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Cesarean section by transfundal approach for placenta previa percreta attached to anterior uterine wall in a woman with a previous repeat cesarean section: case report

2004; Informa; Volume: 83; Issue: 1 Linguagem: Inglês

10.1080/j.1600-0412.2004.0033d.x

1600-0412

Masaki Ogawa, Akira Sato, Kazuhito Yasuda, Dai Shimizu, Naoko Hosoya, Toshinobu Tanaka,

Ectopic Pregnancy Diagnosis and Management

We report a case of cesarean section by transfundal vertical incision for placenta previa percreta attached to the anterior uterine wall in a woman with previous repeated cesarean delivery. This approach is useful procedure in such cases. We discuss the effectiveness of cesarean section and transfundal vertical incision. A 33-year-old pregnant Japanese woman with placenta previa was referred to our hospital for perinatal management. She was 28 weeks into her 7th pregnancy, having had four spontaneous miscarriages at 26, 27, 27, and 30 years of age and two cesarean sections at age 28 and 32 years. Both cesarean sections were performed because of cephalopelvic disproportion, and with a low transverse uterine incision. There were no remarkable findings in her familial or past medical history. Ultrasound examination revealed a placenta previa attached to the anterior uterine wall. However, she experienced no worrisome bleeding during the present pregnancy. Precise abdominal and vaginal ultrasonography revealed loss of the normal hypoechoic retroplacental myometrial zone and disruption of the hyperechoic uterine serosa (Fig. 1). Magnetic resonance imaging (MRI) revealed placental previa attachment only to the anterior uterine wall. The maternal serum alpha-fetoprotein level was not increased. Microscopic hematuria was not detected. She was diagnosed provisionally as having placental previa with anterior uterine wall attachment, and, presumably, placenta accreta. After sufficiently informing the patient and her family, we decided that an abdominal total hysterectomy should be performed immediately after the cesarean section. Cesarean section was performed at 37 weeks and 1 day of gestation. Skin incision was performed by low-abdominal vertical median approach extended to a supraumbilicus. Uterine incision was performed by transfundal vertical incision to avoid the transplacental approach. She was delivered of a healthy boy weighing 2964 g with breech extraction for vertex presentation. Apgar score was 8 and 9 at 1 and 5 min, respectively. After delivery, the umbilical cord was clamped and returned to the uterine cavity, and the uterine wall was sutured. Blood loss up to the cesarean section was 300 g. The newborn suffered no hypovolemic shock. Total hysterectomy was then performed. The visceral peritoneum overlying the uterus was undermined and incised laterally just above the bladder. A bladder flap was created by the surgeon's finger. After the manipulation, placental tissue was observed sporadically in the uterine myometrial layer. This finding confirmed placental percreta. Massive bleeding from the placenta percreta continued until resection of her uterus. Total blood loss during the operation was 3746 g, including amniotic fluid. The dissected uterus and placenta were submitted to the pathology department. Histopathological diagnosis was placenta previa percreta. Sonographic findings reveal loss of hypoechoic zone between placenta (PL) and uterine wall, suggestive of placenta accreta. Cesarean section is a useful procedure for the welfare of the fetus, e.g. when fetal status is uncertain; however, this operation can harm the mother, sometimes resulting in subsequent uterine rupture and placenta accreta. In cases of total placenta previa, obstetricians will perform cesarean delivery without exception. They sometimes encounter heavy bleeding during the operation in women with placenta previa located directly beneath the uterine incision. A vertical uterine incision is recommended in these circumstances. In case usual cesarean section with low transverse uterine incision is adopted for placenta previa, each of surgical manipulations must be performed as quickly as possible. However, massive hemorrhage is apt to occur, which may cause the baby subsequent hypovolemic shock. Higher incidence of complications with placenta accrete, increta, and percreta has been reported in patients with placenta previa with previous cesarean section, as compared with those without a previous cesarean section (1). We report a case of placenta previa percreta with anterior uterine wall attachment. In our case, the only way to avoid transplacental incision was to operate on the uterine fundus vertically. This approach was not required to develop the bladder flap. Therefore, cesarean section is performed without adhesiolysis, even in cases with severe adhesions resulting from a previous repeat cesarean section. Low transverse uterine incision should not be performed in cases like ours because this approach will result in massive bleeding before delivery of the fetus. We believe the transfundal approach is a very useful procedure for women with placenta previa percreta. Houston et al. reported the usefulness of the fundal incision on obese pregnant women and concluded that it is safe (2). However, the effect of fundal incision on subsequent pregnancies still remains to be resolved. A large randomized trial is needed to clarify this question. Masaki Ogawa Department of Obstetrics and Gynecology Akita University School of Medicine Hondo 1-1-1 Akita 010–8543 Japan e-mail: ogawam@obgyn.med.akita-u.ac.jp