Placenta Praevia with placenta accreta: A true maternal near miss

Placenta accreta is an uncommon but a potentially life-threatening obstetric condition that requires a multidisciplinary approach to management. The incidence of placenta accreta has increased and seems to parallel the increasing cesarean delivery rate. We present a case of term pregnancy with placenta praevia and placenta accreta referred to a rural tertiary institute of central India in emergency hours with profuse bleeding per-vaginum. This case report is an example of a true near miss as the patient went into cardiac arrest at the time of caesarean section, but could be revived by sustained effort with timely resuscitation, caesarean hysterectomy and internal iliac artery ligation. It is an example of team effort by Obstetricians and Anesthetists to save a maternal life.


Introduction
Placenta accreta refers to a placenta that is abnormally adherent to the uterus 1 . There are three main entities (accreta, increta, and percreta), which are defined by histological degree of placental invasion into the myometrium 1 . It is a serious complication of pregnancy that can be life-threatening for both mother and fetus and can be considered as maternal near miss for the woman who survives after bleeding p rofusely during delivery. Near-miss events are defined as acute obstetric complications during pregnancy, labor or within 6 weeks after termination of pregnancy or delivery that immediately threatens a woman's survival but do not result in her death, either by chance or beca use of hospital care she receives 2 . Placenta accreta is frequently associated with severe obstetric hemorrhage, usually necessitating hysterectomy if medical therapies have failed. We present a case of placenta praevia with accreta refered with profuse bleeding per vaginum who had massive intrapartum he morrhage requiring caesarean hysterectomy with bilateral internal iliac artery ligation and multiple blood transfusions. It w as a true maternal near miss for the woman as she survived.

Case Report
A 30-year-old woman, third gravid with 2 live issues with previous history of one caesarean section was referred to Department of Obstetrics and Gynecology of a rural medical college of central India in emergency hours at 38+4 weeks of gestation with chie f complaints of pain in abdomen and bleeding per vaginum since 4-5 hours. She was a diagnosed case of central placenta praevia on ultrasonography. On general examination patient was conscious and oriented, afebrile, however she had moderate degree of pallor. She had tachycardia with pulse 120 beats per minute and a blood pressure of 90/60 mm of Hg. The uterine height was less than the period of gestation, 34 weeks, but flanks were full and the foetus was in transverse lie. There was fetal bradycardia with fetal heart sounds dropping to 90 beats per minute. Mild uterine activity was present. Her underclothes were soaked with blood and she had active fresh per vaginal bleeding. With a diagnosis of third gra vida with placenta praevia , transverse lie, fetal bradycardia and previous cesarean section delivery, initial management was done by setting up of intravenous line with wide bore cannula and blood samples were taken for investigation as well as for cross-matching. Blood bank was intimated and arrangement for adequate blood was made, relatives of patient were counseled about the seriousness of the condition. The patient was shifted immediately to Operation theatre for emergency cesarean section. Under all aseptic precautions the abdomen was opened by transverse incision and uterus by lower segment transverse incision.
Multiple large torturous vessels were present on the anterior surface of uterus. Placenta was anterior covering the os. Baby was extracted out as breech by access through the placenta. Baby cried immediately and cord was clamped and cut. When an atte mpt was made to remove the placenta there was profuse bleeding from the lower segment as the placenta was firmly adherent to anterior lower s egment at the site of previous scar. Large bleeding vessels could be seen and within few minutes of extraction of t he baby the patient went into cardiac arrest. The woman was immediately intubated and Cardio-pulmonary resuscitation done by anesthetist, ionotropic drugs were started. Blood transfusion was started and further transfusions arranged. Taking into consideration the excessive blood loss and adherent placenta decision was taken to do peripartum hysterectomy. Consent was taken from relatives after explaining the situation in local language.
Total hysterectomy with careful bladder dissection was done as the placenta was attached to lower segment and blood was pooling continuously. After clamping, cutting and ligating of uterine arteries bleeding was significantly controlled. Care was taken to do complete hysterectomy however there was bleeding from vault and from vessels coursing over the superior surface of bladder inpsite of taking hemostatic sutures. Thus finally decision of bilateral internal iliac artery ligation was taken and with all precautions internal iliac artery ligation was done after which bleeding got controlled. The effect could be seen in the form of steadily stabilizing blood pressure. Additionally blood loss was replaced by whole blood which also contributed to stabilizing the woman.
After assuring hemostasis the abdomen was closed in layers. The estimated total blood loss at that time was around 2.5 -3.0 L. Postoperatively she relieved 3 more blood transfusions making a total of 10 units of blood. Dopamine drip of patient was tap ered done with Abstract Placenta accreta is an uncommon but a potentially life-threatening obstetric condition that requires a multidisciplinary approach to management. The incidence of placenta accreta has increased and seems to parallel the increasing cesarean delivery rate. We present a case of term pregnancy with placenta praevia and placenta accreta referred to a rural tertiary institute of central India in emergency hours with profuse bleeding per-vaginum. This case report is an example of a true near miss as the patient went into cardiac arrest at the time of caesarean section, but could be revived by sustained effort with timely resuscitation, caesarean hysterectomy and internal i liac artery ligation. It is an example of team effort by Obstetricians and Anesthetists to save a maternal life. Keywords: Caesarean section, Hysterectomy, Maternal Near miss, Placenta accreta IJBAR (2014) 05 (08) www.ssjournals.com continuous monitoring of vital and intensive care in high dependency unit. The histopathology report of the uterine specimen came out to be placenta accreta with chorionic villi invading the myometrium. With good care, postoperative course was uneventful, and the patient was discharged on 10 th day with good maternal and neonatal condition. The woman had no residual disorders. This was a case of true maternal near miss for the patient as she went into cardiac arrest intraoperatively but could be saved by team of obstetricians and anesthetists and adequate care in intensive care unit.

