Introduction

Spontaneous rupture of the uterus during pregnancy due to placenta percreta is a rare complication, which is potentially life-threatening to the mother and the fetus. In placenta percreta the chorionic villi completely penetrate the uterus and in extreme cases the urinary bladder and the bowel.

Case Report

A 32-years-old mutigravida, with a history of precious cesarean section was admitted at SMGS hospital, Jammu on 5th August 2008 with 30 weeks amenorrhea and minimal bleeding per vaginum. On admission clinically she was 34 weeks with cephalic presentation, ultrasound examination a line pregnancy of 33 ± 2 weeks with a low lying placenta. Approximately ten days later after developing sense and continuous abdominal pain and with a deteriorating clinical condition of severe paella, abdominal tenderness and hypertension an emergency laparotomy was performed and a hemoperitoneum of approximately 2,500 ml of blood was seen. A live female taken with apgar score 8/10 and birth weight of 2.7 kg was delivered. The placenta was completely adherent posteriorly with placental tissue penetrating through the uterine serosa through a uterine wall defect. This necessitated hysterectomy during which a bladder injury occured and was repaired. The total blood loss was estimated at 3,000 ml. The pathology report showed chorionic villi invading the myometrium all the way through serosa consistent with the diagnosis of a placenta percreta.

Discussion

Literature reports on the frequency of placenta accreta, increta and percreta vary between 1:540 and 1:93000. The average incidence is ~1:7000 pregnancies [1]. Predisposing factors include prior dilatation and curettage, endometritis, submucous myomas and uterine scars such as those after Caesarean section. The relationship between abnormal placentation and previous Caesarean section was investigated by Clark et al. [2], who found that the risk of placental praevia increases linearly with the number of previous cesarean sections, 10 % after four or more sections. When a placenta praevia is present, the probability of placenta accreta increases from 5 % without previous Caesarean section to more than 24 % with one, and up to 67 % with four or more prior sections [2]. In this case, the rupture was on the posterior wall, the uterine wall at the site of the rupture was thinned out considerably. Reported complications of placenta percreta include severe bleeding that can be life-threatening, and invasion of neighbouring organs by the placental villi such as the urinary bladder [3]. One of the most severe complications is a spontaneous rupture of the uterus with a haemoperitoneum, as was observed in this patient during laparotomy. This type of complication has been reported in a number of cases all of which necessitated a hysterectomy [4, 5].

Conclusion

Patients with an antepartum diagnosis of placenta praevia who have had a previous caesarean section should be considered at high risk of developing placenta praevia and accreta.