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Interval Hysterectomy for 
Placenta Percreta – a Case Report 

 
Mohammad Sazzadul Huque1, 
Mini Ravi2 
 
1College of Medicine, Gulf Medical 
University, United Arab Emirates;  
2Mafraq Hospital, United Arab Emirates  
 
 
 
 

 

 
Vol. 8, No. 1 (2019)   |   ISSN 2166-7403 (online)  
DOI 10.5195/cajgh.2019.345 |   http://cajgh.pitt.edu 

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HUQUE 
 

 
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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 
 

Central Asian Journal of Global Health 
Volume 8, No. 1 (2019) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2019.345|http://cajgh.pitt.edu 

 
 

Abstract 

Introduction: Placenta percreta is an abnormality of placentation where it invades the serosa and can go beyond it. Complications 
include massive hemorrhage, bladder dysfunction, and severe infections during delivery.  The aim of this study is to report a 
complex case of placenta percreta managed by interval hysterectomy. 
Case presentation: Pre-operative: 34 years old patient with previous three cesarean sections was followed in antenatal clinic. She 
came with repeated bouts of vaginal bleeding at 30-31 weeks. At 32 weeks and 4 days classical cesarean section was done with 
placenta left in situ. Prophylactic bilateral internal iliac artery balloon was inserted. Post cesarean section, uterine artery 
embolization was performed. Post-operative: Clinical features of pulmonary embolism (PE) developed about 4 hours later. Post-
Operative Day 13: Total abdominal hysterectomy was done. After few days of discharge, the patient presented to the emergency 
department with shortness of breath. She was consequently diagnosed with chronic pulmonary embolism and treated with warfarin. 
Conclusion: This is a case of placenta percreta managed by interval hysterectomy. However, the most widely accepted method of 
management is cesarean hysterectomy. In this case, interval hysterectomy was done due to the possibility of bladder invasion by 
placenta, to decrease the amount of blood loss and to reduce the number of days stayed in hospital. Appropriate management for 
the patient must be personalized, whether it is by cesarean hysterectomy or interval hysterectomy,  as each has risks and benefits. 

Keywords: Placenta Percreta; Interval Hysterectomy; Case Report; Complications of Placenta Percreta 

 
Interval Hysterectomy for Placenta 
Percreta – a Case Report 

 
 
 

 
Mohammad Sazzadul Huque1, Mini 
Ravi2 
 

 

1College of Medicine, Gulf Medical 
University, United Arab Emirates;  
2Mafraq Hospital, United Arab Emirates 

Research 

Introduction 

Placenta accreta comes under a broad category 
of abnormal adherent placenta and is classified into three 
different entities: (1) Placenta accreta vera, where 
placenta invades the decidual layer of the myometrium. 
(2) In placenta increta, placental villi invade more deeply 
within the myometrium.1 (3) Placenta percreta is 
diagnosed when the placenta invades up to the serosa and 
can go beyond it.2 Placenta accreta is diagnosed in about 
1:533 pregnancies where 75%-80% are placenta accreta 
vera, 17% placenta increta, and remaining 5% are 
placenta percreta. Overall, the incidence of placenta 
percreta is extremely low but the appearance of this rare 
disorder is increasing due to increase number of cesarean 
deliveries being performed in the past few years 
globally.3,4  

Placenta percreta is considered one of the most 
severe forms of placenta accreta. It is a potentially life-
threatening condition with the risk of severe maternal 

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CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH 
 

 

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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 
Central Asian Journal of Global Health 

Volume 8, No. 1 (2019) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2019.345|http://cajgh.pitt.edu 

 
 

morbidity and mortality. In cases where placenta precreta 
is complicated by bladder invasion, mortality rates can be 
as high as 9.5% in mothers and 24% in newborn.5 Both 
diagnostic methods, sonography and MRI, have good 
sensitivity and specificity for prenatal diagnosis of 
placenta accreta.4 According to American College of 
Obstetricians and Gynecologists, widely acknowledged 
method to manage placenta accreta spectrum is by 
performing cesarean hysterectomy, in which the placenta 
is left in situ after delivery of the fetus because any 
attempts to remove the placenta is associated with 
substantial danger of hemorrhage.6.  Another method of 
management that can be considered for placenta percreta 
is interval hysterectomy. In general, patients who have 
placenta accreta are more likely to have a caesarean 
section (AOR: 4.6). They are at an increased risk for 
being admitted to intensive care unit (ICU)/high 
dependency unit (AOR: 46.1) and to have a hysterectomy 
(AOR: 209.0). Births are expected to be preterm with a 
high level neonatal ICU admission and resuscitation 
needs.7 The median expected blood loss at time of 
cesarean hysterectomy for patients with placenta accreta 
has been reported to be 3 liters and the mean transfusion 
requirement of 5 units of packed red blood cells.8 In 
addition to higher estimated blood loss, placenta percreta 
patients are also at an increased risk of bladder and 
ureteral injury.9 Conservative management where the 
uterus and the placenta are left in-situ at time of cesarean 
delivery was shown to be associated with a reduction in 
blood loss in patients with placenta percreta, decreased 
need for transfusion, and less incidence of disseminated 
intravascular coagulation through uterus involution.8,10  

