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Placenta Percreta

Mrs. XYZ, G4P2L1A1 with 8 months of pregnancy with Placenta Percreta was admitted under Dr Ritu Joshi (Sr. Consultant OBGYN) in La Femme on 1/05/2017 for elective LSCS. Placenta Percreta is a rare condition with high mortality and morbidity for mother and fetus. Its incidence varies from 1:3333 pregnancies to 1:14, 00,000.

The USG of patient showed a single live pregnancy of 33 weeks with a single loop of umbilical cord around the neck and mild polyhydroamnios. The myometrium in lower segment was not appreciable and placental tissue appears to be adherent with serosa and normal blood flow pattern. As she was anemic with the haemoglobin 9.6, two units of PRBC were arranged. Consultation with Urologist done and decided that prior to surgery, a cystoscopy will be done. An oncosurgeon was also requested to be present at the time of surgery in view if internal iliac ligation is required. Femoral catheterization not done. A team of different specialty consultants’ including senior obstetrician Dr. Adarsh Bhargava, Anaesthetist, Urologist, Transfusion consultant, Onco-surgeon and Neonatologist was formed and after internal meeting, a classical caesarean section was decided. In the OT, a cystoscopy was performed and massive congestion was seen in anterior wall of bladder, rest all was normal. Classic caesarean was performed giving midline vertical incision and the uterus was opened by vertical incision in the upper segment. An alive male child was extracted out on 01-05-2017 weighing 2.4 kgs. We waited for the placenta to separate on its own. Upper part of the placenta separated while the lower part was removed manually as much as possible taking care of bladder mucosa. Simultaneously the urologist did cystoscopy in between and guided us.  Injection prostodin was given intrauterine as well as intra muscular. The vertical incision sutured using vicryl no. 1. As the uterus remained contracted and was closed in layers and intra-operatively two units of blood was transfused. Post operation patient was given 4 units of blood.

During the post op period, patient developed fever with chills. She was then fully investigated and treated accordingly. She also had secondary PPH twice and was transfused 2 units of blood. Her serum beta HCG repeated on alternate days in view of remaining placental pieces. The beta HCG levels showed downward trend. Patient was discharged on VII day asymptomatic. On discharge, beta HCG was 35. On Post op discharge day 15th, her beta HCG level was 0.3.

During her post-operative period at home, patient still has bleeding and her sonography which showed only blood clots in fundal part of uterus. Patient was given injection Depo-Provera 150 mg on 10-06-2017. The baby was diagnosed to have mild VSD (Ventricular septal defect) and at present, the baby does not require any treatment.

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