Rare case of Placenta Percreta involving maternal bladder- A report

Dr Ally Murji and Dr John Kingdom at the University of Toronto, Toronto, Ontario, Canada have reported a rare case of placenta percreta Involving Maternal Bladder. The case has appeared in the New England Journal of Medicine.

Placenta percreta, the rarest and most severe form of placenta accreta, can involve the urinary bladder. Because of its propensity for severe hemorrhage, it is a potentially life-threatening condition. Although commonly discovered at the time of delivery, antenatal diagnosis may be achieved with ultrasound, magnetic resonance imaging, and/or cystoscopy. Every attempt should be made to minimize potential for blood loss by avoiding removal of the placenta at the time of delivery and either performing a hysterectomy or using methotrexate therapy to ablate the residual placenta in the postpartum period

A 32-year-old woman with a history of cesarean section was referred to a multidisciplinary placenta program at 24 weeks of gestation after placenta previa was diagnosed on ultrasonography. The patient reported having intermittent, painless hematuria. Abdominal ultrasonography performed with a full maternal bladder revealed avascular, expanded lower uterine segment that raised suspicion for the invasion of placental chorionic villi into the bladder.

Cystoscopy showed a bulging posterior bladder wall with extensive vascularization and a focal area of invading chorionic villi, findings consistent with placenta percreta. Placenta percreta is characterized by the invasion of placental chorionic villi into and beyond the uterine myometrium, sometimes into surrounding structures. The inability of the adherent placenta to separate at delivery can cause catastrophic haemorrhage and substantial maternal complications.

At 33 weeks of gestation, the patient underwent elective midline laparotomy and cesarean delivery of the neonate, as well as hysterectomy and resection of the posterior bladder wall. The procedure was complicated by a loss of 6 liters of blood, leading to massive transfusion. A vesicovaginal fistula developed postoperatively and subsequently healed after prolonged bladder drainage. At the 3-month follow-up, the patient had normal bladder function and the infant was well after hospitalization for prematurity.