Unusual presentation of placenta percreta with bladder involvement at 20 weeks: a case report

Abstract

Introduction and importance: Placenta percreta is a rare and severe form of placenta accreta spectrum (PAS), where the placenta invades beyond the myometrium, often involving adjacent structures such as the urinary bladder. The incidence of PAS is increasing, especially in countries with high cesarean section rates, and poses significant maternal risks, including life-threatening hemorrhage.

Case presentation: A 27-year-old gravida 6, para five patient at 20 weeks gestation presented with hematuria, oliguria, and overflow incontinence. Her medical history included three previous cesarean sections. Ultrasound and cystoscopy confirmed bladder invasion by the placenta, consistent with placenta percreta. A multidisciplinary team decided on a cesarean hysterectomy with partial cystectomy due to significant bleeding.

Clinical discussion: The management of placenta percreta with bladder involvement requires early diagnosis, careful planning, and timely intervention. This case highlights the importance of a multidisciplinary approach, with cesarean hysterectomy being the primary intervention. Preoperative strategies such as internal iliac artery occlusion can reduce blood loss and improve maternal outcomes. Bilateral internal iliac artery ligation was performed due to uncontrolled hemorrhage.

Conclusion: This case underscores the critical role of early detection and multidisciplinary management in optimizing outcomes for patients with placenta percreta, particularly those with bladder involvement. The increasing incidence of PAS necessitates awareness and preparedness to manage such high-risk pregnancies in clinical settings like Pakistan.

Keywords: bladder; hemorrhage; obstetric; placenta accreta; placenta percreta; pregnancy complications.

Figure 1.

Ultrasound image at 19 weeks gestation with (black arrow) indicating the anterior lower-segment placenta completely covering the cervix and a hematoma (black arrow) in the lower pelvis, likely encroaching the bladder lumen.

Figure 2.

(A) Gross specimen of the uterus post-hysterectomy. (B) Histopathological examination showing myometrial invasion by placental villi and bladder wall involvement by villi and intermediate trophoblasts (H&E staining, magnification ×10).