ISSN: 2320-5407 Int. J. Adv. Res.

13(02), 717-721

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/20426
DOI URL: http://dx.doi.org/10.21474/IJAR01/20426

RESEARCH ARTICLE
DIAGNOSIS AND MANAGEMENT OF A CASE OF PLACENTA PERCRETA IN THE FIRST
TRIMESTER OF PREGNANCY: A CASE REPORT

A. Lahkim Bennani1,2, S. Errarhay1,2, K. Laaouini1,2, M. Bendahhou Idrissi1,2, N. Mamouni1,2, C. Bouchikhi1,2

and A. Banani1,2
1. Sidi Mohammed Ben Abdellah University Faculty of Medicine and Pharmacy of Fes.
2. Gynecology and Obstetrics Department 1, University Hospital Hassan II, Fes, Morocco.
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Manuscript Info Abstract
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Manuscript History The continuous increase of Cesarean Deliveries is causing a parallel
Received: 14 December 2024 increase in cesarian scar pregnancy and its complications especially
Final Accepted: 17 January 2025 placenta accreta spectrum disorders.Placenta percretais rarely
Published: February 2025 diagnosed in the first trimester, and leads often to hysterectomy.In this
case report, we report the case of an arab woman of 30-years-old with a
Key words:-
Placenta Accreta Spectrum, Placenta surgical history of two cesarean sections.A placenta percreta was
Percreta, C-Scar Pregnancy, C-Section, discovered following minor vaginal spotting after two months of
Fertility amenorrhea.We present the imaging methods used for the diagnosis of
placenta percreta in the first trimester of pregnancy, as well as the
radiological aspect in ultrasound examination, especiallygeographic
placental lacunae with poorly defined edges, turbulent flow on color
Doppler, interruption of the line between the myometrium and the
bladder.We also present our therapeutic strategy which consisted of
delivery of the placenta associated with hypogastric arteries ligature
and the adjunction of an intra-muscular injection of Methotrexate.This
therapeutic strategy made it possible to preserve subsequent fertility.
Copyright, IJAR, 2025,. All rights reserved.
……………………………………………………………………………………………………....
Introduction:-
The global rise in cesarean deliveries has led to a concurrent increase in complications associated with cesarean
scars, particularly cesarean scar pregnancies (CSP) and placenta accreta spectrum (PAS) disorders. These conditions
pose significant challenges to maternal health, particularly placenta percreta, which is the most severe form of PAS
and involves the invasion of placental tissue through the myometrium, sometimes reaching adjacent organs like the
bladder.

The early identification of placenta accreta spectrum disorders is crucial for enabling conservative treatment and
preserving fertility. The treatment strategy should prioritize a conservative approach. In this case, we will explore
how the management was carried out to both treat the patient and preserve fertility.

Presentation Of The Case:

We present the case of an arab woman of 30-years-old, G3P2, that underwent two previous C-sections interventions.

She presented to gynecological emergency department with minor vaginal spotting, after two months of amenorrhea.

Corresponding Author:- A. Lahkim Bennani

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Address:- Sidi Mohammed Ben Abdellah University Faculty of Medicine and
Pharmacy of Fes.
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The clinical examination revealed a patient stable hemodynamically, with no clinical signs of anemia. The
gynecological examination found minimal dark bleeding originating from the endocervix.

An ultrasound scan demonstrating a live caesarean scar ectopic pregnancy at 11 weeks of gestation, with a placenta
that invades the myometrium and the posterior wall of the bladder. The US examination showed the presence of
geographic placental lacunae with poorly defined edges, without a hyperechoic halo, showing turbulent flow on
color Doppler. This is associated with an interruption of the line between the myometrium and the bladder, and
disappearance of the hypoechoic separation layer, with bulging of the placenta into the bladder.

Figure 1:- US examination showing the aspect of the placenta and the invasion of the posterior wall.

Figure 2:- US examination showing of turbulent flow in the color Doppler.

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An MRI has been made, and had confirmed the diagnosis.

A biological workup showed a hemoglobin level of 11 g/dL and normal coagulation tests.

The therapeutic strategy was as follows: hospitalization, reservation of packed red blood cells, and pre-anesthesia
consultation. The patient was then admitted to the operating room.

A laparotomy was performed, and upon exploration, a gravid uterus was found. There was placental invasion into
the myometrium and the bladder serosa over 2 cm. The upper edge of the placenta was identified, followed by a
hysterotomy and evacuation of the pregnancy, with removal of all visible placental tissue. No bladder dissection or
bladder opening was performed. Hysterorrhaphy was carried out. Then bilateral hypogastric artery ligation in
association with a B-Lynch uterine plicature have been made. Hemostasis was achieved.

