American College of Obstetrics and Gynaecology ACOG committee opinion

CA Armstrong

Cheng Lee

Dimitris Tsivos

DR Hostetler

Fozia Malik

G Kayem

HJW Finberg

Kirana Arambage

Philip Hagan

S Agarwal

English

PubMed

Springer - Publisher Connector

BioMed CentralCases Journal
ssOpen AcceCase Report
A life threatening uterine inversion and massive post partum 
hemorrhage caused by placenta accrete during Caesarean section 
in a primigravida: a case report
Dimitris Tsivos*, Fozia Malik, Kirana Arambage, Philip Hagan and Cheng Lee
Address: Department of Obstetrics and Gynecology, Southend General Hospital NHS Trust, Prittlewell Chase, Westcliff on Sea, Essex, SS0 0RY, UK
Email: Dimitris Tsivos* - dimitristsivos@hotmail.com; Fozia Malik - fozia_sarfraz@yahoo.com; Kirana Arambage - kiranasl@yahoo.co.uk; 
Philip Hagan - philip.hagan@southend.nhs.uk; Cheng Lee - lian@chenglee.freserve.co.uk
* Corresponding author    
Abstract
Background: A 32-year-old Caucasian primigravida was admitted for elective Caesarean Section
at 36 weeks and 6 days with the diagnosis of preeclampsia.
Case presentation: Traction of the umbilical cord after delivery of a healthy baby resulted in
uterine inversion. The placenta was found to be densely adherent to the posterior uterine wall.
Piecemeal excision of the placenta as close as possible to the uterine lining was then performed.
Conclusion: In this way we were able to control a massive post partum hemorrhage and preserve
the fertility of the patient.
Background
Placenta accreta is defined as abnormal adherence, either
in whole or in part of the afterbirth to the underlying uter-
ine wall. Placenta accreta and other pathological placenta-
tions (such as increta, percreta) are rare complications of
pregnancy with potential life threatening and fertility
threatening consequences. The incidence of placenta
accreta has increased ten times over the last fifteen years,
which reflects the increase in the rate of Caesarean Sec-
tions (CS) [1]. Placenta accreta has become the most
important cause of peripartum hysterectomy. A life threat-
ening acute uterine inversion and massive PPH can be
caused by placenta accreta during CS but seldom in a
primigravida (Figure 1).
Case presentation
A 32 year old, primigravida, was admitted in a District
General Hospital for elective Caesarean section at 36
weeks and 6 days with the diagnosis of preeclampsia. She
had two antenatal ultrasound examinations showing a
healthy fetus and posterior fundal placenta.
The patient had lower segment CS of a healthy male infant
under spinal anesthesia. The placenta was found to be
densely adherent to the posterior uterine wall. Traction of
the umbilical cord was applied and subsequently resulted
in uterine inversion.
The placenta was removed by 'piecemeal' excising as close
as possible to the uterine lining. About 80% of the placen-
tal tissue was removed until the uterine inversion was cor-
rected. The uterus was closed in two layers. Two intra-
abdominal drains were sited. The estimated blood loss
was 2.5 litres and five units of blood were transfused
together with 2 units of FFP during intra-operative and
post-operative period. In addition, the patient was treated
Published: 12 February 2009
Cases Journal 2009, 2:138 doi:10.1186/1757-1626-2-138
Received: 3 November 2008
Accepted: 12 February 2009
This article is available from: http://www.casesjournal.com/content/2/1/138
© 2009 Tsivos et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
Cases Journal 2009, 2:138 http://www.casesjournal.com/content/2/1/138with intravenous oxytocin infusion, pr misoprostol and
antibiotics.
On the second post partum day, vaginal Doppler ultra-
sound scan showed significant amount of placental tis-
sues with increased vascularity measuring 2.7 × 6.6 × 6.8
cms within the endometrial cavity (Figure 2).
The patient was discharged on the fifth post-operative day
with a conservative management. A follow up Ultrasound
scan after two weeks showed reduction of placental mass
(Figure 3). In addition, there was significant decrease in
serum beta HCG levels from 2300 u/L on day 1 to 13 u/L
at four weeks post operatively. The patient remained with
minimal vaginal bleeding without abdominal pain. She
had two normal periods after stopping breastfeeding and
was feeling well. She was discharged from the early preg-
nancy unit.
Discussion
A life-threatening uterine inversion can be rarely caused
by placenta accreta [2]. Placenta accreta classically
presents with retained placenta and hemorrhage. The
association between uterine inversion and placenta
accreta is unclear, however, strong traction on the umbil-
ical cord with fundal placenta, excessive fundal pressure,
relaxed uterus, short umbilical cord, uterine anomalies
and antepartum use of magnesium sulphate are known
associated factors [2]. Uterine inversion and retain pla-
centa accreta can both be fatal complications [3].
In the case described the placenta accreta was complicated
by uterine inversion and subsequent massive post partum
hemorrhage, significantly increasing the risk of maternal
mortality. Massive post partum hemorrhage is a major
cause of maternal mortality in the United Kingdom (why
