Placenta Percreta Involving Urinary Bladder

The incidence of placenta accreta is estimated from one in 540 to one in 93,000 deliveries (Smith and Ferrara 1992). Placenta percreta is a variant of placenta accreta in which chorionic villi penetrate the entire thickness of the myometrium and may involve adjacent structures. Placenta percreta involving the bladder is extremely rare (less than 60 published cases) (Washecka and Behling 2002) and is encouraged by uterine scars and cesarean section.

This potentially catastrophic condition may remain undiagnosed or underappreciated until delivery (Leap-hart et al. 1997) and diagnosis is often made only at the time of operation in a life-threatening bleeding. In 31 % of cases, hematuria is present during pregnancy and a preoperative diagnosis established by ultrasound (presence of multiple linear irregular vascular spaces within the placenta) (Comstock et al. 2004) or MRI (Washecka and Behling 2002).

Cystoscopy is not always useful. If placenta percreta is suspected, transurethral biopsy should be avoided because of severe hemorrhage (Teo et al. 1996). The goal of the surgical treatment must be to control bleeding, which usually requires hysterectomy, resection of all tissue involved by the infiltrating placenta, and eventually partial cystectomy or ureteral reimplantation (Price et al. 1991). The tissue planes are often very much indurated and extremely difficult to dissect. Teo et al. (1996) and Bakri et al. (1993) prefer to leave the invasive portion in situ associated, if necessary, with bilateral hypogastric arterial ligation and pressure packing. Methotrexate adjuvant therapy may be helpful in expediting absorption of the remaining placental tissue.

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