We are reporting this rare case to increase the 
awareness about placental percreta and to share our 
experiences with the interval hysterectomy as a treatment 
modality. This is a very interesting case because it shows 
the complete picture of the case from antepartum history 
to operative details and discharge information. It also 
includes information of treatment that took place after 
discharge. It highlights the list of complication one can 
anticipate in a case of placenta percreta.  

Case presentation 

Antepartum history 

34 years old patient, Gravida 6 Parity 3, 
previous 2 miscarriages (18 weeks & 12 weeks), was 
seen first at 23 weeks 4 days of pregnancy. She had 
undergone previous 3 cesarean sections and an 
evacuation of retained products of conception by 
curettage in 2013 for partial hydatidiform mole. At 27 
weeks 5 days, she was admitted for vaginal bleeding. On 
further evaluation by ultrasound (Figure 1), the diagnosis 
of placenta percreta was made (later confirmed by MRI). 
At 29 weeks, she had constipation with 2 episodes of 
urinary retention and she was put on continuous bladder 
drainage. She developed urinary tract infection and 
treated with appropriate antibiotics based on culture 
sensitivity. She continued to have repeated bouts of 
vaginal bleeding of varying amounts and severe 
constipation from 31 weeks of gestation. 

Operative history 

At 32 weeks 4 days, patient underwent 
cystoscopy, which had shown signs of cystitis with no 
definite infiltration. She underwent classical cesarean 
section under combined anesthesia (Epidural + General). 
The umbilical cord was tied near insertion and the 
placenta was left in situ because there was no 
spontaneous separation. Then, the uterus was closed. 
Prophylactic temporary bilateral internal iliac artery 
balloons were inserted and inflated earlier. Uterine artery 
embolization was performed post cesarean section and 
selective angiograms confirmed adequate positioning. 
The patient required large volume of particles and still 
had incomplete embolization with the lower part of the 
uterus still showing some unblocked branches on both 
sides. 

Post-operative course 

Post-operatively, she was transferred to labor ward and 
within 4 hours, she developed clinical features of 
pulmonary embolism (PE). Some of her symptoms 

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HUQUE 

 
This work is licensed under a Creative Commons Attribution 4.0 United States License. 

 
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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 
 

Central Asian Journal of Global Health 
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Figure 1. Clinical images: A. Doppler Ultrasound and B. 
Ultrasound of the Uterine Lower Segment  

included drop in O2 saturation to 81%, tachycardia, chest 
pain, peripheral cyanosis, and signs of respiratory 
distress. Then, she was transferred to ICU and was 
initiated on heparin infusion. On chest X-ray, she had no 
atelectasis, pneumothorax, or pleural effusion. An 
immediate CT scan did not show any PE. There was no 
Doppler evidence of venous thrombosis in the femoral 
and popliteal venous systems. Later on day 1 post-
operative, she had focal patchy consolidation left base 
and was started on parenteral meropenem, linezolid and 
fluconazole for the next 5 days. She had two consecutive 
CT scans on post-operative on days 2 and 3, which were 
negative. On ECG, there was right heart strain. She was 
now on enoxaparin. On the post-operative day 5, she was 
prescribed parenteral piperacillin-tazobactam for 5 days 
and she was shifted out of ICU next day. She had 500ml 
vaginal bleeding on the 9th post-operative day.  2 units 

PRBC were transfused. She was switched to oral 
cefuroxime and metronidazole and planned to continue 
on long-term low dose antibiotic. On post-operative day 
11, she received methotrexate. On day 12, the MRA had 
shown the placenta was still enhancing with some areas 
of infarct and separation, fluid collection in the uterine 
cavity (present from day 1 post op, not increasing), with 
large ovarian veins, hugely distended and extensive 
pelvic varices, R>L, extensive collaterals. Her CRP was 
12.7 mg/L.  

Operative details 

On post-operative day 13, she underwent total 
abdominal hysterectomy. Intraoperatively, the bladder 
was densely adherent, drawn up, with large vessels in the 
broad ligament. The lower segment was bulging due to 
the presence of the placenta. The uterus was about 24 
weeks’ size with adherent omentum. There was 100 mL 
of old blood in the cavity and the placenta was partially 
infarcted. The total blood loss was 2000 mL. 