women die latest report) [4].
In this case, the placenta was clamped as close to the uter-
ine cavity as possible and cut. The base of the placenta was
overrun with haemostatic sutures and this was repeated
until as much of the placenta as possible was removed
(Figure 4). Placental removal enabled correction of uter-
ine inversion.
Despite the many conditions associated with uterine
inversion risk assessment is often lacking making the con-
dition usually unexpected at the time of presentation. The
association between abnormal placentation such as pla-
centa accreta and uterine inversion is well supported [2].
Uterine inversion secondary to placenta accreta during CSFigure 1
Uterine inversion secondary to placenta accreta dur-
ing CS.
Retained placental products 2 days post CSFigur  2
Retained placental products 2 days post CS.
Retained placental product 2 weeks post CSFigur  3
Retained placental product 2 weeks post CS.Page 2 of 3
(page number not for citation purposes)
Cases Journal 2009, 2:138 http://www.casesjournal.com/content/2/1/138Therefore, we advocate antenatal evaluation and risk
assessment for placenta accreta [5]. Prenatal Ultrasound
reported sensitivity of 94% and specificity of 79% for pla-
centa accreta, but offer no more than provisional diagnos-
tic probability statement [6]. Moreover, because 45% of
placenta accreta cases were not detected by ultrasound, it
is important to consider avoiding manual removal of pla-
centa if there were intraoperative signs of accreta [6]. If
clinically or sonographically the patient is suspected ante-
natally to be at risk of placenta accreta, appropriate man-
agement options should be considered, such as attempted
conservative management or hysterectomy and coun-
seling provided about potential sequelae [6]. The tradi-
tional management is abdominal hysterectomy, but this
operation terminates fertility and may have devastating
psychological effects. However, in correct circumstances, a
conservative approach may be suitable. Conservative
management of abnormally invasive placentation can be
effective and fertility can be preserved. It should be only
considered in highly selected cases when blood loss is
minimal and there is wish for fertility preservation [7].
For women who want to preserve their fertility the pla-
centa should be left intact if possible after caesarean deliv-
ery as this approach lowers the risk of subsequent
hysterectomy from 85% to 15%. For women who have
completed their family, hysterectomy with placenta left in
situ is preferable to lower the maternal morbidity rates
[6].
This case report involved conservative management. Peri-
partum hysterectomy was avoided and the aim was to pre-
serve fertility. Prophylactic antibiotics, post partum
oxytocics and the use of misoprostol post operatively
helped to prevent further post partum hemorrhage.
When a patient isinitially opted for conservative manage-
ment, the possibility of recurrence should be discussed
[8]. Furthermore, placentation should be carefully moni-
tored for recurrence in any subsequent pregnancy, partic-
ularly if the placenta is located at the same site as the
previous placenta accreta.
Conservative treatment for placenta accreta may be an
alternative procedure in some selected cases.
Conclusion
We suggest an alternative approach for managing uterine
inversion caused by placenta accreta that involved con-
servative management. This way hysterectomy was
avoided and fertility was preserved.
Abbreviations
CS: Caesarean Section; FFP: Fresh Frozen Plasma
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor – in Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
All authors have made substantial contribution to concept
this case report.
References
1. American College of Obstetrics and Gynaecology ACOG committee
opinion: Placenta accreta. Number 266, January 2002 Com-
mittee on Obstetrics Practice.  Int J GynaecolObstet 2002,
77(1):77-78.
2. Hostetler DR, Bosworth MF: Uterine inversion – a life – threat-
ening emergency.  J Am Board FamPract 2000, 13(2):120-3.
3. Agarwal S, Minocha B, Dewan R: Uterine inversion and concom-
itant perforation following manual removal of placenta.  Int J
GynaecolObstet 2005, 88(2):144-145.
4. Why women die report. Reviewing maternal deaths to make
motherhood safer 2003–2005.  Confidential Enquiry into Maternal
and Child Health (CEMACH) .
5. Finberg HJW: Placenta accreta prospective sonographic diag-
nosis in patients with placenta praevia and prior Caesarian
section.  J Ultrasound Med 1992, 11(7):333-344.
6. Armstrong CA, Harding S, Dickinson JE: Clinical aspects and con-
servative management of placenta accreta.  Obstet and Gynae-
col 2004, 6:132-137.
7. Kayem G, Davy C, Goffinet F, Thomas C, Clément D, Cabrol D:
Conservative versus extirpative management in cases of pla-
centa accreta.  Obstet Gynecol 2004, 104:531-536.
8. Kayem G, Clément D, Goffinet F: Recurrence following conserv-
ative management of placenta accreta.  Inter J GynecolObstet
2007, 99(2):142-143.
Correction of uterine inversion following piecemeal excisionFigure 4
Correction of uterine inversion following piecemeal 
excision.Page 3 of 3
(page number not for citation purposes)