Total bleeding was estimaeted at 900 ml. A transfusion with a unit of packed red blood cells was performed. Given
the presence of bladder invasion, the therapeutic strategy was supplemented with medical treatment using
Methotrexate, followed by weekly monitoring of BHCG levels. This approach allowed for the preservation of the
uterus, minimized urological complications, and maintained future fertility.

Figure3:- Removal of placental tissue.

Discussion:-
A cesarean section pregnancy describes a gestation sac developing inside the scar area of a prior low-segment
cesarean delivery1.

Cesarean scar pregnancies are at high risk of pregnancy complications such as placenta accreta spectrum.

The vascular changes in the utero-placental circulation in cesarian scar pregnancies are due to the loss of the normal
uterine structure in the scar area and the development of placental tissue in proximity of large diameter arteries of
the outer uterine wall. The intensity of these vascular changes, development of placenta accreta spectrum and risk of
uterine rupture depend on the remaining myometrial thickness of the cesarean scar defect at the start of pregnancy 3.

The incidence of placenta previa accreta increase with the number of previous C-sections. It is 4.1% in women with
1 prior cesarean and 13.3% in women with more than two previous cesarean deliveries 4.

The sensitivity and specificity of ultrasound imaging in diagnosing placenta previa accreta in women with a prior
cesarean delivery, presenting with anterior low placenta or placenta previa, are >95% when performed by skilled
operators4.

However, according to a systematic review, placenta accreta spectrum disorders in the first trimester of pregnancy
are rarely diagnosed through imaging techniques and lead to hysterectomy in most cases. According to this

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systematic review, placenta accreta spectrum disorders were defined through imaging techniques in21.15% of the
cases while surgical findings unveiled them in 28.84% of the cases1.

Imaging finding regroups placental lacunae, lacunae swirling in color doppler, presence of an abnormal
uteroplacental interface. In fact, in a study, placental lacunae were present in 85.7% cases versus 15.2% controls.
The number of lacunae was significantly higher in cases compared with controls, with a median of five lacunae. The
median size of the lacunae was also significantly larger in cases compared with controls. Lacunae swirling on
grayscale or color Doppler ultrasound was noted only in placenta accreta spectrum cases. Presence of an abnormal
uteroplacental interface was also observed only in PAS cases8.

Overall, according to the results of recent meta-analyses 9,10 the average sensitivity and specificity of obstetric
ultrasonography for the identification of different placental invasion depths were approximately 90 % and 95 %,
respectively. As for MRI, these numbers were reported to be about 93 % and 94 %. In other words, MRI and
ultrasound may have comparable accuracy for the prenatal diagnosis of PAS

A systematic review has been made about outcomes and management of cesarean Scar Pregnancy. 20,1% of patients
had a miscarriage and 8,3% suffered fetal death. 25,8% had a term delivery and 41,8% patients had a preterm birth.
In 102 (52,6%) patients, a hysterectomy was performed7.

Treatment can be conservative or nonconservative. The most used procedure in the nonconservative management of
PAS is hysterectomy. Conservative management may be considered among those women with fertility need.

In our case, we combined hysterotomy, extirpation of the visible placenta and bilateral hypogastric arteries ligature,
B-Lynch uterine plicature, followed by a Methotrexate injection. This allowed us to do a conservative management,
and preserve later fertility.

Conclusion:-
The incidence of cesarean scar pregnancy and its complications, such as placenta accreta spectrum disorders, is
clearly increasing due to the rising rates of cesarean sections. Consequently, early diagnosis via ultrasound
examination is crucial to anticipate multidisciplinary management.

Delivery of the placenta, combined with hypogastric artery ligation, is advantageous as it reduces intraoperative and
postoperative bleeding, allowing preservation of the uterus. Finally, the administration of Methotrexate with regular
monitoring of β-hCG levels until they become negative is essential.

Declarations:
Acknowledgements:-
We feel grateful to the doctors and staff who have been involved in this work.

Funding:
This research received no external funding.

Institutional Review Board Statement

Not applicable.

Ethical Approval and Consent to participate:

Not applicable.

Consent for publication:

Written informed consent has been obtained from the patient to publish this paper

Data Availability Statement:

Data are available from the corresponding author upon a reasonable request.

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Competing interests:
The authors declare that they have no competing interests

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