Birth with abnormal placenta invasion: placenta accreta spectrum

Abstract

Childbirth by caesarean section has led to an increase in the number of women of reproductive age with an operated uterus. The frequency of placental invasion abnormalities in patients who underwent 1, 2, 3, 4 and 5 operations is 3%, 11%, 40%, 61%, 67%, respectively [1,2].

The aim - on the basis of the presented clinical case, demonstrate the approach in diagnosis, the use of endovascular blood-saving technologies and the involvement of a multidisciplinary team of doctors in the delivery of a pregnant woman with abnormal invasion of the placenta.

Clinical case. A woman with a diagnosis of Pregnancy III - 29 weeks + 4 days. A scar on the uterus after two previous cesarean sections. Complete placenta previa with abnormal invasion of the placenta (PAS II). Expected third birth. MRI of the pelvic organs: state after 2 caesarean sections with corresponding changes in the uterine wall in the form of significant thinning, with signs of partial ingrowth of the placenta tissue. Complete placenta previa with the cervical os overlapping. Planned caesarean section at 36 weeks 1 day. Stenting of the ureters, installation of an aortic occlusion balloon was performed. After that, a corporal caesarean section was performed. A girl was born weighing 2740 g with a height of 49 cm and an Apgar score of 8/9. A ligature was placed on the umbilical cord, and the placenta was left in place, the uterus was sewn up. After balloon occlusion of the aorta and inflation of the balloon, the separation of placentation defect in the lower segment of the uterus of 7x10 cm was started. Metroplasty of the lower segment of the uterus was performed. Anesthetic support - peripheral vascular access G16, epidural anesthesia. The transfusiologist was responsible for the blood preparations that were prepared in advance, the operation of the autohemotransfusion machine, the operation of the thromboelastograph, and periodic blood sampling for research. Monitoring showed stable indicators of hemodynamics with fluctuations relative to the initial data within 20%. Laboratory studies: Hb (g/l) - 116 → 90 → 64 → 91; Red blood cells ×10¹² - 3.59 → 2.73 → 1.88 → 2.92; Fibrinogen (g/l) - 6.38 → 5.7 → 3.55. Infusion of crystalloids - 3000 ml; colloids (gelatin) - 500 ml; autoerythrocytes – 615 ml (HCT=60); donor erythrocytes - 2 units (687 ml); fresh frozen plasma - 3 units (750 ml); albumin 25% - 200 ml; tranexamic acid was additionally administered - 1500 mg. Postoperative period without special features.

Conclusions. Careful preparation of the material and technical base, the involvement of a multidisciplinary team and the use of endovascular blood-saving technologies during operative delivery are the key to the successful performance of organ-saving operations. In this clinical case, despite the presence of a variant of placental ingrowth that is difficult to diagnose and surgically treat, it was possible to perform an organ-preserving operation.

The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies.

No conflict of interests was declared by the authors.