A life threatening uterine inversion and massive post partum hemorrhage caused by placenta accrete during Caesarean section in a primigravida: a case report

Dimitris  Tsivos

Crossref

BioMed CentralCases JournalssOpen AcceCase ReportA life threatening uterine inversion and massive post partum hemorrhage caused by placenta accrete during Caesarean section in a primigravida: a case reportDimitris Tsivos*, Fozia Malik, Kirana Arambage, Philip Hagan and Cheng LeeAddress: Department of Obstetrics and Gynecology, Southend General Hospital NHS Trust, Prittlewell Chase, Westcliff on Sea, Essex, SS0 0RY, UKEmail: Dimitris Tsivos* - dimitristsivos@hotmail.com; Fozia Malik - fozia_sarfraz@yahoo.com; Kirana Arambage - kiranasl@yahoo.co.uk; Philip Hagan - philip.hagan@southend.nhs.uk; Cheng Lee - lian@chenglee.freserve.co.uk* Corresponding author    AbstractBackground: A 32-year-old Caucasian primigravida was admitted for elective Caesarean Sectionat 36 weeks and 6 days with the diagnosis of preeclampsia.Case presentation: Traction of the umbilical cord after delivery of a healthy baby resulted inuterine inversion. The placenta was found to be densely adherent to the posterior uterine wall.Piecemeal excision of the placenta as close as possible to the uterine lining was then performed.Conclusion: In this way we were able to control a massive post partum hemorrhage and preservethe fertility of the patient.BackgroundPlacenta accreta is defined as abnormal adherence, eitherin whole or in part of the afterbirth to the underlying uter-ine wall. Placenta accreta and other pathological placenta-tions (such as increta, percreta) are rare complications ofpregnancy with potential life threatening and fertilitythreatening consequences. The incidence of placentaaccreta has increased ten times over the last fifteen years,which reflects the increase in the rate of Caesarean Sec-tions (CS) [1]. Placenta accreta has become the mostimportant cause of peripartum hysterectomy. A life threat-ening acute uterine inversion and massive PPH can becaused by placenta accreta during CS but seldom in aprimigravida (Figure 1).Case presentationA 32 year old, primigravida, was admitted in a DistrictGeneral Hospital for elective Caesarean section at 36weeks and 6 days with the diagnosis of preeclampsia. Shehad two antenatal ultrasound examinations showing ahealthy fetus and posterior fundal placenta.The patient had lower segment CS of a healthy male infantunder spinal anesthesia. The placenta was found to bedensely adherent to the posterior uterine wall. Traction ofthe umbilical cord was applied and subsequently resultedin uterine inversion.The placenta was removed by 'piecemeal' excising as closeas possible to the uterine lining. About 80% of the placen-tal tissue was removed until the uterine inversion was cor-rected. The uterus was closed in two layers. Two intra-abdominal drains were sited. The estimated blood losswas 2.5 litres and five units of blood were transfusedtogether with 2 units of FFP during intra-operative andpost-operative period. In addition, the patient was treatedPublished: 12 February 2009Cases Journal 2009, 2:138 doi:10.1186/1757-1626-2-138Received: 3 November 2008Accepted: 12 February 2009This article is available from: http://www.casesjournal.com/content/2/1/138© 2009 Tsivos et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3(page number not for citation purposes)Cases Journal 2009, 2:138 http://www.casesjournal.com/content/2/1/138with intravenous oxytocin infusion, pr misoprostol andantibiotics.On the second post partum day, vaginal Doppler ultra-sound scan showed significant amount of placental tis-sues with increased vascularity measuring 2.7 × 6.6 × 6.8cms within the endometrial cavity (Figure 2).The patient was discharged on