Placenta Accreta in a 19-Year-Old Patient

Background: Placenta accreta is an obstetrical complication that occurs when the placenta abnormally implants into the uterine myometrium and is a leading cause of postpartum hemorrhage resulting in maternal and fetal morbidity and mortality. Early antenatal ultrasound diagnosis usually allows for the placenta accreta to be identified and managed by a multidisciplinary team. Without early identification, maternal mortality due to placenta accreta is as high as 7%. Case Presentation: A 19-year-old woman (G2P1011) at 40 weeks 5 days presented to the OB ED and was identified to be in labor. Patient had received prenatal care throughout the pregnancy and there were no identifiable risk factors for postpartum hemorrhage. She received an epidural and had a spontaneous vaginal delivery resulting in a viable male newborn. After repair of a second-degree vaginal laceration, she had persistent bleeding from higher up in the uterus. Patient was identified to have uterine atony and uterotonics were administered with no improvement to bleeding. Patient was transferred to the operating room, and after multiple conservative measures, including Bakri balloon and manual tamponade were unsuccessful, the decision was made to perform a partial hysterectomy. Good hemostasis was noted postop. Patient had an estimated blood loss of 4 liters during the procedure. She received 11 units of packed red blood cells, 2 units of platelets, 8 units of fresh frozen plasma, and 2 units of cryoprecipitate. Sections of the hysterectomy specimen were sent to pathology and showed findings consistent with focal placenta accreta. During the following hours in the ICU, her labs improved, and she remained stable. Since then, she has been discharged home and has not experienced complications outside the normal postpartum and post-hysterectomy complications. Conclusions: This case illustrates the potential complication of placental accreta including life threatening hemorrhage and need for blood transfusion postpartum. The rates of placenta previa and accreta have been increasing likely due to increasing rates of Cesarean delivery, maternal age, and assisted reproductive technology. Recognition of this condition prior to delivery using US is vital for successful management and prevention of pregnancy complications. Cesarean hysterectomy with placenta left in situ between 34 and 35 weeks of gestation is currently the gold standard surgical management of placenta accreta, so it is of particular note that this patient had a spontaneous vaginal delivery at 40w5d.