




































    

 American Journal of Medical and Physical Education  

Vol.9, Issue 1; January-February 2024; 

ISSN: 2994-0524 

Impact Factor: 6.14 

1252 Columbia Rd NW, Washington DC, United States 

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17 | A m e r i c a n  J o u r n a l  o f  M e d i c a l  a n d  P h y s i c a l  E d u c a t i o n  

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PRESERVING POTENTIAL: UTERUS RESILIENCE IN THE CONTEXT 

OF PLACENTA PERCRETA AND UTERINE RUPTURE – A CASE STUDY 
 

  
1Mei X. Wang and Liang Y. Chen2 
1,2Department of Obstetrics and Gynaecology, Fuxing Hospital, Capital Medical University, Beijing, China.  

DOI: https://doi.org/10.5281/zenodo.10598189 

 

Abstract: Adherent placenta disorders, encompassing conditions like placenta accreta, placenta increta, and 

placenta percreta, pose significant threats to maternal health during pregnancy. Of these, placenta percreta 

represents a severe manifestation where chorionic villi invade the uterine serosa and affix to surrounding 

organs, presenting complex challenges in management. This review delves into the distinctive features of 

placenta percreta, emphasizing its gravity compared to other adherent placenta disorders. 

The placental villi play a pivotal role in facilitating nutrient exchange between the mother and fetus. Abnormal 

attachment of fetal chorionic villi to the myometrium, instead of the decidua, leads to the development of placenta 

accreta, increta, or percreta. Placenta percreta, the most severe variant, involves chorionic villi breaching the 

uterine serosa and establishing adherence to adjacent organs. 

This paper presents a compelling case of a woman with a preserved uterus following a history encompassing two 

occurrences of placenta percreta and three incidents of uterine rupture. The rarity and intricacy of such cases 

underscore the urgency for a nuanced understanding of placenta percreta, not only for immediate clinical 

management but also for long-term considerations. 

Despite the gravity of placenta percreta, optimal management strategies remain contentious due to a dearth of 

comprehensive studies evaluating treatment modalities and long-term outcomes for affected individuals (Clausen 

et al., 2014). This review aims to contribute to the evolving discourse on placenta percreta, elucidating the 

complexities of its presentation, management, and the need for sustained research efforts in this critical area of 

maternal-fetal medicine. 

Keywords: Placenta Percreta, Adherent Placenta Disorders, Maternal Health, Uterine Rupture, Pregnancy 

Complications.  

   

  

INTRODUCTION   

Adherent placenta disorders are potentially fatal for pregnant women. Branching villi of the placenta are important 

for nutrient exchange between the mother and fetus. If villi from the fetal component (chorionic placenta) attach 

abnormally to the myometrium instead of the endometrium (decidua), pathologies known as placenta accreta, 

placenta increta, or placenta percreta can result. This review focuses on placenta percreta, which is more severe 

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 American Journal of Medical and Physical Education  

Vol.9, Issue 1; January-February 2024; 

ISSN: 2994-0524 

Impact Factor: 6.14 

1252 Columbia Rd NW, Washington DC, United States 

https://topjournals.org/index.php/AJMPE; mail: topacademicjournals@gmail.com 

 
 

 

 

18 | A m e r i c a n  J o u r n a l  o f  M e d i c a l  a n d  P h y s i c a l  E d u c a t i o n  

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than the other conditions. In placenta percreta, chorionic villi breach the uterine serosa and adhere to the 

surrounding organs. This paper describes the case of a woman with an intact uterus after a history of two instances 

of placenta percreta and three instances of uterine rupture. Techniques for optimal management of placenta 

percreta remain controversial due to a lack of studies on treatment and long-term outcomes of this condition 

(Clausen et al., 2014). This review aimed to synthesize available diagnostic and treatment methods for placenta 

percreta. It highlights the importance of early detection in avoiding complications.  Informed   consent 2          Med. 

Case Stud.  

