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Sonography of Placenta Percreta During the First Trimester

Sparrow Health System Lansing, MI 48912

A 23-year-old primipara woman who had previously undergone cesarean delivery presented to our emergency department with vaginal bleeding and pelvic pain. Notable laboratory findings were anemia and a positive pregnancy test. On abdominal sonography, the gestational sac was seen extending into the anterior cul-de-sac (Fig. 1A). The location of the sac—penetrating through the myometrium and sitting just adjacent to the internal cervical os—was established with transvaginal sonography (Fig. 1B). Images from both examinations revealed echogenic fluid, resulting from hemoperitoneum, throughout the posterior cul-de-sac. The patient underwent immediate surgery, which confirmed that the gestational sac had penetrated the myometrium at the site of the scar of the cesarean delivery and, in fact, had pierced the serosa. Pronounced hemoperitoneum was evident, and cervical mucus could be seen extending through the myometrial defect. A hysterectomy was performed, and the patient had an uneventful postoperative course.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —23-year-old pregnant woman who presented with acute pain and vaginal bleeding. Longitudinal abdominal sonogram reveals gestational sac (open arrowhead) with live embryo extending into anterior cul-de-sac. Endometrium (arrow) is seen as separate structure. Echogenic hemoperitoneum (solid arrowhead) is visible in posterior cul-de-sac.

View larger version (170K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —23-year-old pregnant woman who presented with acute pain and vaginal bleeding. Sagittal transvaginal sonogram shows gestational sac extending through anterior myometrium at site of scar from prior cesarean delivery. Sac is just adjacent to internal cervical os (arrow). Echogenic hemoperitoneum is in posterior cul-de-sac.

Placental invasion of the myometrium is associated with placenta previa, a previous cesarean delivery, and advanced maternal age [1]. Placenta percreta is the rarest form of placental invasion and is characterized by a deep invasion into the myometrium by the placenta that transgresses the serosa. Placenta accreta, which is the most common form of placental invasion and represents 75% of such cases, is limited to the superficial myometrium. Placenta increta is distinguished by deeper extension of the placenta, but the invasion is still confined to the myometrium. All three conditions are commonly classified as placenta accreta in the published literature [2].

Placental invasion of the myometrium is related to a thinned decidual endometrium at the site of implantation (which can occur at the site of a cesarean delivery scar) and subsequent placental extension into the myometrium [2, 3]. Because trophoblastic tissue is highly vascular, placental invasion can cause hemorrhage, a potentially catastrophic complication [3]. Placenta accreta typically is not recognized clinically until late in pregnancy and its detection is problematic. Gray-scale sonography, Doppler sonography, and MR imaging have been used in evaluation of placental invasion with mixed success. Targeted imaging of women at risk, with either Doppler sonography or MR imaging, has shown promise [4]. The sonographic identification of placenta percreta with a live gestation during the first trimester, as was the case in this patient, is extremely unusual and, to my knowledge, has not been previously reported.

References

1. Miller DS, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa—placenta accreta. Am J Obstet Gynecol 1997;177:210 -214[Medline]
2. Avva R, Shah HR, Angtuaco TL. US case of the day: placenta increta. RadioGraphics 1999;19:1089 -1092[Free Full Text]
3. Sonin A. Nonoperative treatment of placenta percreta: value of MR Imaging. AJR 2001;177:1301 -1303[Free Full Text]
4. Levine D, Hulks CA, Ludmir J, Li W, Edelman RR. Placenta accreta: evaluation with color Doppler US, power Doppler US, and MR imaging. Radiology 1997;205:773 -776[Abstract/Free Full Text]

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				D. Levine and M. P. Buetow Placenta Percreta Versus Ectopic Pregnancy Am. J. Roentgenol., January 1, 2003; 180(1): 284 - 284. [Full Text] [PDF]

This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Buetow, M. P. Search for Related Content PubMed PubMed Citation Articles by Buetow, M. P. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?