Ruptured Uterus & Bladder in Twins Pregnancy with Placenta Percreta & Previous Two Cesareans  

OBJECTIVE : 

Placenta previa & previous 2 lower segmen cesarean sections (LSCS ) have OR ratio of 17.4 of placenta accreta  spectrum . Rupture uterus occurs in 1.16% patients with previous 2 LSCS .In our case rupture of uterus occurred very preterm at 29 weeks pregnancy ,this was a twins pregnancy with previous 2 LSCS & placenta previa percreta, ruptured bladder occurred along with uterine rupture  .

CASE REPORT :

A 35 years pregnant woman at  29 weeks,  twins gestation  with previous two LSCS & diagnosed placenta previa percreta during her current pregnancy , was  brought by ambulance with epigastric pain and lower abdominal pain , but no per  vaginal loss . Intravenous line was connected immediately , blood collected for complete blood count & cross matching . One unit blood was started immediately as Hb level was 100g/l Patient was clinically stable & both fetal cardiac activity confirmed , cardiotocogram (CTG) showed contractions & non reassuring CTG with reduced variability for one fetus .Patient was counselled  for emergency cesarean section , & risks of rupture uterus , massive hemorrhage , blood transfusion , bladder and bowel injury and risks of prematurity . Consent was taken for emergency cesarean  +/_ hysterectomy .

Patient  was previously admitted at 26+5 weeks with uterine irritability , MRI  revealed placenta previa percreta with bladder invasion , Corticosteroid  given & patient discharged later with no pain & planned for elective cesarean & tubal ligation at  34 weeks .

At 29 weeks , patient was suspicious of ruptured uterus , emergency cesarean section was done under general anesthesia  complete uterine rupture was confirmed .Placenta was protruding through cesarean  scar , with 4 cm bladder dome rupture & intraabdominal clots & blood around 2 litres . 

Classical uterine incision was done , 2 alive males were born weight 980  & 1005 gms both in good condition .

First placenta removed completely , second  was  percreta  with bladder invasion ,  urologist was called  & subtotal hysterectomy proceeded with ovarian preservation  . Intranop , patient had total blood loss of 4.8 liters and received  7 units packed RBC  , 4 cryoprecepitate , 4 FFP.

 

Bladder injury was repaired  by urologist in 2 layers with suprapubic catheter , bladder drain and antibiotics  given for 2 weeks & patient was shifted postoperatively to intensive care unit. Incident report was filled &  debriefing was done to the patient and her family  .Patient  was discharged in a good condition on day 14 post operatively .

DISCUSSION :

Careful assesment should be made for patients with previous cesarean sections , placenta previa accreta spectrum , couselling is very importsnt at early time , as delivery can happen unexpectedly anytime even very  preterm . Ruptured uterus and bladder are other risks to be counselled about in cases with previous cesareans and placenta percreta , not just massive vaginal bleeding  and risk of hysterectomy  .

CONCLUSION :  

Uterine and bladder rupture an both occur together & should be expected and anticipated early in patients r with previous cesareans  , although they are   unexpected to occur along with placenta previa  percreta syndrome , as here the concern is more about vaginal bleeding , tthis can still outerine ccur  even very preterm and without any sign of bleeding , an it can happen just with contractions & abdominal pain .

Audits and future researches should be made for cases of rupture uterus with placenta percreta and previous cesareans