Was obtained from the patient for publication of this report   

CASE REPORT  

First hospitalisation  

The patient was a 35-year-old woman. She was initially admitted to the hospital because she required labour 

induction in September, 2008. Her last menstruation period was in March, 2008. She had vaginal bleeding twice, 

and she had taken dydrogesterone during early pregnancy. The foetal ultrasonogram showed foetal heart structural 

abnormalities, a supraventricular septum defect, an atrial septal defect, and an endocardial pad defect at 25 weeks 

of gestation. She denied a history of diabetes, hypertension, allergies, or any other remarkable family history. She 

had four pregnancies: premature birth, 1; drug abortion, 1; artificial abortion, 1; and full-term baby, 1. An 

intrauterine injection of Rivanol (100 mg) was administered to induce labour at 0930, and contractions began at 

0000 on the next day. Her water broke naturally at 0300, and a male baby (weight: 975 g, length: 36 cm) with no 

abnormal appearance was born at 0323. The placenta was not delivered spontaneously within 10 min, and vaginal 

bleeding continued. Artificial stripping of the placenta was difficult because the placenta was attached closely to 

the uterine wall; thus, vaginal bleeding continued. The mother became pale and lost consciousness at 0445. Her 

heart rate was 104 beats/min, and her blood pressure was 75-80/35-45 mmHg. The ultrasonogram obtained in the 

emergency ward showed free fluid in the abdominal cavity. Results of the haemogram showed that the 

haemoglobin level, haematocrit level, and platelet (PLT) count were 7.2 g/dL, 23.1%, and 110 000/µL, 

respectively. The other coagulation test results were also abnormal. After her vital signs stabilised, two 

intravenous lines were set, packed red blood cells were reserved for transfusion, and she was transferred to the 

operating room.  

An emergency laparotomy was performed with simultaneous on going resuscitation. Intraoperative findings 

showed about 2500 ml of blood in the abdominal cavity and between the intestinal loops. The uterus was torn at 

the bottom left corner, the diameter of the rupture was about 2 cm, placental tissue was implanted in the uterine 

muscle near the serosal surface, part of the placental tissue was exposed, and active bleeding was present at the 

rupture site. Intraoperatively, the placenta was peeled, the uterus was repaired, and B-Lynch suturing was 

performed because of poor uterine contraction. Additionally, 12 units of packed red blood cells, 4 units of fresh 

frozen plasma, 400 ml of normal frozen plasma, and 1 treatment volume of PLTs were transfused. She was 

transferred to the intensive care unit (ICU) postoperatively. She received antibiotics and anticoagulation therapy.  

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 American Journal of Medical and Physical Education  

Vol.9, Issue 1; January-February 2024; 

ISSN: 2994-0524 

Impact Factor: 6.14 

1252 Columbia Rd NW, Washington DC, United States 

https://topjournals.org/index.php/AJMPE; mail: topacademicjournals@gmail.com 

 
 

 

 

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Postoperative diagnoses included placenta percreta, haemorrhagic shock, and uterine rupture. Results of the 

postoperative placental pathologic examination showed specimens of the uterine wall muscle tissue in the 

placenta. The patient was discharged from the hospital in good condition 9 days after admission.  

Second hospitalisation   

The patient was 39 years old, and she was admitted to the hospital a second time because of infertility in 

December, 2011. Her menstrual volume decreased by 1/3 after labour induction without a change in her menstrual 

cycle. She had no pregnancy without contraception for 1 year. Ultrasonography showed a left ovarian cyst 

measuring 28×15 mm, and it was considered a wrapped effusion. Hysteroscopy showed that the uterine cavity 

was normal, and both tubal openings could be seen. Using B-ultrasound guidance, we found that the muscle wall 

was the thinnest (0.15 cm) on the left side of the bottom of the uterus. A diagnosis of secondary infertility was 

made.  

Laparoscopic pelvic adhesiolysis, uterine repair, and hysteroscopy were performed 5 days later. Intraoperative 

findings showed that the left fallopian tube was distorted, and the left ovum and posterior lobe of the ipsilateral 

broad ligament had wrapped adhesions. Additionally, the ampulla adhered closely to the left posterior wall near 

the left corner of the uterus, part of the intestine adhered closely to the left posterior wall of the uterus, and the 

left ovary was wrapped in the adhesive band.  

Laparoscopically, Meilan fluid was visible, the left oviduct was not smooth, and a significant amount of liquid 

overflowed from the left corner of the bottom of the uterus. Hysteroscopy showed a fissure in the left corner of 

the uterus, a previous uterine rupture, and an old laceration with figure-of-8 suture stitching. The postoperative 

diagnoses included secondary infertility and uterine rupture (the old injury to the uterine muscle wall). She was 

discharged from the hospital in good condition 3 days later.  

Third hospitalisation  

The patient was 40 years old, and she was admitted to the hospital a third time in July, 2013 because of her 

pregnancy with her second child. Her last menstrual period was in November, 2012. Her pregnancy was 

uneventful. The ultrasonogram showed that the foetus’ gestational age was 35 weeks and 4 days, the placenta was 

positioned posteriorly toward the bottom of the uterus, demarcation was unclear between the part of the placenta 

on the left side of the bottom of the uterus and myometrium, and the local area was about 40 mm, which was not 

obvious. The magnetic resonance imaging  (MRI) scan showed that the thin myometrium was about 2 mm at the 

left corner of the bottom of the uterus. Diagnoses on admission were intrauterine pregnancy (35 weeks and 4 

days), left occiput anterior (LOA), scarring of the uterus, placenta percreta, and a poor pregnancy history. The 

uterus had become extremely weak because of a history of uterine rupture (two times).  

