Laparoscopic hysterectomy to manage uterine rupture due to placenta percreta in the first trimester: A case report

Abstract

Placenta percreta causing uterine rupture is a rare complication of pregnancy. It is most commonly diagnosed after the second trimester and can lead to significant morbidity necessitating abdominal hysterectomy of a gravid or immediately postpartum uterus. We describe a patient who presented with abdominal pain at 13 weeks of gestation and was diagnosed with placenta percreta during laparoscopy for presumed appendicitis. Intraoperatively, placenta was seen perforating the uterine fundus and 1 l of hemoperitoneum was evacuated. However, the uterus was hemostatic and the patient was stable, so the procedure was terminated. The patient was then transferred to a tertiary care center, where she ultimately underwent an uncomplicated laparoscopic gravid hysterectomy. We conclude that placenta percreta can occur in the first trimester even in patients without traditional risk factors. In stable patients, it is appropriate to consider minimally invasive hysterectomy with utilization of specific techniques to minimize intraoperative blood loss.

Searching for placenta percreta: a prospective cohort and systematic review of case reports

“…The remaining 28 cases included intraoperative images in 10 cases, 25,35,40,45,48,52,55,59,61,63 immediate postoperative images of hysterectomy specimens in 2 cases, 33,57 laboratory gross images in 10 cases, 28,30,36,39,42,43,46,47,50,56 and combined intraoperative and postoperative images in 6 cases. 37,49,51,54,58,62 The most common macroscopic description (13 of 28 cases [46.4%]) was that of uterine rupture with bulging of the Distribution for the placenta accreta spectrum grading based on the intraoperative findings in the 101 cases of the cohort using the International Federation of Gynecology and Obstetrics' classification 1 Original Research OBSTETRICS ajog.org placenta or both placenta and fetus. Ruptures were reported as fundal in 3 cases 25,33,37 and cervical in 1 case.…”

“…The review of the published microscopic images found chorionic villi directly apposed to a morphologically normal myometrium in 13 cases, 26,35,37,41,43e48,50,51,55 to a scarred uterine myometrium in 9 cases, 24,29e32,49,52,54,60 and to both normal and scarred myometrial tissues in 4 cases. 38,42,58,62 In 2 cases, the villi were apposed on the cervical stroma, 27,29 and in 3 cases, the villi were bounded by fibrinoid. 38,44,58 In 1 case, EVTs might be present in the bowel fat tissue outside a scarred uterine wall after myomectomy.…”

Unsuspected rupture in unscarred uterus at an early gestation: a clinical dilemma

“…Lee et al recently reported eleven published cases of uterine rupture between 13 and 21 weeks and suggested suspecting rupture if ultrasound shows intraperitoneal fluid with gravid uterus. 6 Our case had a documented intrauterine pregnancy with well-maintained uterine contour and in absence of any abdominal tenderness, deteriorating vitals, or signs of shock, any obstetrical emergency seemed unlikely. Besides coarse liver echotexture with ascites with deranged liver function tests suggested liver pathology.…”

“…10 Laparoscopic approach may be favoured in haemodynamically stable patients when avoiding uterine manipulator, intrauterine vasopressin, lateralizing ureters and retroperitoneal dissection to secure uterine arteries at the origin may increase safety margin. 6 In our case, hysterectomy was performed as tissues at the defect were very friable to hold any suture and patient had two live children.…”

“…1 Though rare but PAS associated rupture in early pregnancy, as occurred in our patient, is also reported in unscarred uterus due to pathological invasion of the placenta through uterine wall. 5,6 Abdominal pain with vomiting in early pregnancy can be a minor ailment of pregnancy or it may be due to medical, surgical or gynaecological emergencies including liver disorders, appendicitis, diverticulitis, peritonitis, urinary tract infection, ovarian torsion, haemorrhagic corpus luteum and heterotopic pregnancy. 7 Hence, acute abdomen is nonspecific and has to be carefully evaluated to make a definitive diagnosis.…”