the fifth post-operative daywith a conservative management. A follow up Ultrasoundscan after two weeks showed reduction of placental mass(Figure 3). In addition, there was significant decrease inserum beta HCG levels from 2300 u/L on day 1 to 13 u/Lat four weeks post operatively. The patient remained withminimal vaginal bleeding without abdominal pain. Shehad two normal periods after stopping breastfeeding andwas feeling well. She was discharged from the early preg-nancy unit.DiscussionA life-threatening uterine inversion can be rarely causedby placenta accreta [2]. Placenta accreta classicallypresents with retained placenta and hemorrhage. Theassociation between uterine inversion and placentaaccreta is unclear, however, strong traction on the umbil-ical cord with fundal placenta, excessive fundal pressure,relaxed uterus, short umbilical cord, uterine anomaliesand antepartum use of magnesium sulphate are knownassociated factors [2]. Uterine inversion and retain pla-centa accreta can both be fatal complications [3].In the case described the placenta accreta was complicatedby uterine inversion and subsequent massive post partumhemorrhage, significantly increasing the risk of maternalmortality. Massive post partum hemorrhage is a majorcause of maternal mortality in the United Kingdom (whywomen die latest report) [4].In this case, the placenta was clamped as close to the uter-ine cavity as possible and cut. The base of the placenta wasoverrun with haemostatic sutures and this was repeateduntil as much of the placenta as possible was removed(Figure 4). Placental removal enabled correction of uter-ine inversion.Despite the many conditions associated with uterineinversion risk assessment is often lacking making the con-dition usually unexpected at the time of presentation. Theassociation between abnormal placentation such as pla-centa accreta and uterine inversion is well supported [2].Uterine inversion secondary to placenta accreta during CSFigure 1Uterine inversion secondary to placenta accreta dur-ing CS.Retained placental products 2 days post CSFigur  2Retained placental products 2 days post CS.Retained placental product 2 weeks post CSFigur  3Retained placental product 2 weeks post CS.Page 2 of 3(page number not for citation purposes)Cases Journal 2009, 2:138 http://www.casesjournal.com/content/2/1/138Therefore, we advocate antenatal evaluation and riskassessment for placenta accreta [5]. Prenatal Ultrasoundreported sensitivity of 94% and specificity of 79% for pla-centa accreta, but offer no more than provisional diagnos-tic probability statement [6]. Moreover, because 45% ofplacenta accreta cases were not detected by ultrasound, itis important to consider avoiding manual removal of pla-centa if there were intraoperative signs of accreta [6]. Ifclinically or sonographically the patient is suspected ante-natally to be at risk of placenta accreta, appropriate man-agement options should be considered, such as attemptedconservative management or hysterectomy and coun-seling provided about potential sequelae [6]. The tradi-tional management is abdominal hysterectomy, but thisoperation terminates fertility and may have devastatingpsychological effects. However, in correct circumstances, aconservative approach may be suitable. Conservativemanagement of abnormally invasive placentation can beeffective and fertility can be preserved. It should be onlyconsidered in highly selected cases when blood loss isminimal and there is wish for fertility preservation [7].For women who want to preserve their fertility the pla-centa should be left intact if possible after caesarean deliv-ery as this approach lowers the risk of subsequenthysterectomy from 85% to 15%. For women who havecompleted their family, hysterectomy with placenta left