Successful resolution of hemodynamic shock in a patient with advanced pregnancy and diagnosis of placenta percreta

Abstract text (incl. references and figure legends)

The incidence of placentation disorders is raising,1/2500 pregnancies are affected.(1) The physiopathology of placenta percreta is an anormal deciduation with aberrant anchorage of placental villi outside the endometrium,surpassing the serosa invanding other organs.Risk factors:advanced maternal age,myomectomy,cesarean.(2) Diagnosis by ultrasound and MRI.Termination of pregnancy + hysterectomy is indicated.In case of late diagnose or abortion reticence controlled induction of labor and cesarean+ hysterectomy is suggested.The aim: Obtaining living fetus and minimize bleeding which is the main cause of morbimortality. Embolization of uterine arteries is highly profitable.(2)(3)

Clinical Case: 47-year-old woman with cesarea 7 years ago.Pregnancy by invitro fertilization in London (35+2 weeks) with placenta percreta diagnosis.At our center patient was evaluated by a multidisciplinary team and an elective surgery was planned. Hours later,she was admitted to ER sudden abdominal pain,hypotension,tachycardia.Ultrasound showed:live fetus and hemoperitoneum. Urgent surgery was indicated requiring polytransfusion and amines.

Findings: Free blood (2L), aberrant infiltration of placental vessels throughout the uterus and 30 cm of sigma. Cesarean was successfully performed. Uterine artery embolization failed so an hemostatic balloon was placed in distal aorta controlling bleeding. Hysterectomy+ sigma resection was performed due to massive infiltration. Intestinal ends were left loose. A vacuum assisted therapy was placed keeping the abdomen opened for 48 hours. Due to instability, colostomy was performed in a second look surgery which was reconstructed 3 months later.Both patients were discharged a week later without complications.

Conclusions:Advanced maternal age and previous uterine surgery are risk factors. Gestational control allows early diagnosis and let treatment strategy. Uterine artery embolization immediately after cesarean + hysterectomy seems the best treatment.

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