Discussion
Placenta accreta is a general term used to describe the clinical condition when part of the placenta, or the entire placenta, invades and is inseparable from the uterine wall 3 . When the chorionic villi invade only the myometrium, the term placenta increta is appropriate; whereas placenta percreta describes invasion through the myometrium and serosa, and occasionally into adjacent organs, such as the bladder. Researchers have reported the incidence of placenta accreta as 1 in 533 pregnancies for the period of 1982-2002 4 .
Clinically, placenta accreta becomes problematic during delivery when the placenta does not completely separate from the uterus and is followed by massive obstetric hemorrhage. The average blood loss at delivery is 3,000-5,000 mL 5 . As many as 90% of patients with placenta accreta require blood transfusion, and 40% require more than 10 units of packed red blood cells. Maternal mortality has been reported to be as high as 7% 6 . Maternal death may occur despite optimal planning, transfusion management, and surgical care. In a study described by Shellhas, from a cohort of 39,244 women who underwent cesarean delivery, researchers identified 186 who had a cesarean hysterectomy. The mos t common indication was placenta accreta (38%) 7 .
Women at greatest risk of placenta accreta are those who have myometrial damage caused by a previous cesarean delivery with either anterior or posterior placenta praevia overlying the uterine scar. The authors of one study found that in the presence of a placenta praevia, the risk of placenta accreta was 3%, 11%, 40%, 61%, and 67% for the first, second, third, fourth, and fifth or greater repeat cesarean deliveries, respectively 8 . Placenta praevia without previous uterine surgery is associated with a 1-5% risk of placenta accreta. Besides advanced maternal age and multiparty, reported risk factors include any condition resulting in myometrial tissue damage followed by a secondary collagen repair, such as previous myomectomy, endometrial defects due to vigorous curettage resulting in Asherman syndrome 9 , submucous leiomyomas, thermal ablation 10 , and uterine artery embolization 11 .
The diagnosis is usually established by ultrasonography and occasionally supplemented by magnetic resonance imaging (MRI). Transvaginal and transabdominal ultrasonography are complementary diagnostic techniques and should be used as needed. Transvaginal ultrasound is safe for patients with placenta previa and allows a more complete examination of the lower uterine segment. A normal placental attachment site is characterized by a hypoechoic boundary between the placenta and the bladder. The ultrasonographic features suggestive of placenta accreta include irregularly shaped placental lacunae (vascular spaces) within the placenta, thinning of the myometri um overlying the placenta, loss of the retroplacental "clear space," protrusion of the placenta into the bladder, increased vascularity of the uterine serosa-bladder interface, and turbulent blood flow through the lacunae on Doppler ultrasonography 12,13 . The presence and increasing number of lacunae within the placenta at 15-20 weeks of gestation have been shown to be the most predictive ultrasonographic signs of placenta accreta, with a sensitivity of 79% and a positive predictive value of 92% 14 . These lacunae may result in the placenta having a "moth-eaten" or "Swiss cheese" appearance. Overall, grayscale ultrasonography is sufficient to diagnose placenta accreta, with a sensitivity of 77-87%, specificity of 96-98%, a positive predictive value of 65-93%, and a negative predictive value of 98 (13,14). The use of power Doppler, color Doppler, or three-dimensional imaging does not significantly improve the diagnostic sensitivity compared with that achieved by grayscale ultrasonography al one 15 . Magnetic resonance imaging can also be used, but is more costly than ultrasonography and requires both experience and expertise in the evaluation of abnormal placental invasion.
