Description

Placenta accreta spectrum (PAS) disorders is the abnormal invasion of the placenta to the myometrium.1 One of the risk factors of PAS is a previous caesarean section.2 Only few studies described caesarean hysterectomy in patients with PAS with images. We report a case of a caesarean hysterectomy in a 37-year-old pregnant woman previously diagnosed with PAS who visited the outpatient clinic at 31 weeks of gestation. The patient had undergone two previous caesarean sections. Ultrasonography showed total placenta previa with a high suspicion of PAS. She had no history of bleeding during prenatal care. When the patient reached term, she underwent a caesarean section with a hysterectomy. A midline incision was made for broader access. The lower segment of the uterus presented an atypical vascular pattern representing PAS (figure 1). A classical uterine incision was made to avoid the area, which presented an atypical vascular pattern. After the baby was delivered, the placenta was left in situ as the separation of the placenta from the uterus could have induced bleeding; this is the preferred management for PAS.2 Thus, caesarean hysterectomy was planned for this patient, and written informed consent was obtained prior to the surgical procedure.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

A midline incision of the skin was performed, The lower segment of the uterus presented an atypical vascular pattern.

Before continuing with hysterectomy, the uterine wall was closed to minimise bleeding (figure 2). Thereafter, hysterectomy was performed and the specimen (figure 3) was sent to the pathology laboratory. Pathological examination of the uterus confirmed the diagnosis of PAS and showed that the placenta penetrated into the myometrium but not into the serosa of the uterus. The operative time was 70 min with a blood loss of 2000 mL, and the patient’s postoperative haemoglobin level was 8.8 g/dL (preoperative haemoglobin level: 11.5 g/dL). The patient did not require a blood transfusion, and she was discharged in good condition 4 days postoperatively. The patient’s newborn was healthy.

• Download figure
• Open in new tab
• Download powerpoint

Figure 2

After the baby was delivered, the placenta was left in situ and uterine wall closure was performed before hysterectomy.

• Download figure
• Open in new tab
• Download powerpoint

Figure 3

The uterus was sent for pathological examination, which confirmed the diagnosis of placenta accreta spectrum disorders.

The atypical vascular pattern of the uterus representing PAS is important for clinicians to have knowledge about, especially when handling referral patients, because the antenatal care history of the patients is unknown. This situation may occur in developing countries where an integrated national medical record is not established. If clinicians from a small hospital observe an atypical vascular pattern in the lower segment of the uterus during a caesarean section, the abdomen should be closed, and the patient should be referred to a tertiary hospital if the delivery of the baby can be postponed.