At 37 weeks, she was scheduled for an elective caesarean section with intestinal adhesion adhesiolysis and uterine 

repair. A male baby (weight: 3140 g, Apgar score: 10, 10) was born. The placenta was removed without difficulty. 

Intraoperative findings showed that the left fundus of the uterus was completely ruptured (diameter, about 3 cm), 

the tissue surrounding the Meager area was about 7×7 cm, intestine was adhered around the uterus, double 

attachment could not be observed, oedema and congestion were present, and extensive surrounding tissue adhered 

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 American Journal of Medical and Physical Education  

Vol.9, Issue 1; January-February 2024; 

ISSN: 2994-0524 

Impact Factor: 6.14 

1252 Columbia Rd NW, Washington DC, United States 

https://topjournals.org/index.php/AJMPE; mail: topacademicjournals@gmail.com 

 
 

 

 

20 | A m e r i c a n  J o u r n a l  o f  M e d i c a l  a n d  P h y s i c a l  E d u c a t i o n  

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to the uterus. Uterine repair was performed after the adhesions were separated. Total operative blood loss was 200 

ml.  

Postoperative diagnoses were gravida 3, parity 2, intrauterine pregnancy (37 weeks and 1 day), LOA, scarring of 

the uterus, placenta percreta, uterine rupture, a poor pregnancy history, and pelvic adhesions. Results of the 

postoperative pathologic examination showed implanted placenta tissue consistent with placenta percreta. The 

patient and her baby were discharged from the hospital in good condition 4 days later. Her postoperative recovery 

was good, and she was followed up for 6 years. The patient remained healthy with regular menstruation.   

DISCUSSION  

Morbidly adherent placentation (MAP), which includes placenta accreta, increta, and percreta, is a serious 

complication of pregnancy associated with perinatal massive haemorrhage, intensive care unit (ICU) admission, 

and caesarean hysterectomy (Vahanian et al., 2015). MAP occurs in approximately 1 in 500 to 1,000 pregnancies 

(Vahanian et al., 2015). This rate has increased up to 10-fold in the past 20 years, and it is largely attributed to 

increasing rates of caesarean deliveries (Eshkoli et al., 2013). The reported incidence in the United States 

increased from 0.08% in 1985 to 0.3% in 2005 (Rao et al., 2012). The domestic incidence of MAP increased by 

10 times within nearly 30 years, with the increasing rates of abortion, hysteroscopic operation, and caesarean 

section (Lian and Wang, 2013). The present patient had placenta percreta, which is more severe than the other 

classifications. In placenta percreta, chorionic villi breach the uterine serosa and adhere to the surrounding organs 

(Solheim et al., 2011). The steadily increasing rate of placenta previa and caesarean section may result in an 

increased number of patients with abnormal placentation (Solheim et al.,  2011).  Additional Zhao 3  

risk factors for MAP include uterine operation, caesarean delivery, advanced maternal age (≥35 years), 

multiparity, and a history of endometrial ablation (Belfort, 2010).  

The occurrence of placenta percreta will significantly affect the outcome of pregnancy, causing postpartum 

hemorrhaging, uterine perforation, and other serious complications; additionally, it can even endanger the lives 

of pregnant women and their foetuses.  

Uterine rupture in pregnancy is rare, and it can often be life threatening and catastrophic. It is very difficult to 

manage placenta percreta and uterine rupture during vaginal delivery; thus, invasive treatment is needed to control 

for the occurrence of serious complications after various rescue measures are ineffective. Severe complications 

of placenta percreta are significantly higher with vaginal delivery than with caesarean section. Pregnancy with 

placenta percreta is associated with a high risk of uterine rupture.  

Placenta percreta is rare, but three instances of uterine rupture with delivery of normal newborn infants, as seen 

in our patient, are very rare. The first instance of placenta percreta with uterine rupture was not a prenatal 

diagnosis, so the patient had more complications and was transferred to the ICU. The second instance of placenta 

percreta was diagnosed before pregnancy; thus, prenatal preparation was adequate to prevent intraoperative 

bleeding and to ensure a good postoperative recovery and preservation of the uterus.  

