Hysterectomy with Fetus In Situ for Uterine Rupture at 21-Week Gestation due to a Morbidly Adherent Placenta

Abstract

Background: Uterine rupture due to a morbidly adherent placenta is a rare obstetrical cause of acute abdominal pain in the pregnant patient. We present a case to add to the small body of published literature describing this diagnosis.

Case: A 32-year-old G5T2P1A1L2 with multiple prior cesarean sections presented at 21⁺³ weeks' gestation with abdominal pain and presyncope. Ultrasound showed a large volume of complex intraabdominal free fluid and a heterogenous placenta with irregular lacunae and increased vascularity extending to the posterior bladder wall. Exploratory laparotomy identified a uterine defect and a hysterectomy was performed due to significant bleeding. Pathology confirmed a diagnosis of placenta percreta.

Conclusion: Early recognition and management of uterine rupture due to a morbidly adherent placenta are essential to prevent catastrophic hemorrhage.

Figure 1

Doppler ultrasound in the sagittal plane at midline in the pelvis demonstrates turbulent peripheral vascularity in the placenta extending across the myometrium to the posterior wall of the bladder. The bladder contour is otherwise smooth; however, the finding remains highly suggestive of placenta percreta. No defect in the uterine wall could be identified, but given the large volume of hemorrhagic ascites, an emergency diagnostic laparoscopy was subsequently performed.

Figure 2

Intact hysterectomy specimen. Anterior wall demonstrates softened tumescence, with patchy hemorrhagic and congested appearance.