Placenta percreta in a healthy uterus of a primiparous woman, a case report

Technical Summary: Placenta Percreta in a Healthy Uterus of a Primiparous Woman

Problem Statement
Placenta percreta, the most severe manifestation of the Placenta Accreta Spectrum (PAS), is characterized by chorionic villi penetrating the myometrium and invading adjacent organs such as the bladder. While this condition is a leading cause of maternal hysterectomy and severe hemorrhage, it is strongly associated with specific risk factors, including prior uterine surgery, previous cesarean sections, and advanced maternal age. The clinical challenge addressed in this report is the occurrence of placenta percreta in a primiparous woman with a healthy uterus and no history of surgical intervention. Such cases are extremely rare and often lead to diagnostic oversight due to the absence of classic risk factors, potentially resulting in delayed intervention and catastrophic maternal outcomes.

Methodology
This study follows the CARE (CAse REport) guidelines and presents a single-case report of a 26-year-old primiparous woman of Persian ethnicity. The patient presented at 37 weeks of gestation with labor pains and vaginal spotting.

• Diagnostic Approach: An antenatal ultrasound at 36 weeks identified complete placenta previa with features suggestive of placental adhesions, despite the patient's lack of surgical history. A multidisciplinary team (including oncology, perinatology, urology, and anesthesia) was assembled prior to intervention.
• Intervention: Due to the high risk of hemorrhage, a vaginal examination was avoided. The patient underwent an immediate emergency cesarean section via a classical uterine incision.
• Surgical Management: Intraoperative findings confirmed extensive placental invasion into the uterine serosa and the external surface of the bladder. Attempts to manually separate the placenta were abandoned due to the risk of life-threatening hemorrhage. Consequently, a salvage hysterectomy was performed, which included the resection of the upper third of the vagina and a segment of the bladder, followed by bladder repair.

Key Results

• Clinical Outcome: The procedure resulted in the delivery of a live female infant (2,990 g) with an Apgar score of 9/10.
• Maternal Recovery: The patient required blood product support (two packs of fresh frozen plasma and two units of packed cells) but recovered without complications. She was discharged on the third postoperative day with her infant.
• Intraoperative Findings: The surgery confirmed the diagnosis of placenta percreta with direct invasion of the bladder, necessitating partial organ resection.

Key Contributions

1. Documentation of Rare Etiology: This report provides evidence that placenta percreta can occur in the absence of traditional risk factors (such as prior cesarean sections or uterine curettage) in a primiparous woman with a healthy uterus.
2. Diagnostic Emphasis: The case underscores the critical importance of high clinical suspicion during prenatal ultrasound, particularly when placenta previa is detected. The authors highlight specific sonographic markers (e.g., loss of the zona lucida, placental lacunae, myometrial thinning) that should be scrutinized even in low-risk populations.
3. Management Strategy: The report demonstrates that the successful outcome was contingent upon timely diagnosis and the rapid coordination of a multidisciplinary team. The authors contrast their successful management with other reported cases where delayed intervention led to maternal and fetal mortality.

Significance and Claims
The authors claim that this case highlights a critical gap in clinical vigilance: the tendency to overlook PAS in patients lacking classic risk factors. The paper asserts that:

• Early Detection is Vital: Maintaining a high index of suspicion during the second-trimester ultrasound (ideally at 18 weeks) is essential for timely diagnosis, even in primigravidas.
• Team-Based Care is Determinative: The successful preservation of maternal and fetal life in this complex case was directly attributed to the "time" and "skilled and experienced team" approach, contrasting with outcomes in similar cases where such resources were unavailable or delayed.
• Surgical Necessity: In cases of confirmed placenta percreta with massive bleeding and organ invasion, hysterectomy remains the primary salvage option, though conservative management may be considered in stable patients within well-equipped facilities.

The study concludes that while rare, the occurrence of PAS in healthy, primiparous uteri necessitates a shift in diagnostic protocols to ensure early identification and appropriate, multidisciplinary intervention.