Management consists of a multidisciplinary approach. If diagnosed in antenatal period the delivery planning should involve an anesthesiologist, obstetrician, pelvic surgeon such as a gynecologic oncologist, intensivist, maternal -fetal medicine specialist, neonatologist, urologist, hematologist, and interventional radiologist to optimize the patient's outco me 16 . To enhance patient safety, it is important that the delivery be performed by an experienced obstetric team. Because of the risk of massive blood loss, attention should be paid to maternal hemoglobin levels in advance of surgery, if possible 17 . The timing of delivery in cases of suspected placenta accreta must be individualized. This decision should be made jointly with the patient, obstetrician, and neonatologist. Patient counseling should include discussi on of the potential need for hysterectomy, the risks of profuse hemorrhage, and possible maternal death. A guiding principle in management is to achieve a planned delivery because data suggest greater blood loss and complications in emergent cesarean hysterectomy versus planned cesarean hysterectomy 18 . Although a planned delivery is the goal, a contingency plan for emergency delivery should be developed for each patient.
Preoperatively, the blood bank should be placed on alert for a potential massive hemorrhage. Current recommendations for bloo d replacement suggest a 1:1 ratio of packed cells to fresh frozen plasma. Additional units of blood and coagulation factors should b e infused quickly and as necessitated by the patient's vital signs and hemodynamic stability.
Generally, the recommended management of suspected placenta accreta is planned term cesarean hysterectomy with the placenta left in situ because removal of the placenta is associated with significant hemorrhagic morbidity. Occasionally, a subtotal hyster ectomy can be safely performed, but persistent bleeding from the cervix may preclude this approach and make total hysterectomy necessary. However, this approach IJBAR (2014) 05 (08) www.ssjournals.com might not be considered first-line treatment for women who have a strong desire for future fertility. Therefore, surgical management of placenta accreta may be individualized.
Various studies have shown that bilateral internal iliac artery ligation is also an effective method of controlling bleeding in patients with placenta accreta, especially in those who are young and want to retain their reproductive functions 19 .
Despite the early and accurate prenatal diagnosis, hysterectomy remains the most common surgical procedure in cases of PPH fo r placenta praevia accreta 20 . Nowadays, conservative interventions are recommended before radical procedure in order to minimize surgical complications and preserve fertility. The conservative options for PPH included uterotonics drugs, external compression with uterine sutures (B-Lynch, Hayman, Cho), intrauterine packing (Bakri balloon), and selective devascularization by ligation or embolization of the uterine artery 21 . However in placenta accreta per se many of these options may not work except for embolisation which has a great advantage in saving lives but requires a proper setup.

Conclusion
Placenta accreta is an uncommon but potentially lethal complication of pregnancy requiring intensive management. Although hysterectomy traditionally has been the definitive treatment for placenta accreta, clinicians should consider conservative ma nagement like bilateral internal iliac artery ligation for patients who wish to preserve fertility. Adequate transfusion facilities; sensitive ultrasound examination and rapidly responding, highly skilled surgical and anesthesia teams should be available nonetheless. In the present case multidisciplinary team approach and prompt surgical management saved the life of a woman.