Post-hysterectomy period 

Post-operatively, she was in ICU for 2 days 
receiving anticoagulation treatment (bridging treatment 
with enoxaparin + warfarin) and patient controlled 
analgesia. She had a bout of severe cough on day 4 and 
loose motions on day 5. She was diagnosed with vault 
hematoma, which was retro-vesical, about 120 ml in 
volume, treated conservatively. On day 10 she had been 
discharged from the hospital. 

She presented to the ER on the post-operative 
day 16 and was diagnosed with chronic pulmonary 
embolism. Patient had a pulmonary embolus within the 
right middle lobe pulmonary artery; areas of sub-
segmental embolus within the right lower lobe 
pulmonary arteries. She had no pleural effusions or 
consolidation and no mediastinal lymphadenopathy. She 
was readmitted for 4 days. She was started on therapeutic 
enoxaparin + warfarin. She was continued on 6 mg 
warfarin for 4 weeks after discharge.  

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Volume 8, No. 1 (2019) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2019.345|http://cajgh.pitt.edu 

 
 

Discussion 

In the field of abnormal placentation, placenta 
percreta is the most uncommon and most dangerous 
among them.  The diagnosis of this condition can be 
achieved during pregnancy by ultrasound and/or 
magnetic resonance imaging. The main aim of the 
therapy should be to minimize the blood loss by doing a 
hysterectomy, or by preventing the elimination of the 
placenta at the time of delivery, or via methotrexate 
regiment for the ablation of the remaining placenta in the 
post-delivery period.11 In USA, the most common 
method of threatment for placenta accreta is cesarean 
hysterectomy. The complications of cesarean 
hysterectomy are bladder and/or ureters injury, severe 
hemorrhage and maternal demise. Placental retention 
with uterine conservation during the time of delivery and 
interval hysterectomy are the other options available for 
stable patient. These techniques can result in decreased 
amount of blood loss and bladder/other organs 
resection.12 

Previous studies report cases of invasive 
placentation that were managed by interval 
hysterectomy. One case had placental invasion up to the 
anterior abdominal wall. By delaying patient’s 
hysterectomy and using uterine artery embolization, 
patient was able to undergo the hysterectomy and bladder 
resection with less morbidity when compared to the 
scenario when procedure would have been performed 
during cesarean delivery, which was already made 
difficult by the immense hemorrhage.12 In the case series 
by Wong et al, eight suspected cases of abnormal 
placentation were managed. In three cases, the placentas 
were separated from the uterus with minimal difficulty. 
In two cases of placenta percreta without invasion of 
bladder, cesarean hysterectomy was done. In the 
remaining three cases of percreta with bladder invasion, 
the entire placenta was left in-situ. Resolution occurred 
in two of them, over a period of 8 and 12 months 
respectively. The last one had post-operative course 
complication with deep vein thrombosis and 

disseminated intravascular coagulation. This patient 
underwent hysterectomy with preoperative uterine artery 
embolization, inferior vena cava filter placement and 
ureteric stenting. Hence, the conservative management is 
potentially safe and attractive alternative to the other 
modalities. However, cautious and vigilant patient 
selection with individualized assessment is needed.13 

In our case, we chose interval hysterectomy 
because of possible bladder invasion by placenta, to 
decrease the amount of blood loss, and to reduce the 
hospital stay. In another study of 93 patients with 
abnormal placentation, 20 patients have been 
diagnostically confirmed to have placenta percreta. Out 
of these women, 11 underwent immediate hysterectomy; 
9 underwent interval hysterectomy. Median approximate 
blood loss for women who underwent immediate 
hysterectomy (2.8L) was significantly higher compared 
to interval hysterectomy (1L). Median duration of stay 
for the immediate hysterectomy was 15 days compared 
to 7 days for the interval hysterectomy. However, there 
was a trend towards increased rate of infection with 
interval hysterectomy.14  

In conclusion, this case highlights the need to 
investigate various management options for patients with 
placenta percreta. While it is a rare diagnosis, it is 
increasing in incidence. It should be highlighted that 
cesarean section should be reserved to the patients for 
whom it is indicated. In addition, it is difficult, risky, and 
expensive to manage such cases. Nevertheless, proper 
management for the patients must be individualized 
whether it is cesarean hysterectomy or interval 
hysterectomy, as each option has its own risk and 
benefits, and must be performed with caution. 

 

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HUQUE 

 
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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 
 

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Volume 8, No. 1 (2019) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2019.345|http://cajgh.pitt.edu 

 
 

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	Interval Hysterectomy for Placenta Percreta – a Case Report
	Abstract
	Keywords: Placenta Percreta; Interval Hysterectomy; Case Report; Complications of Placenta Percreta
	Interval Hysterectomy for Placenta Percreta – a Case Report
	Research

