Morbidly adherent placenta in 2nd trimester in a twin pregna
Morbidly adherent placenta has become one of the leading causes of maternal morbidity and mortality with a rising incidence. It consists of an abnormal attachment of the placenta to the uterine wall, with accretas being the most common type. The main risk factors consist of previous cesarean section and presence of placenta previa. Hemorrhage is the most common complication.

34 years-old patient, G8 P4125 at 13 weeks and 6 days with Class C diabetes and 1 prior c-section, presented with vaginal bleeding. Ultrasound demonstrated a diamniotic/dichorionic pregnancy with placenta previa and accreta for baby A. Despite counseling patient decided to continue pregnancy. At 16 weeks and 1 day patient was readmitted after previable premature rupture of membranes of baby A and decided for termination of pregnancy.

Hysterectomy was performed by Gynecology team and became complicated when right uterine artery was ligated due to exposure of placental tissue. Frank hemorrhage ensued and Gynecology Oncology team was called due to complexity of the case. Aortic clamping was performed to control bleeding followed by cystotomy due to adhesions. The estimated blood loss was 30 liters and patient received 33 units of PRBC, 14 units of FFP, 3 units of cryoprecipitate and 4 units of platelets. On post-operative day 1, Urology performed cystostomy repair; patient was discharged with long-term Foley.

Outpatient cystogram showed an open-roofed vesicovaginal fistula with intraperitoneal extravasation. Nephrostomy tubes for diversion of urine had no improvement. Exploratory laparotomy, lysis of adhesions and repair of vesicovaginal fistula with creation of omental flap were later performed. Foley catheter was kept for 6 weeks and leakage of urine resolved. Pathology confirmed findings of placenta previa and placenta percreta.

Lesson learned:-
- Morbidly adherent placenta imposes a very challenging situation when the diagnosis is performed as early as the first and second trimester.

- The most crucial factor to improve outcomes is to have an adequate prenatal diagnosis and preparedness from a multidisciplinary team lead by a Gynecologic Oncology surgeon to manage complications.

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Dr. M●●●l P●●●l
Dr. M●●●l P●●●l Obstetrics and Gynaecology
We also had a ssme type of case at a.bad civil hospital... every one need to be more vigilant
Dec 23, 2018Like
Dr. S●●●●●v S●●●●●1
Dr. S●●●●●v S●●●●●1 Obstetrics and Gynaecology
MAP (morbidly adherent placenta) has become a very high risk pregnancy condition not only in the last trimester but also in the 2nd trimester as well due to rampant caesarean sections and caesarean sections on request and growing of nursing homes and young Gynaecologists in the country and also due to a phobia against using oxytocin to induce Labour. Though I have successfully managed nearly 20 cases with hysterectomy and leaving placenta incretta and percreta to self terminate by autolysis after vaginal delivery this 2nd trimester confrontation with placental morbid adhesion poses a real problem and I feel it' s better to advise to rule out such conditions during very ante natal check ups.... Read more
Dec 23, 2018Like1