Placenta Percreta Invading the Urinary Bladder

EDITORIAL COMMENT: Placenta praevia percreta is the most fearsome surgical complication of pregnancy. The incidence is steadily increasing as Caesarean section rates escalate, since in the majority of cases the patient has had a previous lower segment Caesarean section. This case report was accepted for publication to indicate to readers that elective cystostomy can facilitate hysterectomy in these cases. Successive triennial reports of maternal mortality in Australia have made the point that in cases of placenta praevia accreta the decision to perform hysterectomy should not be delayed. When the diagnosis is obvious after the abdomen has been opened the baby should be delivered by classical Caesarean section and, after rapid closure of the upper segment incision, hysterectomy should be commenced with the placenta undisturbed. It is best to begin the hysterectomy before attempted removal of the morbidly adherent placenta results in massive bleeding, which is often associated with disseminated intravascular coagulopathy. When adhesions to the bladder are dense it can be helpful, as the authors report in this case, to electively open the bladder to facilitate hysterectomy. In this case haematuria was an important warning that hysterectomy would be necessary and it was a brave decision to deliver this woman vaginally since the diagnosis of placenta percreta was as certain as it is ever likely to be before an attempt is made to deliver the placenta. Three of the 86 maternal deaths which occurred in Australia during the 1985–1987 triennium were due to haemorrhage from placenta praevia accreta. Summary: The case of a woman with a placenta percreta invading the urinary bladder treated by hysterectomy and partial bladder resection is presented. It is emphasized that if physicians in an emergency clinic are aware of this rare condition, preoperative diagnosis can be made and surgical intervention may be accomplished under ideal conditions.