to potential hemorrhagic events. We report a particular case of placenta percreta with massive hematuria due to maternal bladder invasion, and describe the surgical protocol performed that resulted in an excellent outcome. Case Report: A 33-yearold patient, at 27 th weeks gestational age, presented in the emergency room of the Urology Department with urinary blood clot acute retention, because of massive hematuria from a placenta percreta with bladder invasion. After extracting the clots from the bladder, and coagulation of an area of venous ectasies of the posterior wall, hematuria ceased, but appeared after two days, necessitating again the bladder clots removal and coagulation. A surgical team with gynecologists, urologists, anesthesiologists and a neonatologist was composed, and after bilateral ureteral double J insertion, cesarean section was performed followed by hemostatic hysterectomy and partial cystectomy, bilateral internal iliac artery ligature and repair of the bladder wall. The postoperative evolution was without incidents; the Foley catheter was removed in the 14 th postoperative day. Conclusion: In the context of a massive hematuria of a pregnant woman, the urologist must always consider a diagnosis of complicated placenta percreta.Placenta percreta represents the most severe form of abnormal trophoblastic adherence beyond the decidua basalis, among the three representatives of the placenta accreta spectrum (PAS), a rare condition with reported incidence of 1/500 to ½/500 pregnancies (1, 2). PAS includes 75-80% cases of placenta accreta vera (less than 50% myometrial invasion by the trophoblast), 17% cases of placenta increta (more than 50% myometrial invasion by the trophoblast), and 5% cases of percreta (invasion of uterine serosa and neighboring pelvic organs) (2, 3). Moreover, the abnormal adherence can be complete (throughout the entire placenta), partial (limited to only one or more cotyledons), or focal (in isolated areas) (4).More than 2 caesarean sections (CS), including shorter intervals between previous CS and current pregnancy (less than 2 years), and concurrent placenta praevia (in 75% of cases) are the most common known risk factors, followed by advanced maternal age, multiparity, endometritis, hypertension, assisted reproductive technology, submucosal leiomyomas, other uterine surgeries and anomalies (poor quality of scarring and CS performed on long time ruptured membranes leading to chorioamniotitis), smoking (3,(5)(6)(7)(8)(9). Because of the rise in the numbers of CS performed in recent years, the risk of PAS disorders is increasing up to 10 times in the last 50 years (10,11).The information regardless of treatment of the placenta percreta with bladder invasion are limited, because of the exceptional rarity of this event. Approximatively 70 cases are reported as case presentation, the largest series comprising 54 patients (12).

Vesicouterine adherence is independent of the degree of villi implantation: A retrospective case-control study

“…However, these local neovascularity are often immature and friable 21,22 and are easily susceptible to rupture either spontaneously or during surgical manipulation which usually results in massive hemorrhage. This could explain the signi cant association between the depth of villi of implantation and blood loss observed in our study (p = 0.046) and the occurrences of spontaneous hematuria in PAS cases with bladder adherence reported in literature [23][24][25] . However, such overt hypervascularity are absent in low grade PAS regardless of the presence of vesicouterine adherence, which correlated with a signi cantly reduced incidence of signi cant blood loss (p < 0.001).…”

Lifesaving diagnosis of placenta accreta spectrum using MRI: Report of five cases

“…Hematuria is one of the maternal signs of bladder invasion in PAS [10] , although in one of our cases the MRI did not show bladder invasion and it was later confirmed during surgery. This case demonstrates the importance of MRI in differentiating between bladder invasion and rupture of the vesical vessel.…”

“…MRI is used for PAS evaluation and diagnosis when ultrasound examination is inconclusive, in cases of placental invasion of the posterior and lateral walls—which is difficult to assess in obese patients—and possible invasion of the parametrium and other adjacent organs (bladder, cervix, and pelvic side walls) [7 , 10] . MR imaging findings that suggest PAS are: placental bulge, a heterogenous placental signal intensity with lumpy contour and a rounded edge, dark T2 intraplacental bands, abnormal placental vascularity, loss of the retroplacental T2 dark zone, myometrial thinning, focal interruptions of the myometrium (highly specific for increta and percreta), and bladder tenting (highly specific for percreta) [7 , 11] .…”

Urothelial cell carcinoma of bladder in the second trimester of pregnancy: A clinical case presentation

“…In the differential diagnosis, leiomyomas, schistosomiasis, endometriosis, and particularly placenta percreta invading the bladder, which can cause life-threatening bleeding, should be considered. [7][8][9] When malignancy is detected on ultrasonography, the safest advanced imaging method that can be applied is MRI, and it is preferably performed after the first trimester. However, the use of gadolinium-enhanced MRI during pregnancy, especially in the first 24 weeks, should be avoided due to the uptake of gadolinium by the embryo, excretion through the urinary tract, and re-entry into the fetal circulation.…”