RCOG World Congress 2023

MANAGEMENT OF HEMATURIA IN EARLY PREGNANCY DUE TO PLACENTA PERCRETA: CASE REPORT

HUDA ALMAYOUF; SYEDA MOHSINA IFFATH; WESAM ALMEKHLAFI
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY; KING SAUD MEDICAL CITY; SAUDI ARABIA

OBJECTIVE:

§Urological manifestation of placenta accreta spectrum(PAS) is normally at term.

§ We report this case to raise awareness of this rare presentation (hematuria in early pregnancy)

and an alternative approach to management.

CASE REPORT:

§42yr old, G6P5, previous 5 caesareans, 22 weeks pregnant was referred to us as a case of placenta Previa with frank hematuria and no vaginal bleeding.

§ USG revealed placenta covering os(increta/percreta). MRI showed features of percreta with bladder invasion.

§ Patient had acute massive hematuria with significant drop in Hb%,

§ A multidisciplinary team decision was taken to terminate the pregnancy to prevent further complications that was agreed by the patient and her family.

§ Procedure involved cystoscopy, bilateral DJ stenting, bilateral internal iliac artery ligation, Hysterotomy.

§ Placenta found invading the bladder with highly vascular uterine segment.

§ Decision for alternative approach of leaving placenta in situ with delayed hysterectomy to minimize hemorrhage was taken. Blood loss was 1 litre.

§ Postoperatively she received methotrexate(MTX) 3 doses and antibiotics.

§ USG on 10th postoperative day showed shrinkage in placental size with dropping serum BHCG levels.

§ She was followed up with serial BHCG , until 4 months when she presented with heavy vaginal bleeding.

§ Total hysterectomy was performed then, with a small bladder injury that was successfully repaired, with 1 litre blood loss.

After 14days of Foleys catheterization she was discharged home and further seen in clinic in 4 weeks, without any complaints

DISCUSSION:

Hematuria is a very rare presentation of PAS. In such cases elective caesarean delivery, hysterectomy, cystotomy or partial cystectomy is often complicated by massive hemorrhage and urinary complications. An alternative approach as in this case of leaving placenta in situ followed by delayed hysterectomy, combined with methotrexate may be a safer option in some cases.

CONCLUSION:

Incidence of PAS is increasing with increased rates of caesareans. The best therapeutic options are still controversial. PAS, with bladder invasion is a rare, but life threatening problem. High index of suspicion, early diagnosis remains crucial. Delayed hysterectomy may be a strategic option. The use of MTX in conservative approach requires further evaluation.

RCOG World Congress 2023

MANAGEMENT OF HEMATURIA IN EARLY PREGNANCY DUE TO PLACENTA PERCRETA: CASE REPORT

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