Placenta percreta with iatrogenic megaureter: A maternal near miss case presentation

Introduction

Placenta percreta, is a rare pregnancy disorder in which the placenta penetrates the uterine myometrium and can invade the surrounding organs. It is a potentially life-threatening condition with severe maternal morbidity and mortality. Both sonography and MRI are used for prenatal diagnosis of placenta accreta. Prenatal diagnosis allows management of these patients in specialized tertiary centers, where a multidisciplinary approach will improve the outcome. A team of anesthesiologist, obstetrician, urologist, neonatologist, and blood bank officer is needed for successful management of these patients.

Purpose

Management and complications of placenta percreta in rare blood group.

Methods

We present the case of a young age multigravida with placenta percreta and blood group 0 negative.

Results

She was managed by cesarean hysterectomy after bilateral internal iliac artery ligation before proceeding with placenta removal that was not recommended but aiming for excision and conservative surgical treatment with iatrogenic bladder injury and ureteral ligation that was not diagnosed intraoperative. We encountered a fullness in the retro-peritoneum that was not progressing so we considered it as hematoma but was revealed later as acute ureteric dilation from ligation. Due to poor availability of blood, she recieved limited amount. After 10 hours, she was mild hemodynamically unstable with right hydronephrosis and abdominal collection on ultrasound. She was reoperated with ureter caherterization and evacuation of hematoma. The patient was discharged 10 days after in good condition.

Conclusions

A decision between radical and conservative strategies for placenta accreta must be made based on the degree of placental infiltration and other variables: the patient's hemodynamic status and her desire to remain fertile. In our opinion, cesarean hysterectomy remains the best therapeutic option to treat placenta percreta. Radical surgery should be done for poor availability of blood especially in rare blood types in other types of placenta accreta. Fullness in the retroperitoneal space should not be ligated except after excluding ureter dilatation and confirming hematoma by aspiration and disscetion. Megaureter may be gestational or pathological from ureteric ligation that is differentiated by hydronephrosis. Internal iliac artery ligation followed by cesarean hysterectomy with no trial of removal of placenta should be done to limit blood loss in placenta percreta. Fullness of bladder after repair should be washed as may be blood clot retention from bleeding. Megaureter could be presented intraoperative within minutes of ligation of the ureter and after hours by asymmetry between both kidneys regarding hydronephrosis. Bladder repair can be done by gynecologist but ureter ligation is better to be done by a urologist. Ureter identification should be considered before hysterectomy by visual assessment or dissection or proceeding with hysterectomy very close to cervix especially in total hysterectomy.