Traditionally, placenta percreta is treated by removing the uterus, as it is effective for reducing maternal mortality 

and stopping bleeding rapidly and completely. Decisive hysterectomy should be performed in patients with 

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 American Journal of Medical and Physical Education  

Vol.9, Issue 1; January-February 2024; 

ISSN: 2994-0524 

Impact Factor: 6.14 

1252 Columbia Rd NW, Washington DC, United States 

https://topjournals.org/index.php/AJMPE; mail: topacademicjournals@gmail.com 

 
 

 

 

21 | A m e r i c a n  J o u r n a l  o f  M e d i c a l  a n d  P h y s i c a l  E d u c a t i o n  

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serious intraoperative bleeding, shock, a coagulation dysfunction or blood shortage, a large area of placenta 

percreta, a thin uterine wall, and poor uterine contractions. Kohn et al. (2016) reported the case of a pregnant 

woman in whom hysterectomy was performed because of placenta percreta and incomplete uterine rupture after 

endometrial ablation was performed at 18 weeks of pregnancy. However, removal of the uterus would cause the 

patient to lose fertility, resulting in physical and psychological damage, and some patients cannot accept this 

outcome. Thus, conservative treatment should be considered if the patient’s condition is relatively stable. 

However, this depends on an accurate prenatal diagnosis, adequate pre-operative preparation, and a skilled 

surgical operation.  

The key to conservative treatment is effective haemostasis. If the area of placenta percreta is small, local resection 

and suturing may be appropriate during caesarean section (for example, wedge resection or excision and a partial 

figure-of-8 suture or ring suture). Ligation of the uterine muscle can facilitate haemostasis. The B-Lynch suture 

can also be used, and the uterus can be sutured at the anterior and posterior walls. In clinical practice, surgeons 

can combine several surgical procedures to stop bleeding. For pregnant women at high 4 Med.Case Stud.  

Risk for uterine rupture, such as scarring of the uterus and placenta percreta, it is necessary to provide detailed 

and prudent prenatal counselling, evaluate the relationship of the uterine muscle and placenta with 

ultrasonography regularly, and recommend caesarean section as soon as possible. If uterine rupture is suspected, 

a timely caesarean section to terminate the pregnancy may be necessary, or laparotomy can be performed to make 

a clear diagnosis in an attempt to keep the uterus.  

The treatment for placenta percreta should be selected according to the patient’s condition, blood loss, and rate 

of blood loss, taking into consideration the type and location of the placenta percreta, surgeon’s skills, rescue 

capacity of the medical institution, and the patient’s reproductive requirements. A comprehensive analysis must 

be conducted to make the right decision.  

A prenatal diagnosis and identification of abnormal placentation are vital for the following reasons: 1) to plan the 

date, place, and mode of delivery; 2) to ensure the availability of highly qualified specialists in the field of 

obstetrics and anaesthesia, and 3) to ensure the availability of a sufficient amount of blood and blood substitutes. 

If the MRI scan or ultrasonogram findings are suggestive of placenta percreta pre-operatively or prenatally, 

sufficient preparations should be made, including adequate blood preparation, a detailed, reasonable surgical 

program, and treatment methods to control bleeding and avoid unnecessary hysterectomy (Palacios-Jaraquemada, 

2013).  

Conclusion  

Patients with placenta percreta may not have any symptoms, and placenta percreta may not affect intrauterine 

foetal development; however, if it is found during delivery, it is more difficult to manage, especially in cases of 

natural childbirth. Therefore, an early diagnosis is particularly important. Additionally, an early diagnosis of 

uterine rupture can save a patient’s life. An adequate prenatal assessment, accurate diagnosis, and timely treatment 

are essential to reduce maternal and child mortality and complications.  

CONFLICT OF INTERESTS  

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 American Journal of Medical and Physical Education  

Vol.9, Issue 1; January-February 2024; 

ISSN: 2994-0524 

Impact Factor: 6.14 

1252 Columbia Rd NW, Washington DC, United States 

https://topjournals.org/index.php/AJMPE; mail: topacademicjournals@gmail.com 

 
 

 

 

22 | A m e r i c a n  J o u r n a l  o f  M e d i c a l  a n d  P h y s i c a l  E d u c a t i o n  

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The author has not declared any conflict of interests.  

ACKNOWLEDGMENTS  

The author thanks Editage (www.editage.cn) for the English language editing. The study was supported by the 

Capital Medical University Foundation - Clinical Research Cooperation Fund (17JL23).  

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Kohn JR, Popek E, Diaz-Arrastia CR, Guan X, Shamshirsaz AA, Belfort MA, Fox KA (2016). Placenta percreta 

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