insitu is preferable to lower the maternal morbidity rates[6].This case report involved conservative management. Peri-partum hysterectomy was avoided and the aim was to pre-serve fertility. Prophylactic antibiotics, post partumoxytocics and the use of misoprostol post operativelyhelped to prevent further post partum hemorrhage.When a patient isinitially opted for conservative manage-ment, the possibility of recurrence should be discussed[8]. Furthermore, placentation should be carefully moni-tored for recurrence in any subsequent pregnancy, partic-ularly if the placenta is located at the same site as theprevious placenta accreta.Conservative treatment for placenta accreta may be analternative procedure in some selected cases.ConclusionWe suggest an alternative approach for managing uterineinversion caused by placenta accreta that involved con-servative management. This way hysterectomy wasavoided and fertility was preserved.AbbreviationsCS: Caesarean Section; FFP: Fresh Frozen PlasmaConsentWritten informed consent was obtained from the patientfor publication of this case report and accompanyingimages. A copy of the written consent is available forreview by the Editor – in Chief of this journal.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsAll authors have made substantial contribution to conceptthis case report.References1. American College of Obstetrics and Gynaecology ACOG committeeopinion: Placenta accreta. Number 266, January 2002 Com-mittee on Obstetrics Practice.  Int J GynaecolObstet 2002,77(1):77-78.2. Hostetler DR, Bosworth MF: Uterine inversion – a life – threat-ening emergency.  J Am Board FamPract 2000, 13(2):120-3.3. Agarwal S, Minocha B, Dewan R: Uterine inversion and concom-itant perforation following manual removal of placenta.  Int JGynaecolObstet 2005, 88(2):144-145.4. Why women die report. Reviewing maternal deaths to makemotherhood safer 2003–2005.  Confidential Enquiry into Maternaland Child Health (CEMACH) .5. Finberg HJW: Placenta accreta prospective sonographic diag-nosis in patients with placenta praevia and prior Caesariansection.  J Ultrasound Med 1992, 11(7):333-344.6. Armstrong CA, Harding S, Dickinson JE: Clinical aspects and con-servative management of placenta accreta.  Obstet and Gynae-col 2004, 6:132-137.7. Kayem G, Davy C, Goffinet F, Thomas C, Clément D, Cabrol D:Conservative versus extirpative management in cases of pla-centa accreta.  Obstet Gynecol 2004, 104:531-536.8. Kayem G, Clément D, Goffinet F: Recurrence following conserv-ative management of placenta accreta.  Inter J GynecolObstet2007, 99(2):142-143.Correction of uterine inversion following piecemeal excisionFigure 4Correction of uterine inversion following piecemeal excision.Page 3 of 3(page number not for citation purposes)

American College of Obstetrics and Gynaecology ACOG committee opinion: Placenta accreta.

Cabrol D: Conservative versus extirpative management in cases of placenta accreta. Obstet Gynecol

Clinical aspects and conservative management of placenta accreta. Obstet and Gynaecol

MF: Uterine inversion – a life – threatening emergency.

Placenta accreta prospective sonographic diagnosis in patients with placenta praevia and prior Caesarian section.

Recurrence following conservative management of placenta accreta.

Uterine inversion and concomitant perforation following manual removal of placenta.

Why women die report. Reviewing maternal deaths to make motherhood safer 2003–2005.

https://casesjournal.biomedcentral.com/track/pdf/10.1186/1757-1626-2-138?site=casesjournal.biomedcentral.com

A life threatening uterine inversion and massive post partum hemorrhage caused by placenta accrete during Caesarean section in a primigravida: a case report

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