Pelvic packing – Life saving in a case of placenta percreta with bladder invasion

Abnormal adherent placenta is a rare complication of pregnancy, associated with high maternal obstetrical complications. Placenta percreta occurs when the villi penetrate the full thickness of the myometrium and may invade different organs such as the bladder or the rectum. It may cause massive haemorrhage thereby requiring emergency hysterectomy. Although commonly discovered at the time of delivery, antenatal diagnosis of placenta percreta may be achieved with ultrasound, magnetic resonance imaging, cystoscopy and colonoscopy. Manual removal of adherent placenta is forbidden because forceful separation may result in severe bleeding. Conservative management (left in situ placenta with or without administration of Methotrexat, uterotonics drugs and even bilateral ligation of the uterine or internal iliac arteries) is not effective and can not be practiced in an emergency situation such as placenta percreta with massive hemorrhage. Depending on the severity of the hemorrhage and the depth of invasion of the placenta into the bladder, excision and or reconstruction of the bladder may be necessary. Usually it takes a multidisciplinary approach in a tertiary center with intensive care. The case can be extremely complicated even in a well equipped center when the diagnosis of placenta percreta is a intraoperative surprise especially by the severity of hemorrhage and when there is no possibility of rapid blood transfusion, plasma and clotting factors. We present a case report, followed by a discussion on the alternatives for diagnosis and management of placenta percreta with bladder invasion. Hysterectomy, the restoration of bladder and massive blood transfusion were stages of treatment but in terms of development CID and diffuse uncontrollable bleeding, pelvic packing with cotton gauzes saved the life of the patient.

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