What should we do to optimise outcome in twin pregnancy complicated with placenta percreta? A case report

Thirty-three years old women with dichorionic diamniotic twin pregnancy admitted to our perinatology clinic at her 28^th gestational week with a preliminary diagnosis of complete placenta previa. She had two healthy-living children, one of which was delivered by CS, and one spontaneous abortion, which ended up with curettage.

Follow-up of the patient was done weekly until 35^th gestational age. Prior to the delivery, we were unable to determine the myometrial thickness at uterovesical contiguity by ultrasonography. Additionally, placental lacunes were prominent, and there were multiple tortuous vessels at uterovesical junction (Fig. 1). Preliminary diagnosis was placenta percreta. Two-step surgery, first remaining the placenta in utero with intention of afterward-hysterotomy and -metroplasty, was planned to decrease complications due to surgery and massive blood transfusion.

CS was performed through a vertical midline abdominal incision. The incision was extended superiorly and inferiorly from the umbilicus in order to provide a major route to deliver fetuses without damaging the decidual-placental interface. Profuse, engorged, whorl-like patterned uteroplacental vessels were seen at the intraoperative evaluation at both parametra, particularly at the left side, and over the bladder (Fig. 2). The lower uterine segment and corpus uteri were both invaded by the placentas. Therefore, it was a necessity to perform a fundal incision rather than a classical incision to the uterus. Each of the umbilical cords was tied for twice with no. 1 silk sutures after delivery of fetuses. Both of the placentas were abandoned in situ. Myometrium was sutured primarily with no. 1 vicryl sutures in two layers (Fig. 2). Patient was not administered uterotonics during and after the procedure. Cefazolin was continued during post-operative period for 4 days. Intramuscular methotrexate was administered in 50 mg/m² dose to enhance placental involution at the postoperative day 1. Patient was discharged at the postoperative day 4. She was advised for regular visits for once in two weeks. Transabdominal and suprapubic ultrasonographic survey, serum quantitative measures for leukocytosis and C-reactive protein (CRP) were conducted at every visit. At post-operative first week, ultrasonography yielded a 70 × 101 mm residual placenta at the left lower segment of the uterine cavity, and the second placenta which is 57 × 99 mm in dimensions at the right lower segment of the uterine cavity. Patient did not encounter any sort of bleeding. Serum CRP was negative (<0.5 mg/dL), and serum leukocyte counts were normal. Serum beta-hCG value was 324.86 IU/ml. The subsequent calls during follow-up did not yield any symptoms and abnormal test results until post-operative 5^th week. Serum CRP was measured 2.8 mg/dL at that time. She was administered oral metronidazole twice a day and 3^rd generation cephalosporins once a day for the treatment of the infection. The ultrasonographic measurement yielded shrinkage in dimensions of both placentas. One week later, she admitted to our clinic with severe inguinal and lower abdominal pain, and leukorrhea. There was a discomfort on abdominal palpation. Additionally, tenderness was prominent at inguinal regions, particularly at the left side. Maximum body temperature was 38.7 °C. Serum CRP was measured to increase 29.8 mg/dL. The second operation was planned. The operation was performed through the infraumbilical vertical midline incision. Uterus was pink to grayish in color. Distal part of the uterine corpus and bilateral adnexa were enlarged extremely due to uterine vasculature and mass of the placentas. Vesicouterine pouch was obliterated. Prophylactic ligation of bilateral hypogastric arteries was followed by routine technique for total hysterectomy (Fig. 3). The division of uterine neovasculature at the boundary of lower uterine segment and bladder and dissection of vesicouterine space was accomplished by using electrosurgical vessel sealing equipment. Our measures yielded a 1100 ml total blood loss at intraoperative period. Three units of erythrocyte suspension and 2 units of fresh frozen plasma were delivered to the patient at the perioperative and postoperative period. She was administered 3^rd generation cephalosporin for 7 days. Postoperative follow-up was uneventful. The patient was discharged at the postoperative 7^th day.

Placental sectioning showed extensive hemorrhage in the villous tissue with extensive inflammatory response and tissue necrosis at the microscopy.